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J Thorac Cardiovasc Surg 2003;126:1664-1665
© 2003 The American Association for Thoracic Surgery
Letters to the editor |
a Division of General Thoracic Surgery, Catholic University, Rome, Italy
To the Editor:
We read with great interest the report from Marra and colleagues1 recently published in the Journal, and we warmly congratulate them on their excellent, accurate, and exhaustive analysis and report. They have confirmed that within the pathologic N1 (pN1) group of tumors involvement at the intralobar level is substantially better prognostically than that at the hilar level (as well as single versus multiple nodes or stations).
Because this strongly and comprehensively supports the idea that it is correct to stratify (classify) the pN1 cases according to the level (intralobar best, hilar worst) in addition to the number of involved lymph nodes (one better, more than one worse) we amicably invite Marra and colleagues to clarify their position regarding the possible use of such important information, especially regarding the opportunities to actually "stratify for optimization" in terms of adjuvant and neoadjuvant treatment. In fact, the discussion of their experience is mainly focused on the evaluation of such evidence in comparison to others' similar work. Regarding adjuvant treatment, we have developed a timely consolidated experience in the adoption of postoperative radiotherapy in completely resected non–small cell lung cancers, even in the early stage.2,3 Moreover we have directly discussed the Post Operative Radiotherapy Trialists Group conclusions4 and strongly support the evidence that modern radiotherapy, accurately planned and administered, can give good results with acceptable side effects in this class of tumors.
From the report of Marra and colleagues,1 we have taken the idea that because for the best prognostic class pN1 cases any therapeutic effort aimed at the local control could have significance, modern radiotherapy could certainly find its place, especially at the investigational level. For the worst prognostic class pN1 cases, we agree with Marra and colleagues1 that an attempt at systemic (rather than local) control is justified. In the setting of neoadjuvant treatment, we see the point of view of the Marra and colleagues1 when they note that it is "promising." The core fact in managing patients with N1 disease in the clinical setting is that it is truly difficult to obtain a substantially correct diagnosis of true clinical N1 status. In their very reported experience, in fact, Marra and colleagues1 noted a limited (24.5%) pathologic confirmation rate of clinical N1 assessment. Moreover, when a suspicion of N1 involvement is present at the clinical staging, this is rarely histologically or cytologically assessable; thus an induction treatment planned on the basis of the clinical N1 status alone may still be considered hazardous. In fact, the best that is currently done in the ongoing phase III induction trials for early stage non–small cell lung cancers is to exclude, when N1 status is suspected, the involvement of N2 stations by cervical mediastinoscopy, leaving substantially uncovered the erroneously clinically upstaged to N1 cases (true N0s). We would be very grateful if Marra and colleagues could disclose and describe their point of view regarding these issues.
References
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