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Lung cancer with pleural dissemination: why not operation?

2002; Elsevier BV; Volume: 74; Issue: 5 Linguagem: Inglês

10.1016/s0003-4975(02)03942-5

1552-6259

Marc Riquet, Christophe Foucault, François Souilamas,

Gastric Cancer Management and Outcomes

In a recent issue, Sawabata and colleagues [1Sawabata N. Matsumura A. Motohiro A. et al.Malignant minor pleural effusion detected on thoracotomy for patients with non-small cell lung cancer is tumor resection beneficial for prognosis?.Ann Thorac Surg. 2002; 73: 412-415Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar] reported on operation for non-small cell lung cancer (NSCLC) with malignant pleural effusion detected at thoracotomy. They concluded that tumor resection was not beneficial for survival of these patients. This conclusion could discourage, and even contraindicate any attempt at resection. However, in their series, 5-year survivors were observed when either complete or incomplete resections were performed. From 1984 to 1999, we operated on 38 patients for NSCLC whose preoperative workup did not disclose any contraindication in our department. At thoracotomy, we were surprised to discover macroscopic pleural dissemination. The thoracotomy remained exploratory in 20 patients (survival: median, 13 months; 5 years, 0%). A lung resection with pleurectomy and mediastinal lymph node dissection was performed in 18 patients (survival: median, 31 months; 5 years, 21%). The difference in survival was significant (p = 0.009) between groups. In a multicentric study, Ichinose and colleagues [2Ichinose Y. Tsuchiya R. Koike T. et al.The prognosis of patients with non-small cell lung cancer found to have carcinomatous pleuritis at thoracotomy.Surg Today. 2000; 30: 1062-1066Crossref PubMed Scopus (26) Google Scholar] reported similar results (collected cases n = 227). According to Ohta and associates [3Ohta Y. Tanaka Y. Hara T. et al.Clinicopathological and biological assessment of lung cancers with pleural dissemination.Ann Thorac Surg. 2002; 69: 1025-1029Abstract Full Text Full Text PDF Scopus (27) Google Scholar], a limited operation for local control in such patients is sufficient. We also observed this in our small series: median survival after pneumonectomy (n = 5), 24 months and after lobectomy (n = 13), 33 months.Pleural dissemination in the absence of other metastatic disease is probably a particular entity that resembles pleural cavity seeding due to visceral pleural involvement [4Manac’h D. Riquet M. Medioni J. et al.Visceral pleura invasion by non-small cell lung cancer an underrated bad prognostic factor.Ann Thorac Surg. 2001; 71: 1088-1093Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar], or possibly a latter stage. The NSCLC pleural dissemination is an interesting topic deserving much more consideration. Operation must not be discouraged. Few articles deal with this subject. Reyes and colleagues [5Reyes L. Parvez Z. Regal A.M. Takita H. Neoadjuvant chemotherapy and operations in the treatment of lung cancer with pleural effusion.J Thorac Cardiovasc Surg. 1991; 101 (letter): 946-947PubMed Google Scholar], who were among the first to report success after operation, demonstrated the correct course when they pointed out that the most logical therapeutic approach is neoadjuvant chemotherapy. At the end of their article, Sawabata and colleagues [1Sawabata N. Matsumura A. Motohiro A. et al.Malignant minor pleural effusion detected on thoracotomy for patients with non-small cell lung cancer is tumor resection beneficial for prognosis?.Ann Thorac Surg. 2002; 73: 412-415Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar] suggest a trial of multimodality treatment for patients with NSCLC with malignant effusion. We believe trials are not only warranted but necessary because they may offer a chance of cure. This does not apply only to unsuspected malignancy discovered at thoracotomy, but should encompass other NSCLC with pleural effusion. This requires suitable patient selection for such trials and the need to convince physicians and oncologists of the possibility of adjuvant operation and not just drainage of the pleural effusion with or without pleurodesis with sclerosing agents. In a recent issue, Sawabata and colleagues [1Sawabata N. Matsumura A. Motohiro A. et al.Malignant minor pleural effusion detected on thoracotomy for patients with non-small cell lung cancer is tumor resection beneficial for prognosis?.Ann Thorac Surg. 2002; 73: 412-415Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar] reported on operation for non-small cell lung cancer (NSCLC) with malignant pleural effusion detected at thoracotomy. They concluded that tumor resection was not beneficial for survival of these patients. This conclusion could discourage, and even contraindicate any attempt at resection. However, in their series, 5-year survivors were observed when either complete or incomplete resections were performed. From 1984 to 1999, we operated on 38 patients for NSCLC whose preoperative workup did not disclose any contraindication in our department. At thoracotomy, we were surprised to discover macroscopic pleural dissemination. The thoracotomy remained exploratory in 20 patients (survival: median, 13 months; 5 years, 0%). A lung resection with pleurectomy and mediastinal lymph node dissection was performed in 18 patients (survival: median, 31 months; 5 years, 21%). The difference in survival was significant (p = 0.009) between groups. In a multicentric study, Ichinose and colleagues [2Ichinose Y. Tsuchiya R. Koike T. et al.The prognosis of patients with non-small cell lung cancer found to have carcinomatous pleuritis at thoracotomy.Surg Today. 2000; 30: 1062-1066Crossref PubMed Scopus (26) Google Scholar] reported similar results (collected cases n = 227). According to Ohta and associates [3Ohta Y. Tanaka Y. Hara T. et al.Clinicopathological and biological assessment of lung cancers with pleural dissemination.Ann Thorac Surg. 2002; 69: 1025-1029Abstract Full Text Full Text PDF Scopus (27) Google Scholar], a limited operation for local control in such patients is sufficient. We also observed this in our small series: median survival after pneumonectomy (n = 5), 24 months and after lobectomy (n = 13), 33 months. Pleural dissemination in the absence of other metastatic disease is probably a particular entity that resembles pleural cavity seeding due to visceral pleural involvement [4Manac’h D. Riquet M. Medioni J. et al.Visceral pleura invasion by non-small cell lung cancer an underrated bad prognostic factor.Ann Thorac Surg. 2001; 71: 1088-1093Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar], or possibly a latter stage. The NSCLC pleural dissemination is an interesting topic deserving much more consideration. Operation must not be discouraged. Few articles deal with this subject. Reyes and colleagues [5Reyes L. Parvez Z. Regal A.M. Takita H. Neoadjuvant chemotherapy and operations in the treatment of lung cancer with pleural effusion.J Thorac Cardiovasc Surg. 1991; 101 (letter): 946-947PubMed Google Scholar], who were among the first to report success after operation, demonstrated the correct course when they pointed out that the most logical therapeutic approach is neoadjuvant chemotherapy. At the end of their article, Sawabata and colleagues [1Sawabata N. Matsumura A. Motohiro A. et al.Malignant minor pleural effusion detected on thoracotomy for patients with non-small cell lung cancer is tumor resection beneficial for prognosis?.Ann Thorac Surg. 2002; 73: 412-415Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar] suggest a trial of multimodality treatment for patients with NSCLC with malignant effusion. We believe trials are not only warranted but necessary because they may offer a chance of cure. This does not apply only to unsuspected malignancy discovered at thoracotomy, but should encompass other NSCLC with pleural effusion. This requires suitable patient selection for such trials and the need to convince physicians and oncologists of the possibility of adjuvant operation and not just drainage of the pleural effusion with or without pleurodesis with sclerosing agents. ReplyThe Annals of Thoracic SurgeryVol. 74Issue 5Preview Full-Text PDF