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Abstract

I read a response from Riquet and colleagues to our article [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], which reported operation for non-small cell lung cancer (NSCLC) with malignant minor pleural effusion detected at thoracotomy. They pointed out that the 5-year survival rate for patients with pleural involvement was approximately 20% in other studies [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, 3Ohta Y. Tanaka Y. Hara T. et al.Clinicopathological and biological assessment of lung cancers with pleural dissemination.Ann Thorac Surg. 2000; 69: 1025-1029Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar], and that operation should not be discouraged. However, the number of patients who underwent adjuvant therapy was high in these studies.The reason why our completely resected group of patients had a poor survival rate may be due not only to no adjuvant therapy but also a high rate of p1 or p2, which often is associated with a high rate of malignant pleural effusion. Malignant cells in the pleural effusion may arrive from the visceral pleura above a NSCLC. Tumor cells are detected on the pleura above a NSCLC in 20% to 30% of patients [4Ichinose Y. Yano T. Asoh H. Yokoyama H. Fukuyama Y. Katsuda Y. Diagnosis of visceral pleural invasion in resected lung cancer using a jet stream of saline solution.Ann Thorac Surg. 1997; 64: 1626-1629Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 5Sawabata N. Ohta M. Maeda H. Fine-needle aspiration cytologic technique for lung cancer has a high potential of malignant cell spread through the tract.Chest. 2000; 118: 936-939Crossref PubMed Scopus (72) Google Scholar]. Therefore, it is very difficult to distinguish frank malignant effusion from a contaminated effusion. Although pleural involvement is a poor prognostic factor [6Manac’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], survival rate may be different between contaminated and primary pleural effusions.Notwithstanding contaminated or primary effusions, malignant pleural effusion indicates a poor prognosis. However, I believe that operation for NSCLC with malignant pleural effusion should not be discouraged but should be tried with adjuvant or induction therapy. Trials of multimordality treatment may offer a good chance of survival in patients with NSCLC with pleural involvement alone and no distant metastasis. I read a response from Riquet and colleagues to our article [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], which reported operation for non-small cell lung cancer (NSCLC) with malignant minor pleural effusion detected at thoracotomy. They pointed out that the 5-year survival rate for patients with pleural involvement was approximately 20% in other studies [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, 3Ohta Y. Tanaka Y. Hara T. et al.Clinicopathological and biological assessment of lung cancers with pleural dissemination.Ann Thorac Surg. 2000; 69: 1025-1029Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar], and that operation should not be discouraged. However, the number of patients who underwent adjuvant therapy was high in these studies. The reason why our completely resected group of patients had a poor survival rate may be due not only to no adjuvant therapy but also a high rate of p1 or p2, which often is associated with a high rate of malignant pleural effusion. Malignant cells in the pleural effusion may arrive from the visceral pleura above a NSCLC. Tumor cells are detected on the pleura above a NSCLC in 20% to 30% of patients [4Ichinose Y. Yano T. Asoh H. Yokoyama H. Fukuyama Y. Katsuda Y. Diagnosis of visceral pleural invasion in resected lung cancer using a jet stream of saline solution.Ann Thorac Surg. 1997; 64: 1626-1629Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 5Sawabata N. Ohta M. Maeda H. Fine-needle aspiration cytologic technique for lung cancer has a high potential of malignant cell spread through the tract.Chest. 2000; 118: 936-939Crossref PubMed Scopus (72) Google Scholar]. Therefore, it is very difficult to distinguish frank malignant effusion from a contaminated effusion. Although pleural involvement is a poor prognostic factor [6Manac’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], survival rate may be different between contaminated and primary pleural effusions. Notwithstanding contaminated or primary effusions, malignant pleural effusion indicates a poor prognosis. However, I believe that operation for NSCLC with malignant pleural effusion should not be discouraged but should be tried with adjuvant or induction therapy. Trials of multimordality treatment may offer a good chance of survival in patients with NSCLC with pleural involvement alone and no distant metastasis.