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Ann Thorac Surg 2003;75:633-634
© 2003 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy
e-mail: lorenzo.spaggiari{at}ieo.it
To the Editor:
I read with interest the article by Dr Martinod and colleagues [1] concerning the management of superior sulcus tumors. I fully agree that the choice of thoracic approach should not be made on a dogmatic basis, but I think that a distinction in "terminology" is necessary. Schematically, tumor arising in lung apex could be divided into three situations: the "true" superior sulcus tumor that arises posteriorly without any contact with subclavian vessels; the "true" anterior apical lung cancer that we might name "anterior Pancoast tumor" with tight contact with or early infiltration into the subclavian vessels; and an intermediate situation characterized by neoplasms involving both anterior and posterior structures. The choice between the surgical approaches to obtain complete oncological resection with tumor-free margins should take into account the three different types of apical chest tumors. For superior sulcus tumors, the classic posterior approach should be used, whereas for anterior Pancoast tumors and the others described, the anterior approach should be used first to obtain complete oncological resection margins and dissection of the subclavian vessels.
The assection of Martinod and associates [1] that the high incidence of wedge resections in their study (almost 25% of the patients) was due to the use of the anterior approach is incorrect. Rather, the incidence was high because some centers perform lung resection only through the anterior approach. This approach should be used to obtain tumor-free margins. Anatomical lung resection and radical lymph node dissection are mandatory in the treatment of lung cancer and should be performed subsequently using an associated thoracotomy [2].
Finally, I agree that N3 ipsilateral supraclavicular lymph nodes can represent local extension rather than distant metastases (N1 instead of N3) [3], but this is true only in patients withnegative N2 disease at mediastinoscopy. However, even in this situation, only an anterior approach can allow radical cervical and thoracic lymph node dissection as part of a complete resection.
In our recent analysis (European Association for Cardiothoracic Surgery/European Society of Thoracic Surgeon Joint Meeting, Lisbon, Portugal: L. Spaggiari personal communication, Sep 16–19, 2001) of 41 patients with apical lung cancer operated on in the last 4 years, 25 patients (61%) had a transmanubrial osteomuscular-sparing approach [4]. There were no postoperative deaths, and among the patients without vertebrectomy, the resection was complete in 94%. The 3-year probability of survival was 79.3% with a rate of local recurrence of 23.5%. Thus, the use of an anterior approach (transmanubrial approach) allowed a high rate of complete resection with good results in terms of local recurrence and midterm survival.
Given that completeness of resection is one of the most important prognostic factors affecting survival [5] and that local-regional recurrence is one of the most important causes of failure in this extended surgical procedure, the correct choice of surgical approach can influence the final results.
In conclusion, even though the choice among the different anterior approaches depends on experience and preference, I believe that the decision in favor of an anterior or posterior approach in the treatment of apical chest tumors should be dictated by oncological concerns and not by the preferences of the surgeon.
References
This article has been cited by other articles:
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  L. Spaggiari, M. D'Aiuto, G. Veronesi, F. Leo, P. Solli, M. Elena Leon, R. Gasparri, D. Galetta, F. Petrella, A. Borri, et al. Anterior approach for Pancoast tumor resection MMCTS, October 18, 2007; 2007(1018): 1776. [Abstract] [Full Text] [PDF]
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