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Ann Thorac Surg 2006;81:1180-1181
© 2006 The Society of Thoracic Surgeons

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Correspondence

Adjuvant Radiation With Modern Techniques is the Standard of Care for Stage III Thymoma

Department of Radiation Oncology, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, Box 1236, New York, NY 10029

(Email: jamie.cesaretti{at}msnyuhealth.org).

To the Editor:

I read with interest the article by Mangi and Colleagues [1]. The authors claim that adjuvant radiation is not needed for stage III thymoma based on the retrospective review of follow-up records of 45 patients treated between 1972 and 2004 at the Massachusetts General Hospital. Thirty-eight of the patients received radiation based on various criteria including clinical intuition. The comparison group consisted of 7 patients, 5 of whom were observed without adjuvant treatment for more than 12 months. I strongly believe that such a strong negative conclusion regarding efficacy of adjuvant radiotherapy is without merit when based on a very small observation group. In addition, the authors did not consider important quality factors that predict success of radiotherapy.

The irradiated patients were treated with a median dose of 4,550 cGy (range, 3,000 to 6,100 cGy). Of the 38 patients treated with radiation 14 (32%) recurred; of the 5 treated only with surgery and followed-up for more than 12 months, 2 (40%) recurred. Among patients treated with radiotherapy, 10 of 14 (71.4%) recurred in the pleura. Of patients who failed and were observed, 2 of 2 had pleural recurrences (100%).

An interesting article published in 2004 by Zhu and colleagues [2] evaluated disease and treatment-related factors of 175 patients with thymoma of which 41 had stage III disease. Multivariate analysis revealed that the Masaoka stage and radiation dose (50 Gy versus > 50 Gy) were the only factors that predicted survival. Finding a radiation-dose response relationship for survival at a dose level that is higher than the reported median dose of the treated patients in the Massachusetts General Hospital study calls into question the validity of the authors' conclusions. In addition, an article by the same first author in 2002 reported results of 14 patients treated with radiotherapy for stage II thymoma with an identical median radiation dose level of 4,550 cGy (range, 3,000 to 6,100 cGy) and an identical standard error of 188 cGy for the group [3]. The conclusion from the earlier study was that radiotherapy is unnecessary for stage II thymoma, which was based on failure in a single patient in the nonirradiated arm. The same median radiation dose, range, and standard error in two different clinical groups of patients treated at Massachusetts General Hospital with stage II and stage III thymomas is an unlikely statistical coincidence and implies that radiotherapy quality factors were not adequately addressed in either study.

In addition, the authors did not review modern radiation methods in their discussion. These changes will lead to a dramatic decrease in the morbidity of mediastinal radiotherapy [4, 5]. Intensity-modulated radiation therapy and helical tomographic therapy have improved the therapeutic ratio for anterior mediastinal tumors and are being used throughout the country to treat anterior mediastinal tumors.

Based on the data presented, I believe that the authors have failed to make the case that radiotherapy is an unnecessary component in the treatment of stage III thymomas. A central flaw of the article is that it has ignored important radiotherapy quality factors such as dose, field size, target volume, and technique. Also, the side effects of antiquated radiotherapy techniques are overstated and ignore the modern reality of precise radiation treatment planning.

	References

Top References

 

1. Mangi AA, Wain JC, Donahue DM, Grillo HC, Mathisen DJ, Wright CD. Adjuvant radiation of stage III thymomais it necessary?. Ann Thorac Surg 2005;79(6):1834-1839.[Abstract/Free Full Text]
2. Zhu G, He S, Fu X, Jiang G, Liu T. Radiotherapy and prognostic factors for thymomaa retrospective study of 175 patients. Int J Radiat Oncol Biol Phys 2004;60(4):1113-1119.[Medline]
3. Mangi AA, Wright CD, Allan JS, et al. Adjuvant radiation therapy for stage II thymoma Ann Thorac Surg (review) 2002;74(4):1033-1037.
4. Goodman KA, Toner S, Hunt M, Wu EJ, Yahalom J. Intensity-modulated radiotherapy for lymphoma involving the mediastinum Int J Radiat Oncol Biol Phys 2005;62(1):198-206.[Medline]
5. Welsh JS, Bradley K, Ruchala KJ, et al. Megavoltage computed tomography imaginga potential tool to guide and improve the delivery of thoracic radiation therapy. Clin Lung Cancer 2004;5(5):303-306.[Medline]

This article has been cited by other articles:

				S. Tomaszek, D. A. Wigle, S. Keshavjee, and S. Fischer Thymomas: Review of Current Clinical Practice. Ann. Thorac. Surg., June 1, 2009; 87(6): 1973 - 1980. [Abstract] [Full Text] [PDF]

				C. D. Wright Reply Ann. Thorac. Surg., March 1, 2006; 81(3): 1181 - 1182. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cesaretti, J. A. Search for Related Content PubMed PubMed Citation Articles by Cesaretti, J. A. Related Collections Mediastinum Related Article