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Ann Thorac Surg 2003;75:1358
© 2003 The Society of Thoracic Surgeons
Department of Thoracic Surgery, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy
e-mail: lorenzo.spaggiari{at}ieo.it
To the Editor:
We read with interest the article by Dr Donington and associates [1] regarding the treatment of lung cancer developing in the residual lung after pneumonectomy for bronchogenic carcinoma. Despite the number of pneumonectomies performed, the percentage of operations on the residual lung is still low: about 3% of all pneumonectomies [1]. The reasons are both functional and oncologic but often this therapeutic option is denied by the "belief" that this surgery is impossible. We not agree with this opinion and we have used for many years this operation for the treatment of lung cancer in a single lung [2], even when extracorporeal circulation was needed [3]. However, at present we "feel" that more restrictive oncologic criteria for selection are needed for satifactory oncologic results. As reported in the paper patients with metastatic disease showed a 5-year probability of survival of 14% whereas patients with metachronous disease had a 5-year probability of 50%. Postoperative morbidity and mortality were 44% and 8.3% respectively. Starting from these results all efforts should be made to exclude patients with metastatic disease from surgery and those with multiple nodules requiring extended resections. Further, considering that the preferred operation is single wedge resection without lymph node dissection [1, 2], patients with suspicion of N1 or N2 disease should be excluded from surgery. Mediastinoscopy or left anterior mediastinotomy, or both, is the procedure of choice for mediastinal investigation; however, because these operations in pneumonectomized patients can be very difficult we recommend high-definition computed tomography (CT) thoracic scan and position emission tomography (PET) scan for all potential candidates.
In our recent experience from 1998, 6 patients underwent single lung resection for a second primary cancer [5] after pneumonectomy for bronchogenic carcinoma. The median interval between pneumonectomy and operation on the single lung was 54 months. All except 1 had CT thoracic and PET scans before resection: no abnormal mediastinal lymph nodes were observed, and in 1 patient with adenocarcinoma PET scan was fully negative. One patient had a metastatic (adenocarcinoma) in a pulmonary lymph node (station no. 12) evident on the preoperative CT thoracic scan but the PET scan was negative. However, it was resected during anatomic segmentectomy. No postoperative mortality was observed and the percentage of postoperative complications was 16.6%. The 3-year probability of survival is 53% with 4 patients alive and still at risk.
In conclusion we think that surgery on the residual lung is feasible with acceptable postoperative morbidity and mortality if rigid selection criteria are applied [2, 4]. This therapeutic option may cure selected patients. The best oncologic candidates are those with a second primary metachronous lesion that can be resected with a limited wedge resection in patients without any morphologic (CT scan) and metabolic (PET scan) suspicion of pulmonary and mediastinal lymph nodes. Finally, patients with N2 disease at the time of pneumonectomy, patients with synchronous tumor, and patients with multiple nodules should be carefully selected and first treated by chemotherapy, given the poor prognosis of metastatic disease [1].
References
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