Ann Thorac Surg 2007;84:1723. doi:10.1016/j.athoracsur.2007.07.051
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited commentary
Norman Snow, MD
Department of Cardiothoracic Surgery, University of Illinois, Chicago, 849 S Wood St, Suite 417 (M/C 958), Chicago, IL 60612-7322
(Email: nsnow{at}uic.edu).
This article [1] illustrates two important principles of the peer review system used by serious, reputable surgical journals as well as others.
The first is that the observations and caveats of the editorial advisors often prompt a serious reappraisal and revision of the wording, and therefore the intended message of the article. This series of 4 patients is useful for stimulating our approach to this rare disease, but we must be cautious that a few cases may be lacking sufficient data so as not to render expansive conclusions inappropriately. Changing operative approaches from "esophageal sparing wide local excision" to esophagectomy make it difficult to settle on the proper approach. Difficulty with enucleation suggests that it was attempted as a first step, despite eventual need for a more extensive resection. Two of four patients experienced recurrence. Was it the disease or the surgical technique? It is just not possible to tell for certain.
Points of value include an emphasis on preoperative diagnosis prior to therapy, now that fine needle aspiration and endoscopic ultrasound is available and should not compromise eventual excision. Esophagectomy where possible seems the preferred operative approach, although the suggestion of the authors for local excision of small tumors is not substantiated from any dataset. The use of positron emission tomographic technology is a useful addition to patient staging and follow ups. It may well be that neoadjuvant therapy will be helpful, but data are presently lacking for verification. Comments from the cancer societies must be scrutinized to insure that the anatomy and physiology are accounted for with esophageal gastrointestinal stromal tumors (GIST) as opposed to intestinal GIST tumors.
The only collected information indicates that survival is poor and that surgery offers the best chance for improved outcomes. The conjecture regarding this type of surgery, the use (or lack) of Imatinib (Novartis) and the location of the surgery are not conclusively demonstrated by the present data. This is not to say that this article does not help us further understand esophageal GIST tumors, but simply put there is a great deal that is still unknown. Certainly, cooperative locoregional or national data sharing would be a great benefit in this regard and should be encouraged.
In addition, the editorial review process has allowed the authors to search farther in the field and offer a broader perspective through the existing databases available to them. The revised article gives us a much clearer picture of what others have learned and how esophageal GIST tumors have been presented and treated, along with some crude outcome information. By presenting this additional information, mined from current literature more extensively cultivated, this article carries much greater significance than the original manuscript, despite its examination of a tumor rarely seen in the general practice of thoracic surgery; for this we are indebted to the authors.
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References
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- Blum MG, Bilimoria KY, Wayne JD, de Hoyos AL, Talamonti MS, Adley B. Surgical considerations for the management and resection of esophageal gastrointestinal stromal tumors Ann Thorac Surg 2007;84:1717-1723.[Abstract/Free Full Text]
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