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Ann Thorac Surg 1998;65:1516-1517
© 1998 The Society of Thoracic Surgeons
a Thoracic Department, Institut Mutualiste Montsouris, 6 place de Port au Prince, 75013 Paris, France
To the Editor
My colleagues and I thank Dr Spaggiari and his colleagues for their comment. We were very interested by their case report, and extremely pleased to see our technique of en bloc resection of chest apical tumors invading vertebral bodies has been performed by other teams.
As far as the technical aspect of the approach is concerned, in our first cases, we used the triple procedure described by Spaggiari and colleagues [1]. At the present time, with increasing experience and the development of the transmanubrial approach, most of the apical chest tumors we operate on are resected through a double approach only: anterior cervicothoracic and median posterior. The inferior part of the cervicothoracic incision can be easily extended to the anterior part of the axillar area, and this affords excellent exposure of the three first ribs. After resection of the anterior half of both first and second ribs, the approach to the superior mediastinum and the pulmonary hilum is very nice, and it is relatively easy, with experience, to perform a regular transscissural lobectomy, without effraction of the tumor block, and a complete superior mediastinal lymph node dissection as well [2]. An important step is to complete cautiously the dissection of the prevertebral plane, through the anterior approach, and to divide the nervous roots beyond the tumoral mass before closure of the manubrial edge and the cervicothoracic incision.
Appropriately Dr Spaggiari and colleagues put into their discussion the induction treatment in these patients with IIIB disease. This important question places in a prominent position the lack of the current revised staging system in establishing clear guidelines for multimodal treatments in locally advanced non–small cell lung cancer [3]. Indeed, theoretically IIIB disease should not be considered as resectable. Nevertheless, in some selected patients, as shown by the case reported by Spaggiari and colleagues, surgical resection is feasible and could be considered as a definitive locoregional treatment [4]. Our own subgrouping system, recently proposed, urges to propose to these patients an induction strategy (Fig 1) [5]. This raises Spaggiari and colleagues’ second question concerning the lymph node involvement. There is a high probability of distant failure in T4 tumors, N2 disease, a fortiori N3 diseases, and T4 associated with N disease. Mediastinal spreading is evaluated by mediastinoscopy in case of lymph node enlargement on the computed tomographic scan. We do not propose radical resection in N2 patients. In the absence of mediastinal nodal involvement, an isolated node close to the tumor in the cervical region could be considered as N1 disease. Hopefully, positron-emission tomographic scanning will help us in the near future to determine candidates for this major operation, according to the N status. The role of induction chemotherapy in preventing distant metastases has not been clearly assessed, despite the results recently reported [6, 7]. However, we consider an induction treatment as reasonable with the aims of attempting to reduce the tumor volume and preventing distant failure [8]. At the present time our patients receive two cycles of cisplatin, 100 to 120 mg/m2 every 4 to 6 weeks, and vinorelbine, 30 mg/m2 every week, preoperatively, and so far we have not observed any additional morbidity caused by this preoperative chemotherapy.
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Updated data of our series concern 20 patients who have undergone en bloc vertebrectomy for thoracic tumors. Among them, 12 were operated on for apical non–small cell lung cancers associated with Pancoast syndrome. The overall 3-year survival estimate for the 12 patients is 35%, with a median survival of 13.5 months. Seven patients died, but only 2 with local recurrence. The other 5 deaths were caused by postoperative complication (1 patient), other cancer (1 patient), and metastatic disease (3 patients). Among the 5 patients alive, 1 has a tumor implantation in the anterior thoracic wall on a chest tube orifice. I completely agree with Spaggiari and colleagues that the real oncologic advantage of this operation has not been proved, if one considers the risk of postoperative morbidity and mortality and the consequences of the surgical division of the nervous roots. Further efforts and prospective studies are mandatory to assess the role of the surgical resection in these particularly severe situations where Pancoast tumors invade the spine.
References
This article has been cited by other articles:
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  L. Spaggiari and U. Pastorino Transmanubrial approach with antero-lateral thoracotomy for apical chest tumor Ann. Thorac. Surg., August 1, 1999; 68(2): 590 - 593. [Abstract] [Full Text] [PDF]
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