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Mary White, MB; Ross McManus, PhD; Thomas Ryan, MB
Author and Funding Information

From the Department of Anaesthesia (Drs White and Ryan), St. James’s Hospital; and the Institute of Molecular Medicine (Dr White), and the Department of Clinical Medicine (Dr McManus), Trinity College Dublin.

Correspondence to: Mary White, MB, Department of Anaesthesia, St. James’s Hospital, James St, Dublin 8, Ireland; e-mail: drmbwhite@yahoo.co.uk


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Drs White, Ryan, and McManus have an existing patent and a patent application pending for the relationship between cytokine gene expression and the occurrence of infection after thoracotomy and the onset of sepsis in patients with infection. Drs McManus and Ryan have received grant monies from Health Research Board and Enterprise Ireland, state-funded research foundations. Drs McManus and Ryan have also received benefits in kind in the form of travel expenses from Pfizer and Merck.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(3):831. doi:10.1378/chest.11-1181
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To the Editor:

We appreciate the comments by Dr Hsin and colleagues regarding our recent study.1 It is indeed probable that the choice of surgical approach for cancer resection can influence the inflammatory and immune response to surgery, as we acknowledged in our article. To this end and to ensure the study was powered adequately, we restricted recruitment to open lung resection surgery because the incidence of postoperative pneumonia is substantial25%2 as opposed to 3%.3,4

The authors suggest that the cytokine gene expression might be different depending on the choice of surgical access; however, we have no data to prove this point. They correctly note the lack of data detailing cytokine gene expression following lung resection as a function of different surgical access. However, it is notable that prior reports of cytokine response to thoracic surgery exclusively report levels of protein in the peripheral blood, reflecting inflammation on a global level. In contrast, we examined cytokine gene transcription in a distinct population of cells, namely peripheral lymphocytes, which we consider a reflection of immune rather than inflammatory response to surgery.

IL-6 is produced by hepatocytes and endothelial cells,5 is readily measured in peripheral blood, and correlates with the severity of inflammation. However, cytokines that regulate the interaction of innate and adaptive immunityIL-12 and IL-23and cytokines that reflect T-cell activationinterferon γare not readily measured as proteins in peripheral blood, but can easily be assayed at the transcriptional level using a polymerase chain reaction.6,7 In sepsis and after thoracic surgery, gene expression of these cytokines in peripheral blood lymphocytes, which orchestrate and mediate an appropriate bactericidal immune response rather than an inflammatory response, are downregulated, reflecting an immune compromise state. In this response, we wish to emphasize the distinction between biomarkers of the inflammatory response and those of the immune response to surgery.

White M, Martin-Loeches I, Lawless MW, et al. Hospital-acquired pneumonia after lung resection surgery is associated with characteristic cytokine gene expression. Chest. 2011;1393:626-632 [CrossRef] [PubMed]
 
Dales RE, Dionne G, Leech JA, Lunau M, Schweitzer I. Preoperative prediction of pulmonary complications following thoracic surgery. Chest. 1993;1041:155-159 [CrossRef] [PubMed]
 
Kaiser LR, Bavaria JE. Complications of thoracoscopy. Ann Thorac Surg. 1993;563:796-798 [CrossRef] [PubMed]
 
Yim AP, Liu HP. Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg. 1996;612:538-541 [CrossRef] [PubMed]
 
White M, Lawless MW, O’Dwyer MJ, et al. Transforming growth factor beta-1 and interleukin-17 gene transcription in peripheral blood mononuclear cells and the human response to infection. Cytokine. 2010;503:322-327 [CrossRef] [PubMed]
 
O’Dwyer MJ, Mankan AK, Stordeur P, et al. The occurrence of severe sepsis and septic shock are related to distinct patterns of cytokine gene expression. Shock. 2006;266:544-550 [CrossRef] [PubMed]
 
O’Dwyer MJ, Mankan AK, White M, et al. The human response to infection is associated with distinct patterns of interleukin 23 and interleukin 27 expression. Intensive Care Med. 2008;344:683-691 [CrossRef] [PubMed]
 

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References

White M, Martin-Loeches I, Lawless MW, et al. Hospital-acquired pneumonia after lung resection surgery is associated with characteristic cytokine gene expression. Chest. 2011;1393:626-632 [CrossRef] [PubMed]
 
Dales RE, Dionne G, Leech JA, Lunau M, Schweitzer I. Preoperative prediction of pulmonary complications following thoracic surgery. Chest. 1993;1041:155-159 [CrossRef] [PubMed]
 
Kaiser LR, Bavaria JE. Complications of thoracoscopy. Ann Thorac Surg. 1993;563:796-798 [CrossRef] [PubMed]
 
Yim AP, Liu HP. Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg. 1996;612:538-541 [CrossRef] [PubMed]
 
White M, Lawless MW, O’Dwyer MJ, et al. Transforming growth factor beta-1 and interleukin-17 gene transcription in peripheral blood mononuclear cells and the human response to infection. Cytokine. 2010;503:322-327 [CrossRef] [PubMed]
 
O’Dwyer MJ, Mankan AK, Stordeur P, et al. The occurrence of severe sepsis and septic shock are related to distinct patterns of cytokine gene expression. Shock. 2006;266:544-550 [CrossRef] [PubMed]
 
O’Dwyer MJ, Mankan AK, White M, et al. The human response to infection is associated with distinct patterns of interleukin 23 and interleukin 27 expression. Intensive Care Med. 2008;344:683-691 [CrossRef] [PubMed]
 
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