J Thorac Cardiovasc Surg 2004;128:331
© 2004 The American Association for Thoracic Surgery
Value of intraoperative pleural lavage in staging nonsmall cell lung cancer
Peter Goldstraw, FRCSa,
Eric Lim, MRCSa
a Department of Thoracic Surgery, Royal Brompton Hospital, London, United Kingdom
To the editor:
We are pleased that our article1 warranted an editorial and grateful to dr d'amico for his thoughtful comments. Unfortunately, there is a typographic error in the second paragraph stating that "only 5 of the 292 patients had pathologic stage I or II disease." of course the denominator should be 13. Dr D'amico mentions that our follow-up was incomplete, but in fact we accounted for all the patients in our study.
We accept the fact that the pleural lavage cytology results were positive in only 4.5% of our cases. However, this does not render the technique of no value. Other investigators have found a higher incidence of positive pleural lavage (up to 38% in one study).2 We believe that the value of a prognostic indicator should be based more on the discriminating ability of survival than on the frequency alone. In our study, positive lavage status was a more powerful predictor than tnm stage.
Central to our study was a desire to contribute to the discussion on the prognostic impact of positive pleural lavage cytology in patients who did not have a malignant pleural effusion. All patients with any macroscopic effusion were excluded from the study. The Japan Lung Cancer Society in its first English version3 states that "a positive cytologic examination of intrathoracic washings cannot be classified as T4" without further comment on the appropriate classification for this finding. The International Union Against Cancer in its TNM Supplement (a commentary on uniform use)4 states, when considering peritoneal lavage cytology, that "newer data suggest that the worsening of prognosis as indicated by positive lavage cytology may have been overestimated" and recommends that the addition of "cy +ve" to the T4 category and R1 classification be applied in these circumstances.
We hope that our data will inform the debate for future revisions of the TNM staging system.
- Lim E, Ali A, Theodorou P, Nicholson AG, Ladas G, Goldstraw P. Intraoperative pleural lavage cytology is an independent prognostic indicator for staging non-small cell lung cancer. J Thorac Cardiovasc Surg. 2004;127:11131118[Abstract/Free Full Text]
- Buhr J, Berghauser KH, Gonner S, Kelm C, Burkhardt EA, Padberg WM. The prognostic significance of tumor cell detection in intraoperative pleural lavage and lung tissue cultures for patients with lung cancer. J Thorac Cardiovasc Surg. 1997;113:683690[Abstract/Free Full Text]
- Classification of lung cancer: First English edition. Part III: Surgical findings. Kato H, editor. The Japan Lung Cancer Society. Tokyo: Kanehara and Co, 2000. p. 42
- TNM supplement: A commentary on uniform use. Wittekind CH, Henson DE, Hutter RVP, Sobin LH, editors. 2nd ed. UICC International Union Against Cancer. New York: John Wiley; 2001. p. 8