J Thorac Cardiovasc Surg 2001;121:1225-1226
© 2001 The American Association for Thoracic Surgery
Reply
Kohei Yokoi, MD
Division of Thoracic Surgery
Tochigi Cancer Center
4-9-13 Yohnan, Utsunomiya
Tochigi 320-0834, Japan
Reply to the Editor:
I thank Riquet and Lang-Lazdunski for their comments on our article concerning surgical treatment of lung cancer involving the diaphragm.
1 Riquet and associates 2 also recently published an article concerning the same issue, and I recognize slight differences between results of these studies. That is, although we documented that N stage and the depth of diaphragmatic invasion influenced the outcome of patients with complete resection on the basis of a univariate analysis, 1 they reported that those two characteristics were not prognostic factors. 2
In both studies, 1,2 there were no statistically significant differences between patients with complete resection with respect to pN status (
2 test, P = .177). However, 41 of our 55 patients underwent complete mediastinal lymph node dissection, but the remaining 14 had no mediastinal node sampling. Among the 41 patients, 19 had N0 disease and 22 had N1-2 disease. Among the patients with complete mediastinal staging in both groups, we also found no differences in the incidences of nodal metastasis (2 test, P = .235).
The 5-year survivals for patients who had complete resection of diaphragmatic T3 N0 M0 tumors were 28.3% in our study (n = 26) 1 and 27% in Rocco's series (n = 11), 3 but no 5-year survivor was found in Weksler's report (n = 4). 4 Riquet and coworkers 2 reported that the 5-year survival was 39% in patients with complete mediastinal lymph node dissection (13 with T3 N0 M0 disease and 26 with T3 N1-2 M0 disease), although the detailed data were not available. From those results, I consider that the prognosis of some patients with radically resected T3 N0 M0 disease is not always pessimistic.
According to the suggestion by Riquet and Lang-Lazdunski, we herein show the depth of diaphragmatic involvement and the extent of combined resection in association with pathologic stage among 40 patients whose tumors were completely resected(Table I). There were no significant relations between those two factors and the pathologic stage (2 test, P = .884 and P = .602, respectively). Of the 11 tumors resected in combination with the diaphragm and other neighboring organs (chest wall in 7 patients, pericardium in 3, and parietal pleural in 1), 6 had shallow invasion of the diaphragm and the remaining 5 had deep invasion. In those 40 patients, the extent of combined resected organs significantly affected the prognosis; the 5-year survival of patients with combined resection of the diaphragm only was 34.2% (95% confidence intervals, 14.8%-53.7%), and no 5-year survivor was found among patients with excision of the diaphragm and other organs (log-rank test, P = .019). We further performed a multivariate analysis by the Cox proportional hazards model (Table II). The extent of combined resection was a nearly significant factor affecting survival adjusted for the depth of tumor invasion to the diaphragm.
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Table I. The depth of tumor invasion to the diaphragm and combined resected organs in each stage among patients who underwent complete resection (n = 40)
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As noted in the published articles, 1-4 the surgical results of lung cancer involving the diaphragm were worse than those of other T3 tumors. Consequently, I think a new treatment strategy is needed for all of the tumors, such as neoadjuvant and/or adjuvant therapy as proposed by Weksler, 4 Riquet, 2 and their colleagues.
12/8/114935doi:10.1067/mtc.2001.114935
References
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Yokoi K, Tsuchiya R, Mori T, Nagai K, Furukawa T, Fujimura S, et al. Results of surgical treatment of lung cancer involving the diaphragm. J Thorac Cardiovasc Surg 2000;120:799-805.[Abstract/Free Full Text]
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Riquet M, Porte H, Chapelier A, Brichon P-Y, Bernard A, Dujon A, et al. Resection of lung cancer invading the diaphragm. J Thorac Cardiovasc Surg 2000;120:417-8.[Free Full Text]
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Rocco G, Rendina EA, Meroni A, Venuta F, Pona CD, Giacomo TD, et al. Prognostic factors after surgical treatment of lung cancer invading the diaphragm. Ann Thorac Surg 1999;68:2065-8.[Abstract/Free Full Text]
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Weksler B, Bains M, Burt M, Downey R, Martini N, Rusch V, et al. Resection of lung cancer invading the diaphragm. J Thorac Cardiovasc Surg 1997;114:500-1.[Free Full Text]
