We thank Dr. Rott for his contribution to the discussion on indications for video-assisted thoracoscopic surgery (VATS) for pulmonary nodules. Surgical evaluation of a malignancy-suspected solitary pulmonary nodule was recommended in the first German S3 guideline (2010) (recommendation grade A). If surgery is feasible, transthoracic puncture should be avoided (recommendation grade B). Unfortunately, the chapter on pulmonary nodules was not updated in the new guideline (2018).
The exclusion criteria specified in our study (1) refer to the new surgical methods to be evaluated that do not use pleural drainage. They do not represent any limitations for conventional VATS with pleural drainage.
We cannot agree with the opinion of Dr. Rott, that thoracoscopic lung biopsy should be restricted to cases of pulmonary nodules that remain diagnostically unclear after repeated computed tomography (CT)–guided biopsy. VATS allows an immediate and definitive diagnosis in 96–100% of cases. Further advantages over non-surgical biopsy procedures include: no delay in obtaining a diagnosis, an immediate and definitive oncological radical therapy (in the case of malignancy, endoscopic segmentectomy or lobectomy in the same session), sufficient tissue for histological examination and molecular diagnostics, and avoidance of complications of non-surgical biopsy procedures. Along these lines, the guidelines of the National Comprehensive Cancer Network (NCCN) (Version 5.2019) recommend that non-surgical biopsy be omitted for patients with a malignancy-suspected pulmonary nodule.
Complications after CT-guided lung biopsy are not limited to pneumothorax, as intrapulmonary hemorrhage, hemothorax, or air embolism may also occur. The complication rate is approximately 34%, with life-threatening complications occurring in approximately 6% of cases (2). This is thus higher than the complication rate after video-assisted thoracoscopic removal of lung tissue (3). Furthermore, half of all non-diagnostic (“negative”) biopsies are false negatives for malignancy (2).
Footnotes
Conflict of interest statement
The authors of both contributions declare that no conflict of interest exists.
References
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