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Ann Thorac Surg 2004;78:753
© 2004 The Society of Thoracic Surgeons

Correspondence

Is surgery for T4 non–small-cell lung cancer worthwhile?

C.S. Pramesh, MS, FRCS, Rajesh C. Mistry, MS, Ramakant K. Deshpande, MS, FICS, Sanjay Sharma, MS, FICS

Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai 400012, India

e-mail: cspramesh{at}vsnl.net

To the Editor:

We read with interest the article [1] in The Annals on surgical resection of T4 non–small-cell lung cancer (NSCLC). Osaki and colleagues need to be congratulated on bringing out an important point that not all stage IIIB tumors are to be considered inoperable. It is all too common for all T4 tumors to be lumped together as "stage IIIB" with the clearly more advanced N3 disease and considered only for palliative treatment.

However, we believe that the article should have also emphasized that this cohort of 76 patients was a highly selected group. Rather than the 772 consecutive patients with NSCLC treated with surgical resection in the department, a more important numeric figure would be the total number of T4 N0–2 M0 NSCLC patients who presented to the department over the same time frame and how the remaining patients (not considered for surgery) were treated. The take-home message of the article should not be that all T4 tumors are resectable and have a reasonable long-term survival but that among carefully selected patients (preferably with the criteria specified for such selection), long-term survival is possible.

We also disagree with the authors regarding the use of mediastinoscopy and strongly advocate routine mediastinoscopy for these patients. With a significant survival advantage noted with neoadjuvant chemotherapy in T1–3 N2 disease [2, 3], there is no reason to believe that T4 N2 tumors would behave differently. We would thus be inclined to treat patients with T4 N2 disease with neoadjuvant chemotherapy and consider them for surgical resection later. We would also stress the point that patients with T4 N0–2 tumors should have rigorous screening for distant metastases (including position emission tomography and computed tomography, where available) to rule out M1 disease. Operating on patients with occult M1 disease would unfairly negate the positive results of surgical resection.

Because randomized controlled trials would be nearly impossible to conduct in this highly selected group of patients, continued reporting (as case series) of patients with T4 cancers treated surgically should be encouraged. Once a significant number of patients is reached, a systematic review might help to arrive at objective criteria for deciding when surgical resection is worthwhile. It could also confirm or refute the intuitive belief that patients with T4 categorization because of involvement of the carina or intrapericardial pulmonary vessels have better long-term survival than other patients with T4 disease.

References

  1. Osaki T., Sugio K., Hanagiri T., et al. Survival and prognostic factors of surgically resected T4 non-small cell lung cancer. Ann Thorac Surg 2003;75:1745-1751.[Abstract/Free Full Text]
  2. Roth J.A., Fossella F., Komaki R., et al. A randomized trial comparing perioperative chemotherapy and surgery with surgery alone in resectable stage III A non-small cell lung cancer. J Natl Cancer Inst 1994;86:673-680.[Abstract/Free Full Text]
  3. Rosell R., Gomez-Codina J., Camps C., et al. A randomized trial comparing preoperative chemotherapy and surgery with surgery alone in patients with non-small cell lung cancer. N Engl J Med 1994;330:153-158.[Abstract/Free Full Text]




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