| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2002;73:1694
© 2002 The Society of Thoracic Surgeons
a Department of Radiation Oncology, University Hospital, Hoppe-Seyler-Strasse 3, D-72076 Tuebingen, Germany
e-mail: bjeremic{at}med.uni-tuebingen.de
To the Editor
I have read with great interest the article by van Rens and colleagues [1] about the survival analysis after resection of metachronous non-small cell lung cancer (NSCLC) in 127 patients. Although the authors presented their data well, unfortunately, no patterns of failure were presented. We are, therefore, left without an answer to the question: "Where does the cancer recur after the second surgery?" This is one of the vital questions in this disease, since 5-year survival figures of 40%, 13%, 20%, and 25%, respectively, for surgical stages IA through IIB, are clearly inferior to results obtained after resection of the initial NSCLC. To explain the discrepancy in survival, the authors speculate that the first tumor still has an impact on survival after the second resection. This may well be the case, but this hypothesis could not have been verified by using overall survival (OS) as the only endpoint. Instead, data analysis using other endpoints, such as cause-specific survival (CSS), may be more appropriate, and could be helpful in distinguishing the true results of the second operation. This is especially true of van Rens and coworkers’ series, since a number of their patients (two-thirds) were more than 65 years old and, thus, were more likely to have comorbid disease of the pulmonary or cardiovascular systems. CSS accounts for possible intercurrent deaths.
An alternative approach to these patients is radiation therapy (RT) without a second operation. This treatment has been successfully used, over the years, in patients with technically operable, but medically inoperable, clinical early stage NSCLC. With high-dose RT, it is possible to obtain 5-year survivals of 25% to 30% in clinical stages I and II [2–5], and may go up to 40% survival in cases of TIN0 [6]. We have shown that in long-term survivors, after RT alone, a second cancer occurs at approximately the same rate as after a second resection. For these patients, a second course of RT alone also may be a very effective treatment option.
Of a total of 194 patients with early stage NSCLC treated in a single institution over the period of 12 years, we documented 26 second, metachronous cancers [7]. The OS at 5 years was 30% and the CSS was 100% at 1 year, 80% at 2 years, and 53% at 3 to 5 years for the 9 patients with a radiated second lung cancer (six clinical stage I and three stage II). Neither acute nor late severe toxicity was observed with high-dose radiation (in all but 1 patient) using local RT fields. These fields may be interpreted as the radiotherapeutic "equivalent" to limited surgical resection. Although retrospective, coming from a single institution, and reporting on a few patients, these results show that RT is a viable alternative to surgery in cases of a second NSCLC. RT may be valuable for elderly patients, who have a 30-day operative mortality of greater than or equal to 7.0% (for patients 
70 years of age) [8].
Patients with early stage NSCLC treated with either surgery or RT are at a constant risk of developing a second cancer. This risk increases with time, and I can only agree with van Rens and coworkers [1] completely about the necessity of close surveillance in this patient population.
References
Related Article
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
