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Ann Thorac Surg 2004;78:2207
© 2004 The Society of Thoracic Surgeons
Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, 7979 Wurzbach Rd, San Antonio, TX 78229, USA 78229
cthomas{at}ctrc.net
To the Editor:
Congratulations to Singhal and colleagues [1] for reporting the important University of Pennsylvania experience regarding the question of adjuvant radiotherapy after resection of Masaoka stages I and II thymomas. Their results along with prior observations [2, 3] and the accompanying discussion by Dr Wright of the Massachusetts General Hospital thoracic surgery group, clearly call for a prospective study of both early-stage and locally advanced thymic neoplasms. The lack of prospectively validated consensus recommendations on the optimal approach for thymomas is suboptimal for our patients [4]. However, the last paragraph of their report states that a prospective trial may not be doable for stage II patients "given the small number of patients involved and the long-term follow-up that would be required" to show any difference. This assumption may not be absolute.
Our multidisciplinary pediatric oncology colleagues have been very successful in prospectively studying rare solid tumors such as rhabdomyosarcoma, Wilms' tumor, and neuroblastoma. More recently, the thoracic surgery community, building on the prior hypothesis-generating work of select multidisciplinary academic thoracic oncology programs [2], successfully led the development, completion, and analysis of the first prospective multiinstitutional protocol for superior sulcus (Pancoast) tumors [5, 6]. This phase-II intergroup and surgeon-led study basically established a new standard of care on which to build future studies. More importantly, it has shown that an uncommon subset of non–small cell lung cancer can be prospectively studied within a North American cooperative group mechanism.
As both a medical and radiation oncologist with a commitment to thoracic oncology, I can appreciate the challenge that the article by Singhal and co-workers and its accompanying discussion broach. It is likely that a concerted effort will be put forth by the thoracic surgery–led Thoracic Committee of the American College of Surgeons Oncology Group, to prospectively study early-stage as well as locally advanced thymic neoplasms in parallel phase-II studies. Such studies would need to have the following features: uniform pretreatment imaging; written guidelines regarding surgical approach (including processing and orientation of the en bloc specimen for the pathologist after resection as well as mandatory guidelines on describing the extent of tumor adherence to surrounding structures [ie, phrenic nerve] in the dictated operative report); central review by a dedicated pathologist well versed in mediastinal tumor specimen analysis; tissue banking for future translational research studies (ie, gene microarray chip analysis); and, if radiotherapy is included in the schema of any prospective study; formal radiotherapy guidelines that include mandatory three-dimensional conformal techniques. Furthermore, such a study may present an opportunity to validate at least one of the staging systems that populate the literature on these tumors [4, 7].
The American College of Surgeons Oncology Group appears to be the forum that currently is poised to conduct phase II studies. Pending agreement from our European and Asian thoracic surgery colleagues, possibly a phase-III trial end point can be addressed. Until the multidisciplinary thoracic oncology community, albeit led by forceful academic surgeons, as suggested by Dr Wright, moves forward, clinicians will be left only with hypothesis-generating retrospective data from select high-powered institutions [1, 3, 7–10]. The present currency regarding lack of prospective modern clinical trial data for thymic neoplasms can be addressed. In this regard, we need only consider the recent experience with superior sulcus (Pancoast) tumors and the long-standing historical approach to pediatric tumors. How refreshing it is for today's thoracic oncologists when seeing a patient with a Pancoast tumor to no longer have to quote the data from Shaw and Paulson from nearly a half a century ago [11]!
References
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