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ontribute to jeopardize the prognosis of such patients,ncluding the size of the tumor, the extent of surgeryequired, and the difficulty to achieve a complete resec-ion, but the pulmonary vein and left atrium invasionoes not seem in itself to worsen the terminal results,hen compared with pericardial invasion alone. Thearticularly important lymph drainage richness of theericardium observed in applied anatomy [2, 3] may thusave effectively contributed to enhance the lymphaticpread of tumor cells, and hence to disseminate theisease. The LN involvement, twice as frequent as in theeneral population, observed in this stage subgroupsay be the consequence of the lymphatic drainage.Cause of death in our series was mainly related to distantetastases, and the importance of LN positivity may be theain indicator of the pericardial involvement related to

oor prognosis. As is evident because of our low patientumbers with N0, we cannot prove this reasonable hypoth-sis. Maybe future multicentric research with more casesill confirm completely this theory.

eferences

1. American Joint Committee on Cancer (AJCC). Cancer stag-ing handbook. In: Edge SB, Byrd DR, Compton CC, Fritz AG,Greene FL, Trotti A, eds. AJCC cancer staging manual. 7thed. Chicago: Springer, 2010:299–323.

2. Eliskova M, Eliska O, Miller AJ. The lymphatic drainage of theparietal pericardium in man. Lymphology 1995;28:208–17.

3. Riquet M, Le Pimpec Barthes F, Hidden G. Lymphaticdrainage of the pericardium to the mediastinal lymph nodes.Surg Radiol Anat 2001;23:317–9.

4. Mountain CF. Revisions in the international system forstaging lung cancer. Chest 1997;111:1710–7.

5. Goldstraw P, Crowley J, Chansky K, et al. The IASLC cancer

able 5. T4 Patients From the Literature

Ratto [12] (2004) Osaki [13] (2003)

eft atrium 19 5 � 1 PVive-year survival 14% 33%edian 25 months

quamous cell 14 (73.7%) 4 (66%)0 3 (15.8%) 3 (50%)1 5 (26.3%) 1 (16.7%)2 11 (57.9%) 2 (33.3%)neumonectomy 12 (63.2%) 5 (83.3%)0 11 (57.9%) 47/76 (61.8%)

ata concerning left atrium and pulmonary vein (PV) invasion.a Data conc2 patients with cancer invading great vessels and left atrium.

staging project: proposals for the revision of the TNM stage

The objective of the study was to elucidate on the

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2010 by The Society of Thoracic Surgeonsublished by Elsevier Inc

groupings in the forthcoming (seventh) edition of the TNMclassification of malignant tumours. J Thorac Oncol2007;2:706–14.

6. Mountain CF, Dresler CM. Regional lymph node classifica-tion for lung cancer staging. Chest 1997;111:1718–23.

7. Riquet M, Hidden G, Debesse B. Direct lymphatic drainageof lung segments to mediastinal nodes. J Thorac CardiovascSurg 1989;97:625–32.

8. Kwiatkowski F. [SEM (statistiques, epidémiologie, médecine):un outil de gestion informatique et statistique adapté à larecherche en cancérologie]. Bull Cancer 2000;87:715–21.

9. Burt ME, Pomerantz AH, Bains MS, et al. Results of surgicaltreatment of stage III lung cancer invading the mediastinum.Surg Clin North Am 1987;67:987–1000.

0. Pitz CCM, Brutel de la Rivière A, Elbers HRJ, WestermannCJJ, van den Bosch JM. Results of resection of T3 non smallcell lung cancer invading the mediastinum or main bron-chus. Ann Thorac Surg 1996;62:1016–20.

1. Yildezeli B, Dartevelle PG, Fadel E, Mussot S, Chapelier A.Results of primary surgery with T4 non-small cell lungcancer during a 25-year period in a single center: the benefitis worth the risk. Ann Thorac Surg 2008;86:1065–75.

2. Ratto GB, Costa R, Vassallo G, Alloisio A, Maineri P, BruzziP. Twelve-year experience with left atrial resection in thetreatment of nonsmall-cell lung cancer. Ann Thorac Surg2004;78:234–7.

3. Osaki T, Sugio K, Hanagiri T, et al. Survival and prognosticfactors of surgically resected T4 nonsmall-cell lung cancer.Ann Thorac Surg 2003;75:1745–51.

4. Pitz CCM, Brutel de la Rivière A, van Swieten HA, Wester-mann CJJ, Lammers van den Bosch JM. Results of surgicaltreatment of T4 non-small cell lung cancer. Eur J Cardiotho-rac Surg 2003;24:1013–8.

5. Spaggiari L, D’Aiuto M, Veronesi G, et al. Extended pneu-monectomy with partial resection of the left atrium, withoutcardiopulmonary bypass, for lung cancer. Ann Thorac Surg2005;79:234–40.

6. Fukuse T, Wada H, Hitomi S. Extended operation for non-small cell lung cancer invading great vessels and left atrium.

itz [14] (2003) Spaggiari [15] (2005) Fukuse [16] (1997)

15 � 25 PV 15 1419.1%a 39%b 17%b

14 months77 (86.5%)a 10 (66.7%) 27 (64.3%)c

11 (12.4%) 2 (13.3%) 14 (33.3%)c

43 (48.3%)a 5 (33.3%) 6 (14.3%)c

35 (39.3%)a 8 (53.3%) 22 (52.4%)c

71 (79.8%)a 15 (100%) 10 (71.4%)13 (32.5%) 15 (100%) 5 (35.7%)

g all T4 patients (n � 89). b Three-year probability of survival. c Of

Eur J Cardiothorac Surg 1997;11:664–9.

NVITED COMMENTARY

he article by Riquet and colleagues [1] describes a series of1 patients operated on for nonsmall cell lung cancer withnfiltration of the pericardium alone (T3) or of the pericar-ium associated with pulmonary veins or the atrium (T4).

rognostic role of pericardium infiltration in relationshipith nodal status and infiltration of the pulmonary veins.The most important findings of this study [1] were that

he majority of patients had large tumors and needed

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neumonectomies; one third of the patients had an

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ncomplete resection, and more than half of the patientsad positive mediastinal lymph nodes. As a conse-uence, the long-term survival of this series was poor.hese results were in line with previous investigations onimilar patients. Most of the patients died of distantetastases, but most notably there were 40% who died of

nrelated events to cancer, presumably owing to cardio-ulmonary derangements favored by pneumonectomy.In my opinion, the most important message of thisork is that in case of centrally located tumors that are

linically suspicious for pericardial infiltration, a scrupu-ous preoperative mediastinal staging should be manda-ory. In case of pathologically confirmed N2 disease aesection is unwarranted outside clinical trials, owing tohe dismal prognosis (5-year survival of 12%).

The series reported in the article by Riquet and col-eagues [1] spans a long period of time. In the earliesthase of the series, many imaging techniques (positronmission tomography) or minimally-invasive surgicalrocedures (video-assisted thoracic surgery or video me-iastinoscopy) could not be applied because they wereot available or not yet fully developed. These diagnostic

ools are now part of the surgeon’s armamentarium andllow us to more accurately stage or re-stage (after induc-ion chemo-radiotherapy) these patients preoperativelynd possibly spare the patient from a useless operation.

The authors [1] should be commended for having

ollected such a challenging series of patients. Although

he surgical outcome does not seem to warrant such anggressive surgical approach, the data reported in thisrticle [1] is a useful scientific resource for clinical andcientific purposes.

There are some analyses that the authors [1] may beilling to perform on the data at hand and that in mypinion would add to the present report as follows: (1) aime trend analysis to see whether (in the most recenteriod) the characteristics of the patients changed inegard to N status (perhaps more accurate staging pro-ess) compared with the earlier phase of the series, and2) a case-matched analysis between patients with N2isease (with and without pericardium involvement) tossess the exact prognosticator role of pericardialnfiltration.

lessandro Brunelli, MD

ivision of Thoracic Surgeryspedali Riuniti Anconaia Conca 71ncona, 60020 Italy

-mail: brunellialex@gmail.com

eference

. Riquet M, Grand B, Arame A, et al. Lung cancer invading thepericardium: quantum of lymph nodes. Ann Thorac Surg

2010;90:1773–8.