Ann Thorac Surg 2001;72:980-981
© 2001 The Society of Thoracic Surgeons
Correspondence
Lung cancer invading the diaphragm: Reply
Gaetano Rocco, MDa,
Erino A. Rendina, MDb
a Department of Thoracic Surgery, Northern General Hospital, Herries Rd, S5 7AU Sheffield, United Kingdom
b Department of Thoracic Surgery, University "La Sapienza", 00161 Rome, Italy
e-mail: grocco{at}tany.fsnet.co.uk
To the Editor
We also read with much interest the article by Riquet and colleagues [1], which was published 8 months after our review [2]. We believe that Riquet and colleagues should be commended on having managed to collect a considerable number of patients with lung cancer invading the diaphragm (T3-diaphragm), a very rare condition. Nevertheless, we would like to make a few comments about the letter, which contains several incorrect citations from our manuscript and the report on which the letter is based:
- In the series by Riquet and colleagues, when the postoperative and non–lung cancer related deaths were to be excluded, the cause of death was due to systemic dissemination in 81% (21/16) of the patients, despite primary diaphragmatic reconstruction. Their figure is considerably higher than our mortality from distant metastases after prosthetic reconstruction of the diaphragm (22% (2/9), not 90% as quoted in their letter). Furthermore, recent experimental evidence favors, from a mechanical standpoint, the prosthetic reconstruction of the diaphragm over the simple primary suture for the surgical repair of large diaphragmatic defects [3].
- In the report by Riquet and colleagues, 13 patients showed no histologic invasion of the diaphragm, 6 had only an histologically proven invasion of the diaphragmatic pleura, and in 4, the operative data were not available. In other words, 23 of 58 patients (40%) were questionably included in their series. Moreover, the follow-up period was not specified. In this situation it is extremely difficult, if not impossible, to compare those data with the ones from other series. In our opinion, no final conclusion should be drawn in the absence of proper mediastinal staging (which was not performed in 34% of the patients) and survival stratification.
- In contrast to what is suggested by the interpretation of our report provided by Riquet and colleagues, we emphasize that surgery for T3-diaphragm should be the primary treatment modality only when N2 disease is excluded and when the invasion of the diaphragm is not substantially suspected at preoperative workup. Video-assisted thoracoscopic evaluation can be a valuable adjunct to mediastinoscopy in defining the nodal status, whereas it may be insufficient to fully determine local resectability (ie, tenacious inflammatory adhesions mimicking neoplastic infiltration).
It is likely that the publication of the French multicentric study as a brief communication has penalized the authors’ efforts. However, we feel that our conclusion as quoted by Riquet and colleagues, that a multicentric study is needed to assess the validity of the prognostic factors after resection of T3-diaphragm, still holds true.
References
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Riquet M., Porte H., Chapelier A., et al. Resection of lung cancer invading the diaphragm. J Thorac Cardiovasc Surg 2000;120:417-418.[Free Full Text]
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Rocco G., Rendina E.A., Meroni A., et al. Prognostic factors after surgical treatment of lung cancer invading the diaphragm. Ann Thorac Surg 1999;68:2065-2068.[Abstract/Free Full Text]
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Menezes S.L.S., Chagas P.S.C., Macedo-Neto A.V., et al. Suture or prosthetic reconstruction of experimental diaphragmatic defects. Respiratory repercussions. Chest 2000;117:1443-1448.[Abstract/Free Full Text]
Related Article
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Lung cancer invading the diaphragm
- Marc Riquet, Xavier Chaufour, and Redha Souilamas
Ann. Thorac. Surg. 2001 72: 979-980.
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