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Ann Thorac Surg 1998;66:2160-2161
© 1998 The Society of Thoracic Surgeons
a Division of Thoracic & Cardiovascular Surgery, Department of Surgery, University of Maryland Medical Center, 22 South Greene St, Baltimore, MD 21201, USA
To the Editor
I would like to thank Drs Kutlu, Metin, and Sayar for their interest and comments regarding our article. Although significant advances have been made in the pre- and postoperative care of patients with cancer of the lung, mortality remains high, especially in the superior sulcus tumors. The preoperative workup of these patients included the clinical presentation, radiography of the chest, bronchoscopy, and cytology. In the early part of the series, diagnosis was made by thoracotomy and biopsy, scalene or supraclavicular node biopsy, and rib biopsy; however, computed-tomography–guided needle biopsy is performed currently.
The staging was performed using chest roentgenograms, computed tomography, magnetic resonance imaging, and medianstinoscopy. Although medianstinoscopy was not used in the early part of the series, mediastinal node assessment was made either at the initial thoracotomy or at autopsy. In the early part of the series, many patients presented late clinically, with evidence of scalene or supraclavicular nodes, and were classified as N3 disease even though medianstinoscopy was not available.
The classification of the patients into five groups was dictated by the extent of the disease and lymph node involvement preoperatively. Patients with advanced disease were treated by radiation only (group 3). Patients who had disease within the chest cavity were assessed as indicated previously. In the early series, only exploratory thoracotomy and biopsy were done when the mediastinum was found to be involved and the tumor unresectable. These patients were treated with postoperative radiation (group 2). Patients who were assessed preoperatively to have no mediastinal node involvement were treated with the intent of cure by preoperative radiation and operation (group 1). However, despite this modality of therapy, there was still a high incidence of local recurrence, between 25% and 70%. As improved results were obtained with chemotherapy in several randomized phase III trials, in nonPancoast tumors of the lung with stage III A or III B disease, we elected to apply such therapy to Pancoast tumors (group 4).
Doctor Kutlu and associates stated that we reported a significant complete resection rate in 67 patients who had operations with a curative intent (92.4%). We should differentiate between operability, resectability, and cure. The rate of operability was 63% (67 of 105 patients). The resectability rate was 48% (51 of 105 patients). Group 2, which comprised 16 patients in the early part of the series, underwent thoracotomy and biopsy because of extensive involvement, without curative resection in most cases. These patients therefore required postoperative radiation. Thus the grouping reflects a stricter selection of patients undergoing operation in the latter group of the series, as well as basing the treatment on the stage of the disease. The only patients reported to have undergone operation with the intent to cure involved those in group 1 (preoperative radiation and surgery [n = 28]), group 4 (preoperative chemotherapy, radiation, and operation [n = 11]), and operation alone (n = 12), a total of 51 of 67 patients undergoing operation, a rate of 76%.
The standard treatment of superior sulcus tumor remains preoperative radiation and operation. However, currently we are assessing the trimodality therapy of radiation, chemotherapy, and operation, which is promising. We agree with Dr. Kutlu and associates that a multicenter randomized prospective trial is the most effective way to determine the optimal therapy for Pancoast tumor.
Related Article
Ann. Thorac. Surg. 1998 66: 2160.
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