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Ann Thorac Surg 2002;73:348
© 2002 The Society of Thoracic Surgeons
a University of Wisconsin Hospital and Clinics, Madison, Wisconsin 53792-3236, USA
b Memorial Sloan-Kettering Cancer Center, New York, New York, USA
c University of Pittsburgh, Pittsburgh, Pennsylvania, USA
To the Editor
We appreciate the interest and comments by Dr Moghissi and associates on our article on fluorescence bronchoscopic surveillance in postoperative patients with non-small lung cancer (NSCLC) [1]. The goal of our study was to define the prevalence of occult second primaries in curatively treated NSCLC patients, and we found this to be approximately 6%. We agree with Moghissi and associates that postoperative patients with compromised pulmonary reserve could potentially benefit from early detection of second primaries at a stage amenable to endobronchial ablative strategies such as photodynamic therapy (PDT). In a small, ongoing series of 10 early NSCLCs treated curatively with PDT at the University of Pittsburgh, a durable complete response has been maintained in 70%, median follow-up 30 months [2].
Moghissi and associates propose two additional patient populations that they feel may benefit from fluorescence bronchoscopic surveillance, specifically, those with microscopically positive margins at the time of resection and those suspected of having a local recurrence. Although not the subject of our current study, we have performed fluorescence bronchoscopy on patients with microscopically positive resection margins. Our experience has been that the potentially involved mucosa is not always visible with fluorescence detection, perhaps because it is incorporated into the bronchial staple line. When carcinoma or carcinoma in situ is confirmed to be present at the bronchial margin in the immediate postoperative period and re-resection is not feasible, we usually offer these patients either high-dose rate endobronchial brachytherapy or three-dimensional conformal external beam radiation. We do not treat patients with persistent or recurrent carcinoma at the bronchial stump with PDT. Majnissen and associates [3] noted a local recurrence rate of 75% in this population of patients, despite an initial complete response. These investigators attributed this high local recurrence rate to difficulty in determining the extrabronchial extent of disease and inhomogeneous light distribution, even with a microlens fiber.
In patients who present with a symptomatic delayed endobronchial recurrence (ie, with hemoptysis, increasing SOB, or recurrent pneumonia), the recurrence is usually evident on conventional bronchoscopy alone. However, if recurrence is suspected solely because of abnormal cytology, we would agree that fluorescence bronchoscopy may be helpful because of its higher relative sensitivity compared with conventional bronchoscopy for identifying small endobronchial lesions and carcinoma in situ [4].
In conclusion, we believe that fluorescence bronchoscopy is a promising surveillance tool for select, high-risk populations. The utility of fluorescence bronchoscopic surveillance should continue to be explored in prospective trials.
References
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