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Ann Thorac Surg 2000;69:971-972
© 2000 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Vienna General Hospital, Wahringer Gurtel 18-20, A-1090 Vienna, Austria
To the Editor
We thank Dr. Shimokawa and colleagues for their kind comments on our paper. In conforming with their opinion, we consider combined resection of the lung and the aortic wall as justified only in highly selected patients. As already pointed out in the conclusion of our paper [1], such a procedure should only be performed after induction chemotherapy and evidence for tumor response. However, we cannot follow their arguments concerning the routine use of cardiopulmonary bypass for this procedure. In their comment, Dr. Shimokawa and associates claim that the only complication in our series arose in a case of aortic arch infiltration. In fact, in this patient the area of infiltration was in the descending aorta, close to the origin of the subclavian artery. Problems arose during cross-clamping of the proximal aorta, when the clamp had to be positioned toward the region of the aortic arch to achieve a clean resection margin. In our opinion, this problem could have easily been avoided by operating with cardiopulmonary bypass.
The use of cardiopulmonary bypass for tumor surgery clearly has the potential of systemic spread of tumor cells. However, in our opinion this risk is by far smaller than the risk occurring during a discontinuity resection. We therefore cannot follow the arguments of Dr. Shimokawa and colleagues, who suggest resection of the tumor as close as possible to the aorta, followed by resection of the remaining tumor together with the aortic wall.
There are numerous data available in the surgical literature that give evidence that any discontinuation resection of a tumor is less favorable than a radical en bloc resection [2]. The most prominent and best-known example for this is probably resection of lung tumors invading the chest wall.
In our opinion, the only meaningful way to perform surgery in these locally advanced tumor stages is a resection, which in its extension avoids any close contact to the border of the tumor and which is performed in a distant layer, free from tumor. This approach, at least in theory, offers the best prerequisite for adequate local tumor control. Combination with systemic chemotherapy could result in improved long-term survival. This understanding forms the basis of our opinion that resection of lung tumors with infiltration of the thoracic aorta should be performed in an en bloc fashion with the routine use of cardiopulmonary bypass.
References
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