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J Thorac Cardiovasc Surg 2008;135:718-719
© 2008 The American Association for Thoracic Surgery
Letter to the Editor |
Toronto General Hospital, Division of the University Health Network, University of Toronto, Toronto, Ontario, Canada
Dr Van Schil's letter clearly enunciates the concern of many surgeons that the combination of chemotherapy and radiation for induction increases the risk of subsequent surgical intervention, whereas the use of induction chemotherapy alone does not. Although the report from Martin and colleagues,1
as well as the data from the Intergroup 0139 trial,2 support this concern, we believe this not to be the case. In our experience, as outlined in our report, the mortalities all occurred early in our experience with this protocol. There were no mortalities in the last 34 patients, including those undergoing pneumonectomy. In doing the chart audit, we noted that the mortalities in the patients undergoing pneumonectomy occurred in patients with large, bulky central tumors, in whom the hilar dissection could be anticipated to be difficult. In retrospect, we would now not consider such patients for resection. Based on our own experience, we do not think that induction chemoradiation results in excessive risk for resection if patients are selected appropriately. Furthermore, this is supported by the work of Sonett and colleagues,3 who used even higher doses of radiation without any operative mortality.
In selecting patients for trimodality therapy, we believe that both the primary and nodal disease must be technically resectable before induction. In particular, the nodes should not be fixed to the airway, nor should the proximal hilar vessels be obliterated by the nodal disease. The latter is determined based on the computed tomographic appearance, and the former is assessed at the time of mediastinoscopy. This speaks to the importance of mediastinoscopy in assessing the mediastinum, not just for the purpose of biopsy of the lymph nodes, which could be done by using endobronchial ultrasound, but also to assess resectability of the nodes.
Patients must be appropriately selected for surgical intervention based on their cardiopulmonary reserve, and it is worthwhile to repeat functional testing after induction to ensure that the induction regimen has not compromised the patient's cardiac or pulmonary function.
The timing of resection is important because beyond 6 to 8 weeks after completion of radiation, fibrosis becomes progressively more severe and increases the difficulty of the dissection.
In our experience the combination of chemotherapy and radiation leads to higher response rates, with significant downstaging beyond what one expects with induction chemotherapy alone. Furthermore, the R0 resection rate using combined therapy is also increased.
In our center induction chemoradiation remains the preferred induction regimen for select patients with N2 disease. We do not think that induction chemoradiotherapy prohibitively increases the risk of pneumonectomy, and in fact, it provides an opportunity for curative resection in selected patients with N2 disease.
References
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