Treatment of Peripheral Lung Tumors Arising After a Prior Pneumonectomy: Response

Abstract

We thank Dr Senthi and colleagues for their interest in our CHEST article.1Yamauchi Y Izumi Y Yashiro H et al.Percutaneous cryoablation for pulmonary nodules in the residual lung after pneumonectomy: report of two cases.Chest. 2011; 140: 1633-1637Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar We agree that the work by Haasbeek et al2Haasbeek CJ Lagerwaard FJ de Jaeger K Slotman BJ Senan S Outcomes of stereotactic radiotherapy for a new clinical stage I lung cancer arising postpneumonectomy.Cancer. 2009; 115: 587-594Crossref PubMed Scopus (47) Google Scholar should have been cited in our article. Although the median follow-up of 16.5 months is rather short, the results are impressive with no local failures and only two of 15 ≤ grade 3 lung-associated toxicities. We agree that stereotactic radiotherapy (SRT) is a less invasive procedure in comparison with cryoablation, particularly if it is done without the implantation of fiducial markers. In terms of safety, pneumothorax after cryoablation can be sufficiently managed by course observation, by chest tube insertion, or, if persistent, by medical pleurodesis. However, in single-lung patients, delayed pneumothorax may have serious consequences if access to medical facilities is limited. We have previously reported that the incidence of delayed pneumothorax after cryoablation occurred in 30 of 193 patients (16%), mostly at 3 days after cryoablation still during admission. However, the incidence could occur as late as 20 days after cryoablation, and eight of these patients were readmitted after being discharged. Therefore, if the incidence of pulmonary toxicities after SRT is actually as low as generally reported (≤ grade 2, 5% ∼10%), we agree that SRT should be offered as a primary treatment option even in single-lung patients. However, one concern remains. To date, SRT for lung cancer has been evaluated mostly in inoperable patients, many with COPD. A recent report suggests that radiation pneumonitis may be milder in patients with COPD in comparison to patients with normal lung function.3Takeda A Kunieda E Ohashi T et al.Severe COPD is correlated with mild radiation pneumonitis following stereotactic body radiotherapy.Chest. 2012; 141: 858-866Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar Another study shows that the decline in pulmonary function after SRT was less in patients with COPD in comparison to patients who underwent SRT primarily because of cardiac comorbidities.4Baumann P Nyman J Hoyer M et al.Stereotactic body radiotherapy for medically inoperable patients with stage I non-small cell lung cancer–a first report of toxicity related to COPD/CVD in a non-randomized prospective phase II study.Radiother Oncol. 2008; 88: 359-367Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar In a study of SRT in medically operable patients with lung cancer, grade 3 pulmonary toxicity was noted in only one patient (1.1%), but this was a retrospective study, and 38 of 87 patients in this study had underlying chronic lung diseases.5Onishi H Shirato H Nagata Y et al.Stereotactic body radiotherapy (SBRT) for operable stage I non-small-cell lung cancer: can SBRT be comparable to surgery?.Int J Radiat Oncol Biol Phys. 2011; 81: 1352-1358Abstract Full Text Full Text PDF PubMed Scopus (483) Google Scholar The majority of patients in the study by Haasbeek et al2Haasbeek CJ Lagerwaard FJ de Jaeger K Slotman BJ Senan S Outcomes of stereotactic radiotherapy for a new clinical stage I lung cancer arising postpneumonectomy.Cancer. 2009; 115: 587-594Crossref PubMed Scopus (47) Google Scholar were also patients with COPD. Therefore, we consider that the incidence of pulmonary toxicities after SRT in patients with normal lung function is still unclear. Ongoing prospective studies on SRT in patients with operable lung cancer with normal lung function will provide answers to this issue. Treatment of Peripheral Lung Tumors Arising After a Prior PneumonectomyCHESTVol. 142Issue 1PreviewWe read with interest the report from Yamauchi et al1 in an issue of CHEST (December 2011) on the use of percutaneous cryoablation to manage lung tumors arising in the contralateral lung postpneumonectomy. The authors indicated they were unaware of reported outcomes for the use of stereotactic radiotherapy (SRT) in this group of patients. In 2009, we reported such outcomes for 15 patients presenting with a new primary lung cancer after prior pneumonectomy.2 One-half of these patients had severe COPD, with maximum tumor diameters ranging between 8 and 38 mm and no local failures after a median follow-up of 16.5 months (range, 4–55 months). Full-Text PDF