Affiliations: Lutheran General Hospital, Park Ridge, IL ,
University of California
I read with some concern the article by Tovar in a recent issue
of CHEST (November 1998).1 The author has
demonstrated that a minimally invasive approach to pneumonectomy is
feasible, but is it appropriate to advocate this approach for the
definitive treatment of lung cancer? I submit that the answer is no—at
least, not yet.
It would be important to know what percentage of all patients he
treated for lung cancer required pneumonectomy and, of those patients,
what proportion were candidates for this approach. In addition, what
selection criteria did he use in determining who required a
pneumonectomy and who was a candidate for the minimally invasive
approach? Three tumors were staged as T2, but the basis for this
designation (eg, size > 3 cm, or of smaller size but with
visceral pleural invasion) was not elucidated.
How were the patients staged before pneumonectomy? If surgical
staging occurred, did any patients receive induction therapy for N2
disease before pneumonectomy? Tovar states that each patient had a
mediastinal lymphadenectomy at the same time as the pneumonectomy. How
many lymph node stations were analyzed for each patient? What was the
extent of disease in each of the lymph node stations? How does this
compare with published results following traditional thoracotomy with
Tovar states that the surgeon’s office communicated with the patient
daily. How were patients followed for perioperative complications, such
as atrial fibrillation and deep venous thrombosis? Were visiting nurses
utilized? What analgesia was used and for how long was it required?
Tovar states that a 6- to 8-cm incision decreases the possibility of
chest wall implantation of tumor, yet provides us with no long-term
evidence to confirm this statement. I suspect that chest wall
implantation with tumor would be likely (Tovar’s Fig 2) as long as the
specimen is removed from the chest cavity without enclosing it in a
protective plastic bag, as is now done when a video-assisted thoracic
surgery approach is used.
I was disappointed that no mortality data (30 day, 1 or 2 year) were
reported in his series of five patients, three of whom had stage IIIa
non-small cell lung cancer.
This approach has not been proven in a randomized controlled
trial to be a cancer operation equivalent to traditional thoracotomy. I
would strongly caution the public and the medical profession against
seeking out minimally invasive surgery for the definitive treatment of
lung cancer at this time. A 4- to 5-day hospital stay with a curative
resection should appeal more to an individual with lung cancer than a
1-day stay following an unproven minimally invasive procedure given the
knowledge that recurrent or persistent disease is rarely cured by
remedial surgery or adjuvant therapy. While thoracic surgeons
everywhere continue to try to decrease the pain associated with
thoracotomy and the length of stay following the procedure by utilizing
smaller incisions, thoracic epidural analgesia, clinical pathways, and
careful assessment of the impact that these changes have on the quality
of the surgical procedure is mandatory.
Correspondence to: Jemi Olak, MD, FCCP, Lutheran General
Hospital, 1700 Luther Lane, Park Ridge, IL 60068; e-mail:
“Surgery is not a province with fixed
O. H. Wagensteen
I thank Dr. Olak for her interest and comments regarding my
recently published article (November 1998).1-1 Access to the
chest cavity through the standard posterolateral thoracotomy consists
of a large incision in which major thoracic muscles are divided, a rib
resected, and one or two other ribs transected to improve visibility.
The technique of opening the thorax and performing a pneumonectomy was
a fairly straightforward exercise in applied anatomy, perfected by the
end of the 19th century when less than 200 cases of lung cancer had
been reported.1-2 This approach, by itself, has significant
complications.1-3 In fact, patients who undergo exploration
without parenchymal resection do not escape severe complications
following an open-and-close procedure (Fig 1).
Olak refers to the traditional thoracotomy as a “cancer operation”
as though a paramedian incision to perform a radical gastrectomy is
less of a cancer operation compared to one performed through a midline
incision. There is no scientific evidence, to my knowledge, that a
larger incision in itself produces more curative resections than a
smaller one. The quality of the resection depends on the intracavitary
technique used to resect the cancerous tissue and not the approach to
access the chest cavity. It is therefore possible to perform an
oncologically sound resection while minimizing collateral damage.
Like most surgeons trained before the advent of laparoscopic
cholecystectomy, I was taught the standard posterolateral thoracotomy
approach as the method of choice to access the chest cavity. The now
anachronic adage, “big surgeons make big incisions,” was
omnipresent in operating suites throughout the country. To decrease
morbidity and discomfort to patients in my practice, I made a gradual
transition to the oblique muscle-sparing minithoracotomy. Initially, I
stopped removing and transecting ribs, then I spared a muscle, and then
I adopted the muscle-sparing approach. Throughout this process, I
developed new skills that allowed me to perform exactly the same
operation that I would have with a wide open thorax.
Olak would like to know what percentage of my patients were candidates
for this approach and what criteria I used in determining who required
pneumonectomy, as though the criteria should change. Since April 1993,
without exception, every patient I have operated on for lung cancer has
received an oblique muscle-sparing minithoracotomy.1-4 The
criterion for lobectomy, bilobectomy, and pneumonectomy has never
changed and the type of access has nothing to do with it. The criterion
is universal and consists of the removal of the least amount of lung
parenchyma necessary to completely clear all malignant tissue and
lymphatic spread. There is no justification to jeopardize the quality
of the resection in the name of a small incision. If the appropriate
skill has not yet been developed, a more redundant approach should be
used. As stated by Morgenstern,1-5 competence is at the
heart of professional ethics and it is always challenged by new
There are two kinds of intracavitary techniques for major lung
resections: mass ligation vs individual ligation of hilar structures.
The former was virtually abandoned in the early 1940s in favor of the
latter. A stapling technique has emerged as a modern version of mass
ligation in thoracoscopic procedures. The value of mediastinal
lymphadenectomy vs nodal sampling remains controversial. I practice the
isolation-ligation of the three hilar elements and find mass ligation
to be an aberration. I also believe that systematic mediastinal
lymphadenectomy is a sounder cancer operation.
Through a minithoracotomy, the specimen can be removed as easily as
with a larger thoracotomy; that is shown in Figure 2 of the
article.1-1 A nonrib-spreading thoracoscopic resection may
lead to deposition of viable clumps of malignant cells during the
extraction of the specimen1-6 and, therefore, a plastic bag
in these cases seems appropriate.
The clinical pathway given in the article is implemented to prevent
complications. If patients are active immediately after surgery, the
possibility of deep vein thrombosis and many other common complications
is nonexistent. Some of our patients did not require any analgesia,
despite early activity, and others required only oral pain medication.
There were no deaths at 30 days, one death at 8 months due to distant
recurrence, and one patient with metastatic disease from the appendix,
who presented with brain metastasis 13 months after surgery and died 3
months later. The other three patients remain alive and cancer-free at
21, 23, and 24 months of follow-up, despite the advanced disease stage.
None of the five patients has had local recurrence.
Olak would like me to present numbers, sizes, and percentages as though
I could statistically prove that the access should be used. She forgets
that the paper is about “can do,” not “should do,” as I clearly
stated in the article.1-1
Finally, I would like to close with the words of A. J.
Walt1-7: “If the objective of surgery is to achieve cure
or palliation with as little discomfort to the patient as possible,
conceptual transformations are inevitable. Genuine recognition of the
tyranny of mind-sets that have inflexible and nonporous walls is
essential to productive change. Paradigm-lepsis is dangerous but not
Correspondence to: Eduardo A. Tovar, MD, FCCP, 100 E.
Valencia Mesa Dr., Suite 301, Fullerton, CA 92835; e-mail:
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