Ann Thorac Surg 2002;73:1539-1540
© 2002 The Society of Thoracic Surgeons
Invited commentary
David M. Shahian, MDa
a Department of Thoracic and Cardiovascular Surgery, Lahey Clinic, 41 Mall Rd, Burlington, MA 01805, USA
e-mail: david.m.shahian{at}lahey.org
This is an interesting and well-documented report of 139 patients who were operated on for superior sulcus tumors in seven French thoracic surgery centers. However, several aspects of the management of these patients merit brief mention because they depart from typical modern practice.
The standard approach to superior sulcus tumors consists of staging to exclude distant disease and mediastinal lymph node involvement, then preoperative radiation therapy, followed by complete surgical resection. This often requires chest wall or vertebral resection, and extensive vertebral body reconstruction and stabilization may be done in conjunction with neurosurgeons or orthopedists. Occasionally, subadventitial dissection of tumor from the subclavian artery or even graft replacement may be required, and this may be facilitated by the anterior approaches introduced by Dartevelle and others. Many groups have added postoperative radiation or chemotherapy for incomplete resection or close margins, although the value of this therapy remains problematic. Five-year survival rates have ranged between 25% to 50% in most series.
Although overall survival in the French study is within the expected range, several features of their management are nontraditional. For example, mediastinoscopy was performed only "when indicated," presumably when the CT or MRI demonstrated lymphadenopathy, a practice that may have contributed to the 13.6% incidence of N2 and N3 nodal disease in their surgical patients. Most groups advocate routine mediastinoscopy in superior sulcus tumor patients because of the dismal prognosis associated with positive mediastinal nodes, although this screening algorithm may change with more widespread use of PET imaging. Most surprisingly, 70.5% of patients in this series received no preoperative therapy, only 17.3% received preoperative radiation therapy, and 8.6% received radiation and chemotherapy. Conversely, 45% of patients received postoperative radiation therapy and an additional 24.8% received postoperative chemotherapy and radiation. Not unexpectedly, the results of the French series confirm a highly significant survival advantage for preoperative radiation therapy and no benefit to postoperative radiation.
There are promising new developments in the management of superior sulcus tumors that are only briefly mentioned in the article by Martinod and associates, the most exciting of which is the use of induction chemoradiation therapy. Rusch and colleagues from the Southwest Oncology Group have recently reported a high rate of resectability after such induction therapy and a 70% 2-year survival for patients who had complete resection. The incidence of locoregional recurrence appears to have dramatically decreased and distant metastatic lesions, especially to the brain, have become the most common sites of recurrence. This has created a potential role for prophylactic cranial irradiation. Extrapolating from the favorable results in other lung cancers, the Southwest Oncology Group investigators have also considered induction chemoradiation for superior sulcus tumors with mediastinal lymph node involvement, a group of patients previously considered hopeless.
Related Article
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Management of superior sulcus tumors: experience with 139 cases treated by surgical resection
- Emmanuel Martinod, Alexandre D’Audiffret, Pascal Thomas, Alain J. Wurtz, Marcel Dahan, Marc Riquet, Antoine Dujon, René Jancovici, Roger Giudicelli, Pierre Fuentes, and Jacques F. Azorin
Ann. Thorac. Surg. 2002 73: 1534-1539.
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