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Ann Thorac Surg 2000;69:343-344
© 2000 The Society of Thoracic Surgeons
Discussion
DR KENNETH A. KESLER (Indianapolis, IN): During the past 16 years, at Indiana University, we have treated 91 patients, the vast majority of whom received cisplatinum and VP16 chemotherapy regimens. This has been established as standard chemotherapy for germ cell cancers by Dr Lawrence Einhorn at our institution, and utilized as primary chemotherapy at most cancer centers worldwide.Seventy-nine of these patients ultimately presented for operation. Just under 60% are alive at 5 years, and approximately 50% are still surviving after 10 years of follow-up. Doctor Walsh and his colleagues report 10 patients that have had complete 2-year follow-up after undergoing operations, 8 of which are still alive, which represents 80% survival, as compared to approximately 70% in our series. This difference seems even more impressive given the fact that Dr Walsh and his colleagues report a very high percentage of patients with extra mediastinal disease, as well as patients that have undergone salvage chemotherapy. Given the low numbers of patients in their series and relatively brief follow-up, however, one wonders if this difference is really significant, particularly since these patients are known to be at constant risk for death secondary to late relapses as well as hematologic malignancies.
In our series, it was not surprising to find the patients that demonstrate tumor necrosis only or benign teratoma in their pathologic specimen, had excellent and good long-term survival, respectively, as compared to patients with pathology demonstrating persistent cancer or degeneration into carcinomatous or sarcomatous elements. Doctor Walsh and his colleagues, found that of the 11 patients that underwent operation, 7 had either necrosis or teratoma, which is 63% of their cases, as compared to 59% in ours, which again appears somewhat improved, but may not have reached statistical significance.
We certainly agree that good surgical procedure, performed by skilled thoracic surgeons, for this disease is important, but good chemotherapy, which converts this disease into more benign forms, is arguably even more important. I do not personally feel qualified to argue differences in chemotherapy regimens, however, I would like to point out that their intensive regimen resulted in 2 chemotherapy-related deaths, which was 10% of their series. One at least wishes that conversion to a benign pathology could be done easier and with less toxicity.
At Indiana University, we strongly encourage patients presenting with this disease to undergo randomization to the phase III intergroup trial, randomizing either to the standard-of-care arm, BEP chemotherapy versus the experimental arm involving high-dose carboplatin, VP16, and cyclophosphamide followed by autologous stem cell rescue.
We agree that operation following chemotherapy is technically difficult, however, we would like to know from the authors, that in cases where more benign pathology such as necrosis or teratoma are anticipated, if attempts to be more surgically conservative are made, particularly to avoid phrenic nerve and/or large anatomic pulmonary resections?
We congratulate Dr Walsh and his colleagues on excellent results in a very high-risk group of patients, and look forward to further follow-up in their series as well as information on further patients that may undergo this regimen at their institution.
DR LAURENS R. PICKARD (Houston, TX): I also congratulate Dr Walsh on very impressive work and a very nice presentation. I just have a question. From your experiences, do you have any recommendations on establishing initial diagnosis and type of biopsy? Do you have any observations that you could make and recommendations for us in that area?
Thank you.
DR DOUGLAS E. WOOD (Seattle, WA): I enjoyed that paper very much, Dr Walsh. We are often under pressure as thoracic surgeons, from our oncologists to consider salvage operation, when there has not been normalization of tumor markers, and you had just one instance of that in your series. That occasionally occurs with metastatic germ cell tumors as well.
Do you have experience in that regard and recommendations to us on whether or not there is any role for operation in the absence of normalization of tumor markers, in either primary mediastinal nonseminomatous germ cell tumors, or metastatic tumors to the lung?
DR JOHN C. CHEN (Orange, CA): My question is more of a practical question, Dr Walsh, in your series did you operate on all patients who underwent chemotherapy, that is, responders as well as nonresponders, because that would certainly influence your outcome?
DR WALSH: I would like to thank all of the discussants for their excellent questions, and especially acknowledge the pioneering chemotherapy and surgical treatment of these complex malignancies by Ken Kesler and his colleagues from Indiana University. Let me take each of the questions in order.
Doctor Kesler, regarding a more conservative surgical philosophy if a benign histology is anticipated, despite normalization of tumor markers with induction chemotherapy, malignant elements can persist in the remaining tumor that requires resection. For this reason, we perform radical en bloc resections of these lesions, even if it requires resection of the superior vena cava, innominate vein, lung or unilateral phrenic nerves. If, however, a phrenic nerve or vascular structure is merely displaced by the tumor rather than invaded, I will spare the structure provided a technical complete resection is possible without breaching the capsule of the tumor.
Doctor Pickard, regarding modalities for making the initial diagnosis, we are very fortunate to have skilled cytopathologists who were able to make the diagnosis in 9 of 20 patients with fine needle aspirations or core needle biopsies alone. Biopsies in the operating room by minimal access procedures (mediastinoscopy, Chamberlain, or video-assisted thoracic surgery) were required in the remaining patients. Serum markers should be routine for any young man presenting with a mediastinal mass. I feel strongly that no patient with an undiagnosed mediastinal mass should require a major thoracotomy for diagnosis and any attempt to initially debulk these lesions is absolutely contraindicated, and will significantly compromise the future surgical attempts to cure the patient.
Doctor Wood, as far as my views of salvage therapy, this is an area of ongoing research at our institution, as we are developing a prospective protocol to examine the role for operation in the patient subsets that you describe. Only 1 patient in this series (in our salvage chemotherapy group) was operated upon with persistent elevated markers. Although a resection of all gross disease was accomplished, the patient rapidly recurred within months after operation. My experience resecting metastatic pulmonary metastases in patients with testicular primaries and persistent elevated markers has not convinced me that there is much of a role for operation in these patients. I am willing, however, to continue to attempt to resect these patients under the setting of an investigational protocol so we can eventually answer your important question scientifically.
Doctor Chen, we operated upon all patients who normalized their markers and had residual mediastinal masses on their repeat computed tomographic scans. Only 1 patient, as I described to Dr Wood, had a resection with persistent elevated markers. Two patients had complete disappearance of their mediastinal primaries after chemotherapy, and did not undergo chest operation. One of these 2 patients required a craniotomy, however, for a persistent brain metastasis. Both of these patients remain free of disease in follow-up.
Related Article
Ann. Thorac. Surg. 2000 69: 337-343.
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