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Point and Counterpoint |

Rebuttal From Drs Tanner and SilvestriRebuttal From Drs Tanner and Silvestri FREE TO VIEW

Nichole T. Tanner, MD, MSCR, FCCP; Gerard A. Silvestri, MD, FCCP
Author and Funding Information

From the Ralph H. Johnson Veterans Affairs Hospital (Dr Tanner), Health Equity and Rural Outreach Innovation Center; and the Division of Pulmonary and Critical Care, Allergy and Sleep Medicine (Drs Tanner and Silvestri), Medical University of South Carolina.

CORRESPONDENCE TO: Nichole T. Tanner, MD, MSCR, FCCP, Division of Pulmonary and Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, 96 Jonathan Lucas St, Ste 812-CSB, Charleston, SC 29425; e-mail: tripici@musc.edu


CONFLICT OF INTEREST: N. T. T. has received grant funding from the CHEST Foundation OneBreath Initiative, American Cancer Society, Olympus Corporation of the Americas, and Cook Medical Inc and consulting fees from Integrated Diagnostics Inc; Cook Medical Inc; Veran Medical Technologies, Inc; and Olympus Corporation of the Americas. None declared (G. A. S.).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(6):1379-1380. doi:10.1378/chest.15-1195
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Dr Li and colleagues1 make four arguments in favor of adding surgery to current guideline-directed standard-of-care chemoradiotherapy alone for treatment of patients who present with superior sulcus tumor (SST) and mediastinal (N2) lymphadenopathy. The first assertion is that research regarding treatment strategies in this population occurred before the trimodality era and, therefore, should be revisited. We agree. Patients with SSTs treated before trimodality therapy did not do well, and those with N2 disease did even worse. The trials that used trimodality therapy for SSTs had better outcomes, but the majority excluded patients with N2 disease. These findings led to the 2013 American College of Chest Physicians (CHEST) lung cancer guidelines recommending this approach for patients with SSTs and N0-1 disease2-5 as well as to the rationale for why the guidelines recommend against surgery in patients with SSTs and N2 disease.2 Armed with these data, our colleagues suggest that the “promising results” from the aforementioned trials should lead us to consider broadening the patient selection strategy to include N2 disease, and they point to several studies to augment this position, the second tenant of their argument.

Dr Li and colleagues1 point to 12 studies in which contemporary trimodality therapy was used in patients with SSTs and N2 disease. Unfortunately, eight of the 12 studies did not report data on outcomes by lymph node status and, thus, cannot be used to make inferences regarding the utility of trimodality therapy in N2 disease. Two studies confirm that N2 disease is an adverse prognostic factor, leaving two studies in a total of 15 patients with N2 disease reporting similar survival compared with patients with N0-1 disease.6,7 The study by Vos et al6 is limited in that follow-up was only to 2 years, leaving eight patients from the trial by Li et al7 in which no significant differences in survival were observed. This evidence amounts to little more than a case series. In addition, a large number of patients in the trial had distant metastatic disease, and no correlations were made between this and nodal status.7 That our colleagues could only identify 15 cases that marginally support trimodality therapy in patients with SSTs with N2 involvement is not persuasive enough to sway the medical community away from firm guideline recommendations against surgery in this setting.

Third, Dr Li and colleagues1 ask us to consider surgery for SSTs with N2 involvement as a means to palliate pain. We find this argument particularly unappealing because the majority of patients experience pain relief from standard radiation therapy. It is reported that only 10% of patients with cancer have pain that is difficult to manage with conventional analgesic drugs, which are the basis for pain management in cancer.8 In cases where pain persists, clinical practice guidelines on the management of cancer pain advocate for the addition of minimally invasive pain management, including nerve blocks.8 Surgery is only recommended in situations of complicated bone metastasis with impending fracture or cord compression.8 In addition, surgery may actually lead to postthoracotomy pain syndrome, which occurs in up to 50% of patients and can be difficult to manage.9

Finally, Dr Li and colleagues1 argue that SSTs are rare, which precludes the necessity for clinical trials in SSTs with N2 disease. Lung cancer is not a rare disease; 221,000 new cases are diagnosed in the United States each year. A trial investigating this question can and should be done.

In summary, the evidence presented by our colleagues fails to support the use of surgery in addition to standard-of-care chemoradiotherapy outside the auspices of well-designed clinical trials. Without any evidence of benefit, patients will only be exposed to the possibility of harm, something we believe that clinicians and patients alike should avoid.

References

Li WW, Burgers JA, Klomp HM, Hartemink KJ. Counterpoint: is N2 disease a contraindication for surgical resection for superior sulcus tumors? No. Chest. 2015;148(6):1375-1379.
 
Kozower BD, Larner JM, Detterbeck FC, Jones DR. Special treatment issues in non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e369S-e399S. [CrossRef] [PubMed]
 
Kernstine KH, Moon J, Kraut MJ, et al; American College of Surgeons Oncology Group; Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cancer Treatment Group; National Cancer Institute of Canada Clinical Trials Group; Southwest Oncology Group. Trimodality therapy for superior sulcus non-small cell lung cancer: Southwest Oncology Group-Intergroup Trial S0220. Ann Thorac Surg. 2014;98(2):402-410. [CrossRef] [PubMed]
 
Rusch VW, Giroux DJ, Kraut MJ, et al. Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas: long-term results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160). J Clin Oncol. 2007;25(3):313-318. [CrossRef] [PubMed]
 
Kunitoh H, Kato H, Tsuboi M, et al; Japan Clinical Oncology Group. Phase II trial of preoperative chemoradiotherapy followed by surgical resection in patients with superior sulcus non-small-cell lung cancers: report of Japan Clinical Oncology Group trial 9806 [published correction appears inJ Clin Oncol. 2011;29(33):4472]. J Clin Oncol. 2008;26(4):644-649. [CrossRef] [PubMed]
 
Vos CG, Hartemink KJ, Blaauwgeers JL, et al. Trimodality therapy for superior sulcus tumours: evolution and evaluation of a treatment protocol. Eur J Surg Oncol. 2013;39(2):197-203. [CrossRef] [PubMed]
 
Li J, Dai CH, Shi SB, Bao QL, Yu LC, Wu JR. Induction concurrent chemoradiotherapy compared with induction radiotherapy for superior sulcus non-small cell lung cancer: a retrospective study. Asia Pac J Clin Oncol. 2010;6(1):57-65. [CrossRef] [PubMed]
 
Ripamonti CI, Santini D, Maranzano E, Berti M, Roila F; ESMO Guidelines Working Group. Management of cancer pain: ESMO clinical practice guidelines. Ann Oncol. 2012;23(suppl 7):vii139-vii154. [CrossRef] [PubMed]
 
Gottschalk A, Cohen SP, Yang S, Ochroch EA. Preventing and treating pain after thoracic surgery. Anesthesiology. 2006;104(3):594-600. [CrossRef] [PubMed]
 

Figures

Tables

References

Li WW, Burgers JA, Klomp HM, Hartemink KJ. Counterpoint: is N2 disease a contraindication for surgical resection for superior sulcus tumors? No. Chest. 2015;148(6):1375-1379.
 
Kozower BD, Larner JM, Detterbeck FC, Jones DR. Special treatment issues in non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e369S-e399S. [CrossRef] [PubMed]
 
Kernstine KH, Moon J, Kraut MJ, et al; American College of Surgeons Oncology Group; Cancer and Leukemia Group B; Eastern Cooperative Oncology Group; North Central Cancer Treatment Group; National Cancer Institute of Canada Clinical Trials Group; Southwest Oncology Group. Trimodality therapy for superior sulcus non-small cell lung cancer: Southwest Oncology Group-Intergroup Trial S0220. Ann Thorac Surg. 2014;98(2):402-410. [CrossRef] [PubMed]
 
Rusch VW, Giroux DJ, Kraut MJ, et al. Induction chemoradiation and surgical resection for superior sulcus non-small-cell lung carcinomas: long-term results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160). J Clin Oncol. 2007;25(3):313-318. [CrossRef] [PubMed]
 
Kunitoh H, Kato H, Tsuboi M, et al; Japan Clinical Oncology Group. Phase II trial of preoperative chemoradiotherapy followed by surgical resection in patients with superior sulcus non-small-cell lung cancers: report of Japan Clinical Oncology Group trial 9806 [published correction appears inJ Clin Oncol. 2011;29(33):4472]. J Clin Oncol. 2008;26(4):644-649. [CrossRef] [PubMed]
 
Vos CG, Hartemink KJ, Blaauwgeers JL, et al. Trimodality therapy for superior sulcus tumours: evolution and evaluation of a treatment protocol. Eur J Surg Oncol. 2013;39(2):197-203. [CrossRef] [PubMed]
 
Li J, Dai CH, Shi SB, Bao QL, Yu LC, Wu JR. Induction concurrent chemoradiotherapy compared with induction radiotherapy for superior sulcus non-small cell lung cancer: a retrospective study. Asia Pac J Clin Oncol. 2010;6(1):57-65. [CrossRef] [PubMed]
 
Ripamonti CI, Santini D, Maranzano E, Berti M, Roila F; ESMO Guidelines Working Group. Management of cancer pain: ESMO clinical practice guidelines. Ann Oncol. 2012;23(suppl 7):vii139-vii154. [CrossRef] [PubMed]
 
Gottschalk A, Cohen SP, Yang S, Ochroch EA. Preventing and treating pain after thoracic surgery. Anesthesiology. 2006;104(3):594-600. [CrossRef] [PubMed]
 
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