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Ann Thorac Surg 1998;66:304
© 1998 The Society of Thoracic Surgeons

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Correspondence

Reply

^a The Cardio-Thoracic Surgical Group, PA, 185 Livingston Ave, New Brunswick, NJ 08901, USA

To the Editor

We appreciate Spaggiari and associates’ interest and concern regarding our recent publication [1]. They ask, "Is it justified to ignore oncologic principles during video-assisted thoracic surgical major lung resections?" A close and careful reading of our article will confirm that we are stringently adhering to all accepted oncologic principles in our surgical operations. I might add that we continue to question the validity of some of these oncologic principles, because survival after surgical resection has remained unchanged for the past 40 years [2]. In fact, carcinoma of the lung has now become the most common cause of cancer death in both men and women. We have not been successful in altering the natural, intrinsic behavior of the disease. Nevertheless, thoracic surgeons should still be congratulated for the excellent advances made in reducing local problems. Terminal events of the past, which were directly related to tumor growth and obstruction, presently are better controlled. Unfortunately, most, if not all, patients currently die of metastases. Anything that can be done to diminish metastases would be of tremendous value [3].

Spaggiari and associates were concerned about the oncologic validity of dividing the tumor in a plastic bag within the chest. Actually, almost all of the tumors in our series could be removed easily in a plastic bag, through the naturally occurring wide interspace in the anterior chest, without having to be divided. Some large tumors (6 to 8 cm) are soft and will compress when squeezed, between the ribs, in the bag. We have now performed 300 video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading and have had to divide only four large, rigid tumors within the bag. Reduction of the tumor has been used very infrequently, and was mentioned merely as another method to avoid the added trauma of rib spreading that could increase tissue injury. There is scientific evidence that tissue injury activates an inflammatory reparative process that elaborates numerous humoral substances. These accelerate cell division and repair of normal tissue. The magnitude of the tissue injury corresponds to the magnitude of the reparative process. Unfortunately, this same reparative cascade of events concurrently affects the tumor, promoting growth and metastases [4]. The four times that the lobe was divided within the protective bag, to avoid tissue injury from rib spreading, it was separated into large segments that could be reconstructed anatomically into the original lobe outside the chest. All parts of the lobe or tumor necessary for accurate pathologic examination were preserved. The neoplasm was evaluated anatomically for vascular and perineural involvement and for various tumor markers.

Our first video-assisted thoracic surgical lobectomy for carcinoma was performed on September 9, 1991, and that patient remains alive and well without any evidence of tumor. A review of our first 200 consecutive video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading for carcinoma, with a median follow-up of 34 months (range, 12 to 76 months), reveals an overall survival of 86% for all stages and a 92% survival for stage I. Video-assisted thoracic surgical simultaneously stapled lobectomy without rib spreading has required no transfusions, permitted more of a "no touch" technique, and because of the small incisions and diminished tissue injury, possibly reduced the associated cascade of biological reparative events, which also favor tumor growth and metastases. We still have much to learn about these pathological processes and their affect on carcinoma, but video-assisted thoracic surgical simultaneously stapled lobectomy without rib spreading seems to be a good oncologic procedure if survival is the criterion.

We are well aware of the technique of Giudicelli. It is excellent and allows the resection to be accomplished very adequately and successfully. Each surgical technique must stand on its own merits. Time will be our impartial judge.

References

1. Lewis R.J., Caccavale R.J., Sisler G.E., et al. One hundred video-assisted thoracic surgical simultaneously stapled lobectomies without rib spreading. Ann Thorac Surg 1997;63:1415-1422.[Abstract/Free Full Text]
2. Pearson F.G. Current status of surgical resection for lung cancer. Chest 1994;106:337S-339S.[Abstract/Free Full Text]
3. Pantel K., Izbicki J., Passlick B., et al. Frequency and prognostic significance of isolated tumor cells in bone marrow of patients with non–small cell lung cancer without overt metastases. Lancet 1996;147:649-654.
4. Reid S., Kaufman M., Murthy S., et al. Perioperative stimulation of residual cancer cells promotes local and distant recurrence of breast cancer. J Am Coll Surg 1997;185:290-306.[Medline]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ralph J. Lewis Robert J. Caccavale Glenn E. Sisler Jean-Philippe Bocage Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Lewis, R. J. Articles by Bocage, J.-P. Search for Related Content PubMed PubMed Citation Articles by Lewis, R. J. Articles by Bocage, J.-P.