HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James W. Asaph Andrew C. Tsen Richard C. Rogers Gary L. Grunkemeier Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Asaph, J. W. Articles by Grunkemeier, G. L. Search for Related Content PubMed Articles by Asaph, J. W. Articles by Grunkemeier, G. L. Related Collections Lung - cancer Related Article

Ann Thorac Surg 2001;72:983-984
© 2001 The Society of Thoracic Surgeons

---

Correspondence

Median sternotomy for primary lung tumors: Reply

^a Earle A. Chiles Research Institute, Providence Portland Medical Center, 4805 NE Glisan St, Portland, OR 97213-2967, USA
^b The Oregon Clinic, PC, 507 NE 47th Ave, Portland, OR 97213, USA
^c Providence Medical Data Research Center, Providence St. Vincent Medical Center, 9205 SW Barnes Rd, Portland, OR 97225, USA

To the Editor

We appreciate the response by Dr Kutlu and colleagues to our paper [1]. Analysis of our 20-year thoracic surgery database has demonstrated median sternotomy (MS) to be at least equivalent to posterolateral thoracotomy (TH) in staging and onocologic outcome. During this period our incision preference evolved from TH to MS, which is now being used in 75% of our pulmonary resections (see Fig 1 in our paper). However, we did note several contraindications for MS such as, left lower lobectomy, intact internal mammary coronary bypass graft, or posterior chest wall tumor invasion [1].

We began routinely doing "systemic nodal dissections" as defined by Goldstraw [2] on all patients undergoing resection for cancer regardless of the incision in 1991. Since the majority of our resections before 1990 were by TH and most now are by MS, the lymph node dissections were more frequent in the MS group. However, at every period, the survival results based on staging were similar in both incision groups.

The technique of "complete staging lymph node dissection" through a MS is as follows: bilateral paratracheal and upper mediastinal lymph nodes (levels 1 to 4 R & L), subcarinal lymph nodes (level 7), ipsilateral inferior pulmonary ligament lymph nodes (level 9), and paraesophageal lymph nodes (level 8) are removed in all patients. In left sided resections, we also remove A-P window lymph nodes (level 5) and paraaortic lymph nodes (level 6).

Subcarinal lymph nodes are removed by developing an extrapericardial plane between the aorta and superior vena cava to expose the trachea. Firm retraction inferiorly on the pericardium overlying the right atrium exposes the carina, allowing easy removal of the level 7 lymph nodes. Level 5 and 6 lymph nodes are approached between the pericardium and parietal pleura, taking care to protect the phrenic nerve.

With a right TH we remove ipsilateral level 4, 7, 8, and 9 lymph nodes, and with a left TH, ipsilateral levels 5, 6, 7, 8, and 9 nodes. Contralateral lymph nodes are not resectable by TH.

We are continuing to review survival data as we accumulate more patients in both the TH and MS groups with systemic nodal dissections. If our hypothesis that we perform a more complete lymph node dissection through a MS is correct, we anticipate that we will see a survival benefit in MS patients because of more accurate staging.

We agree with Dr Kutlu and colleagues that one should be very conservative when considering a combined cardiac and pulmonary operation through a MS. We have performed a few pulmonary resections in patients undergoing cardiac surgery who have had peripheral lesions. They have had a negative paratracheal and subcarinal lymph node dissection before the cardiac procedure; and, if, on completion of the cardiac component and reversal of heparin, they are hemodynamically stable, we have done the pulmonary procedure. The pulmonary resection can be associated with transient hemodynamic instability, and compromised coagulation can subject these patients to potentially severe intrapulmonary hemorrhage.

Our 20-year experience, as published in our article, confirms our conviction that MS is at least equivalent oncologically to TH for resection of lung cancer. We are presently evaluating functional outcomes and quality of life in a large number of prospectively collected lung cancer surgery patients to determine whether MS actually is superior to TH in nononcologic factors.

References

1. Asaph J.W., Handy J.R., Grunkemeier G.L., et al. Median sternotomy versus thoracotomy to resect primary lung cancer: analysis of 815 cases. Ann Thorac Surg 2000;70:373-379.[Abstract/Free Full Text]
2. Goldstraw P. Report on the international workshop on intrathoracic staging. London, October 1996. Lung Cancer 1997;18:107-111.

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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James W. Asaph Andrew C. Tsen Richard C. Rogers Gary L. Grunkemeier Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Asaph, J. W. Articles by Grunkemeier, G. L. Search for Related Content PubMed Articles by Asaph, J. W. Articles by Grunkemeier, G. L. Related Collections Lung - cancer Related Article