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J Thorac Cardiovasc Surg 2008;135:718
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Mortality associated with pneumonectomy after induction chemoradiation versus chemotherapy alone in stage IIIA-N2 non–small cell lung cancer

Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Antwerp, Belgium

To the Editor:

I read with great interest the recent article of the Toronto group on improved results of induction chemoradiation followed by surgery for selected patients with stage IIIA-N2 non–small cell lung cancer.¹ Uy and colleagues¹ are to be congratulated for their detailed analysis and honest data reporting regarding this difficult subset of patients with N2 disease for whom the optimal treatment remains to be defined. As in the Intergroup-0139 trial,² Uy and colleagues¹ adopted an induction therapy of concurrent chemotherapy and radiotherapy, followed by surgical resection if there was no progressive disease on restaging. In 11 cases (27.5%), pneumonectomy was necessary. As previously observed in the INT-0139 trial, mortality in this setting was high: 27% overall, and even 50% for complex pneumonectomies. Causes of death were adult respiratory distress syndrome and postoperative hemorrhage. After induction therapy followed by pneumonectomy, higher incidences have been reported for empyema, bronchopleural fistula, and adult respiratory distress syndrome than are seen after standard resection without induction therapy.³

Uy and colleagues¹ referred to European Organization for Research and Treatment of Cancer trial 08941, results of which were recently reported.^3,4 In this multicenter trial, patients with histologically proven stage IIIA-N2 non–small cell lung cancer were treated with induction chemotherapy—without radiotherapy—and in case of response were subsequently randomly assigned to undergo either surgery or radiotherapy. Pneumonectomy was performed in 46.8% of patients; the 30-day mortality in this subgroup was 6.9%, which was much lower than those reported by Uy and colleagues¹ and in the INT-0139 trial.² Similar results as in the EORTC 08941 study were recently published by a group from Strasbourg; they reported a 30-day mortality of 6.7% in a series of 60 patients undergoing pneumonectomy after induction chemotherapy.⁵

Although Uy and colleagues¹ did not specifically comment on this issue, the type of induction therapy—chemotherapy versus combined chemoradiotherapy—may be important in explaining this mortality difference. Unfortunately, there are no randomized studies directly comparing induction chemotherapy with chemoradiotherapy with respect to outcome after surgical resection for locally advanced non–small cell lung cancer.

Although a pneumonectomy can be safely performed after induction chemotherapy, it remains a high-risk procedure after induction chemoradiotherapy, especially when a complex procedure has to be performed on the right side. Coverage of the bronchial stump with viable tissue is essential to prevent the dreadful complication of bronchial stump dehiscence.

Footnotes

Dr Van Schil reports lecture fees from Pierre Fabre Oncology (Laboratoires Pierre Fabre, Castres, France).

References

1. Uy KL, Darling G, Xu W, Yi QL, De Perrot M, Pierre AF, et al. Improved results of induction chemoradiation before surgical intervention for selected patients with stage IIIA-N2 non–small cell lung cancer. J Thorac Cardiovasc Surg 2007;134:188-193.[Abstract/Free Full Text]
   
2. Albain KS, Swann RS, Rusch VR, Turrisi AT, Shepherd FA, Smith CJ, et al. Phase III study of concurrent chemotherapy and radiotherapy (CT/RT) versus CT/RT followed by surgical resection for stage IIIA-N2 non–small cell lung cancer: outcomes update of North American Intergroup 0139 (RTOG 9309). [abstract 7014] J Clin Oncol 2005;23(16 suppl):624s.
   
3. Van Schil P, Van Meerbeeck JP, Kramer G, Splinter T, Legrand C, Giaccone G, et al. Morbidity and mortality in the surgery arm of EORTC 08941 trial. Eur Respir J 2005;26:192-197.[Abstract/Free Full Text]
   
4. Van Meerbeeck J, Kramer G, Van Schil P, Legrand C, Smit E, Schramel F, et al. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non–small-cell lung cancer. J Natl Cancer Inst 2007;99:442-450.[Abstract/Free Full Text]
   
5. Mansour Z, Kochetkova EA, Ducrocq X, Vasilescu, MD, Maxant G, Buggenhout A, et al. Induction chemotherapy does not increase the operative risk of pneumonectomy. Eur J Cardiothorac Surg 2007;31:181-185.[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Paul E. Van Schil Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Van Schil, P. E. Search for Related Content PubMed Articles by Van Schil, P. E. Related Collections Lung - cancer