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Correspondence

Is Primary Resection of Stage IIIA Lung Cancer Futile?

Department of Thoracic Surgery, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91010

(Email: fgrannis{at}coh.org).

To the Editor:

Riquet and colleagues [1] report their experience in the primary surgical treatment of 586 patients with N2, stage IIIA, non-small cell lung cancer (NSCLC). Cases include both cN0 with pN2 metastasis after mediastinal node dissection, as well as patients with clinical (cN2) disease, and "bulky" cN2 disease, defined as nodes larger than 2 cm. Their patients had relatively high survival of greater than 30% at 5 years with single station N2 and 20% in patients with "bulky" disease, without preoperative mediastinoscopy, preoperative chemotherapy, or chemoradiation therapy.

But isn't this thoracic surgical heresy?

A Google search on "futile thoracotomy" or "thoracotomies" and "N2" returns literally hundreds of manuscripts from oncologist and thoracic surgeon "thought leaders" stating that primary surgical resection of N2 disease is "futile." Both the National Comprehensive Cancer Network and the American College of Chest Physicians (ACCP) NSCLC guidelines recommend liberal use of mediastinoscopy and against primary surgical resection of stage IIIA patients [2–4]. In fact, the ACCP strongly recommends against resection of N2 disease after preoperative chemotherapy. The data of Riquet and colleagues, however, appear to convincingly refute the concept that primary N2 resection is futile.

Personal experience of more than 20 years convinces me that accurate selection of patients for primary resection based on computed tomography and positron emission tomography findings is feasible. In our series, primary resection, including complete and systematic mediastinal node dissection, proved possible in 85% of such patients with cN2 disease [5]. Typically, N2 disease in such cases neither invades paratracheal fascia nor mediastinal organs. Clean en bloc resection of right and left nodal stations 7, 4, 3, and low 2 nodes can usually be accomplished without difficulty at the time of right-sided pulmonary resection. Selected patients with cN0-pN2 and cN2 disease experience long-term survival after such resection. We routinely recommend postoperative adjuvant radiation therapy and, more recently, chemotherapy.

In contradistinction, clean en bloc dissection is typically no longer possible with prior mediastinoscopy, followed by chemotherapy or chemoradiation therapy. Planes of surgical dissection are obliterated, resection of paratracheal nodes is technically difficult, and in some cases, residual cancer cannot be ablated.

Riquet and colleagues' experience suggests questions to be addressed in future research.

First, is it possible that mediastinoscopy might be unnecessary and perhaps harmful in the treatment of NSCLC patients with resectable N2 disease? Mediastinoscopy appears to violate the surgical oncology maxim to avoid tumor contamination by disrupting planes of surgical dissection and potentially spilling tumor cells throughout the mediastinum [6, 7]. Thereafter, because complete resection is compromised, cure is not possible unless adjuvant therapy eradicates residual mediastinal cancer.

Second, a high percentage of patients with bulky N2 required pneumonectomy. Can the authors predict which N2 patients require pneumonectomy? A trial to determine whether preoperative chemotherapy or chemoradiation can shrink tumor sufficient to allow lesser resection than pneumonectomy would be informative.

One final conclusion is inescapable. Primary surgical resection of carefully selected cases of N2 NSCLC is not futile. and "thought leaders" must stop saying that it is.

	References

Top References

 

1. Riquet M, Bagan P, Le Pimpec Barthes F, et al. Completely resected non-small cell lung cancer: reconsidering prognostic value and significance of N2 metastases Ann Thorac Surg 2007;84:1818-1824.[Abstract/Free Full Text]
2. Ettinger DS, Bepler G, Bueno R, et al. Non-small cell lung cancer: clinical practice guidelines in oncology J Natl Compr Canc Netw 2006;4:548-582.[Medline]
3. American College of Chest PhysiciansDetterbeck FC, Jantz MA, Wallace M, Vansteenkiste J, Silvestri GA. Invasive mediastinal staging of lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition) Chest 2007;132(3 suppl):202S-220S.[Medline]
4. American College of Chest PhysiciansRobinson LA, Ruckdeschel JC, Wagner Jr H, Stevens CW. Treatment of non-small cell lung cancer-stage IIIA: ACCP evidence-based clinical practice guidelines (2nd edition) Chest 2007;132(3 suppl):243S-265S.[Medline]
5. Michaelson R, Shaughnessey E, Wagman LD, Grannis Jr FW. Lung cancer unresectable during thoracotomy: reappraisal of an old problem Am Surg 1999;65:1023-1026.[Medline]
6. Fortner JG. Inadvertent spread of cancer at surgery J Surg Oncol 1993;53:191-196.[Medline]
7. Aboulafia AJ, Malawer MM. Surgical management of pelvic and extremity osteosarcoma Cancer 1993;71(10 suppl):3358-3366.[Medline]

This article has been cited by other articles:

				F. W. Grannis Jr Minimal Survival After Chemoradiation Therapy for "Non-Bulky" Stage IIIA NSCLC: What Are the Implications? Ann. Thorac. Surg., April 1, 2009; 87(4): 1320 - 1320. [Full Text] [PDF]

				R. J. Cerfolio Reply Ann. Thorac. Surg., April 1, 2009; 87(4): 1320 - 1321. [Full Text] [PDF]

				M. Riquet, P. Bagan, and E. Banu Reply Ann. Thorac. Surg., July 1, 2008; 86(1): 354 - 354. [Full Text] [PDF]

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