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Ann Thorac Surg 2006;81:1218-1219
© 2006 The Society of Thoracic Surgeons

Original article: General thoracic

Invited commentary

Henning Gaissert, MD

Thoracic Surgical Unit, Massachusetts General Hospital, 55 Fruit St, Blake 1570, Boston, MA 02114

(Email: hgaissert{at}partners.org).


   Introduction
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 Introduction
Online Discussion Forum
 References
 
This article [1] describes chest wall lymphoma as a separate entity in 7 patients and shows long-term survival after surgical resection with postoperative chemotherapy in 3 of the 7. The fact that surgeons are the authors of this article should be no surprise. An account of site-specific characteristics in non-Hodgkin's lymphoma (NHL) seems less important when treatment is based mainly on cell type. What do we learn? A palpable mass was present in all patients, associated with pain or rib destruction in 3 patients each. Histology is described as diffuse B-cell in 5 patients and "malignant" in 2. Bone marrow biopsy was negative in all; 3 patients had disease in other sites.

Patients arrived at chest wall resection by serendipity, it seems. Fine needle aspiration of 6 tumors proved negative in 5, and excisional biopsy and complete resection was the next step for patients with solitary lesions. Biopsy short of excision was not attempted. Mean recurrence-free survival was 102 months, and no patient has had a recurrence thus far. The authors derive conceptual support for surgical debulking from a retrospective study of early-stage diffuse large cell lymphoma that demonstrated improved survival compared with the matched controls [2]. For a time, surgical resection had a similar role in limited gastric NHL until it was replaced by Helicobacter pylori eradication [3].

Can excisional biopsy and complete resection be recommended as a planned, standard approach? Core needle biopsy, an office procedure in a palpable mass, should not be bypassed. The differential diagnosis is just too extensive. Resection, for example, would be deferred in plasmacytoma, a tumor with similar radiographic features. Preoperative diagnosis of lymphoma would result in staging with bone marrow biopsy and further tests to exclude disease in multiple sites. The authors have raised our awareness for the option of resection in chest wall lymphoma. Excision of NHL may be justified in selected patients, but must be balanced with operative morbidity. A curative role of chest wall resection has not been demonstrated.


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Each month, we select an article from the The Annals of Thoracic Surgery for discussion within the Surgeon's Forum of the CTSNet Discussion Forum Section. The articles chosen rotate among the six dilemma topics covered under the Surgeon's Forum, which include: General Thoracic Surgery, Adult Cardiac Surgery, Pediatric Cardiac Surgery, Cardiac Transplantation, Lung Transplantation, and Aortic and Vascular Surgery.

Once the article selected for discussion is published in the online version of The Annals, we will post a notice on the CTSNet home page ( http://www.ctsnet.org ) with a FREE LINK to the full-text article. Readers wishing to comment can post their own commentary in the discussion forum for that article, which will be informally moderated by The Annals Internet Editor. We encourage all surgeons to participate in this interesting exchange and to avail themselves of the other valuable features of the CTSNet Discussion Forum and Web site.

For April, the article chosen for discussion under the Adult Cardiac Dilemma Section of the Discussion forum is:

Critical Evaluation of Chest Computed Tomography Scans for Blunt Descending Thoracic Aortic Injury

Brian A. Bruckner, MD, Daniel J. DiBardino, MD, Todd C. Cumbie, BS, Charles Trinh, MD, Shanda H. Blackmon, MD, Richard G. Fisher, MD, Kenneth L. Mattox, MD, and Mathew J. Wall, MD

Tom R. Karl, MD

The Annals Internet Editor

UCSF Children's Hospital

Pediatric Cardiac Surgical Unit

505 Parnassus Ave, Room S-549

San Francisco, CA 94143-0118

Phone: (415) 476-3501

Fax: (212) 202-3622

e-mail: mailto:karlt{at}surgery.ucsf.edu


   References
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 Introduction
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 References
 

  1. Hsu P-K, Hsu H-S, Li AF-Y, et al. Non-Hodgkin's lymphoma presenting as a large chest wall mass Ann Thorac Surg 2006;81:1214-1219.[Abstract/Free Full Text]
  2. Romagurea JE, Velasquez WS, Silvermintz KB, et al. Surgical debulking is associated with improved survival in stage I-II diffuse large cell lymphoma Cancer 1990;66:267-272.[Medline]
  3. Yoon SS, Coit DG, Portlock CS, Karpeh MS. The diminishing role of surgery in the treatment of gastric lymphoma Ann Surg 2004;240:28-37.[Medline]




This Article
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Henning Gaissert
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