0
Point and Counterpoint |

Rebuttal From Dr Li et alRebuttal From Dr Li et al FREE TO VIEW

Wilson W. Li, MD; Jacobus A. Burgers, MD, PhD; Houke M. Klomp, MD, PhD; Koen J. Hartemink, MD, PhD
Author and Funding Information

From the Department of Cardiothoracic Surgery (Dr Li), Academic Medical Center, University of Amsterdam; and Department of Thoracic Oncology (Dr Burgers) and Department of Thoracic Surgery (Drs Klomp and Hartemink), Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital.

CORRESPONDENCE TO: Wilson W. Li, MD, Department of Cardiothoracic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; e-mail: w.w.li@amc.uva.nl


CONFLICT OF INTEREST: None declared.

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):1380-1381. doi:10.1378/chest.15-1197
Text Size: A A A
Published online

Drs Tanner and Silvestri1 make a compelling argument regarding the lack of high-grade evidence in supporting the use of adjuvant surgical resection in patients with superior sulcus tumors (SSTs) with mediastinal lymph node involvement (N2 disease). Indeed, to our knowledge, there are no randomized trials on trimodality treatment in SSTs with N2 disease. However, the subsequent conclusion that induction therapy followed by surgical treatment in these patients is not supported by current evidence seems to be only the partial truth.

First, let us clarify the details of this dialogue. Foremost, the discussion should be centered on the impact of adjuvant surgical treatment after induction chemoradiation in patients with SSTs and N2 disease. We agree with Drs Tanner and Silvestri1 that robust data on this subject are lacking, although our colleagues seem to have overlooked the majority of reported studies. Table 1 in our counterpoint editorial2 shows that the existing literature includes more patients with SSTs and N2 disease undergoing this treatment strategy than the two studies with 10 cases to which they are referring. Additionally, one of the trials they refer to investigated surgical therapy followed by adjuvant chemoradiation in SST3 and should not be used as evidence in the current discussion. The other trial by Marra et al4 showed an inferior 5-year survival in patients with N2-3 disease compared with those with N0-1 disease. The authors of this study stated themselves that “long-term survivors were also observed in the group with mediastinal lymph node metastases, with a median survival of 28 months.”4

Although more evidence is available, in most of the studies, specific N2 subanalyses were not presented or trimodality treatment was not completed in all patients. However, the only study with a 100% trimodality therapy rate, including N2 subanalyses, showed an equal 2-year survival between N2 and no N2 disease (40% vs 52%, P = .50),5 suggesting that postoperative long-term survival is certainly feasible for patients with SSTs and N2 disease after induction therapy, as previously stated by Marra et al.4

Second, we propose that next to survival, pain management through local control is of essence in this group of patients, a motive that Drs Tanner and Silvestri1 do not mention. We believe that local control is superior after adjuvant surgical treatment, as stated in our counterpoint editorial.2

In our opinion, the debate should not be whether adjuvant surgical treatment is beneficial for patients with SSTs and N2 disease but for which patients with SSTs and N2 disease. We believe that all can agree on the statement that “physicians wish for a better treatment option for SSTs with N2 disease.”1 We do not plan to alter the evidence, but through this dialogue, we sincerely hope that new evidence will emerge to optimize the surgical selection process in patients with SSTs and N2 disease to improve long-term survival and durable pain control. Until such evidence is available, we suggest that the treatment plan for these patients be made with input from the multidisciplinary team.

References

Tanner NT, Silvestri GA. Point: is N2 disease a contraindication for surgical resection for superior sulcus tumors? Yes. Chest. 2015;148(6):1373-1375.
 
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.
 
Gomez DR, Cox JD, Roth JA, et al. A prospective phase 2 study of surgery followed by chemotherapy and radiation for superior sulcus tumors. Cancer. 2012;118(2):444-451. [CrossRef] [PubMed]
 
Marra A, Eberhardt W, Pöttgen C, et al. Induction chemotherapy, concurrent chemoradiation and surgery for Pancoast tumour. Eur Respir J. 2007;29(1):117-126. [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]
 

Figures

Tables

References

Tanner NT, Silvestri GA. Point: is N2 disease a contraindication for surgical resection for superior sulcus tumors? Yes. Chest. 2015;148(6):1373-1375.
 
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.
 
Gomez DR, Cox JD, Roth JA, et al. A prospective phase 2 study of surgery followed by chemotherapy and radiation for superior sulcus tumors. Cancer. 2012;118(2):444-451. [CrossRef] [PubMed]
 
Marra A, Eberhardt W, Pöttgen C, et al. Induction chemotherapy, concurrent chemoradiation and surgery for Pancoast tumour. Eur Respir J. 2007;29(1):117-126. [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]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543