Chest wall invasion in non-small cell lung carcinoma: a rationale for en bloc resection

OBJECTIVE: The choice of surgical approach to non-small cell lung cancer invading the chest wall, extrapleural resection versus en bloc chest wall resection, is much more related to the experience of the surgeon than to objective criteria. The aim of the present study is to help to establish a rationale for en bloc chest wall resection in lung cancer invading the chest wall. METHODS: From January 1990 to June 1999, of 1855 patients having major pulmonary resections for non-small cell lung carcinoma, 104 (5.6%) patients with neoplasms involving the chest wall underwent en bloc chest wall and lung resection plus radical mediastinal lymphadenectomy. RESULTS: All patients underwent complete resection with microscopically disease-free tissue margins. Depth of invasion was into the parietal pleura only in 28 (26.92%), into the pleura and soft tissue in 36 (34.62%), and into the pleura, soft tissue, and bone in 40 (38.46%). No operative mortality was reported. Follow-up was completed in 96 patients. One patient had a local recurrence. The overall 5-year estimated survival was 61.4%. Survival in the subsets T3 N0 and T3 N2 were, respectively, 67.3% and 17.9% (P =.007). The 5-year survival was 79.1% in involvement of parietal pleura only and 54.0% in involvement of soft tissue with or without bone invasion (P =.014). Five-year survival was 53.0% in adenocarcinoma versus 71.8% in squamous cell carcinoma (P =.329) and 74.1% in patients who did undergo radiation therapy versus 46.7% in patients who did not undergo radiation therapy (P =.023). CONCLUSIONS: En bloc resection of the chest wall and lung is the procedure of choice to obtain complete resection in lung carcinoma invading the chest wall. Survival is highly dependent on the completeness of resection, nodal involvement, and depth of chest wall invasion.     

Surgical treatment of lung carcinoma involving the chest wall

From 1969 to 1986, 97 patients with chest wall invasion by lung carcinoma (excluding superior sulcus tumours) underwent surgical resection in two hospitals, La Paz (Madrid) and La Fé (Valencia). The same surgical policy was used in both thoracic surgical units: extrapleural pulmonary resection when tumour involved only the parietal pleura (N = 36), and en bloc chest wall resection when the carcinoma extended into the ribs and intercostal muscles (N = 61). The tumour histology was classified according the WHO criteria. Lobectomy or bilobectomy was carried out in 72%, pneumonectomy in 18% and segmentectomy or wedge resection in 10% of the patients. The perioperative mortality was higher in the en bloc resection group 9/61 (15%) versus 2/36 (6%) for extrapleural dissection. The node staging was NO in 58/97 (60%), N1 in 16/97 (16%) and N2 in 23/97 (24%). The probability of survival was calculated by the Kaplan-Meier method collecting data from the perioperative survivors only. The overall 5-year survival was 23% with no significant differences between the en bloc resection and the extrapleural lung resection groups. The most important predictor of survival was the node stage. The 5-year survival for N1 and N2 were 8% and 6%, respectively. These percentages increased to 34% when N0 patients were considered. Other predictors of survival were not significant. The authors conclude that either extrapleural or en bloc chest wall resection are both valid procedures which may be used depending on the depth of local invasion.     

Chest wall invasion in carcinoma of the lung. Therapeutic and prognostic implications

From 1974 through 1983, 125 patients underwent operation at Memorial Sloan-Kettering Cancer Center for non-small cell carcinoma of the lung invading the chest wall. (Excluded are those with superior sulcus tumors or distant metastases at presentation.) Eighty patients were male and 45 were female. Ages ranged from 33 to 88 years (median 60 years). Histologically, the tumors were epidermoid carcinoma in 46%, adenocarcinoma in 46%, and large cell carcinoma in 8%. All patients underwent thoracotomy (pneumonectomy 19, bilobectomy seven, lobectomy 75, wedge resection 10, and no pulmonary resection 14), with an operative mortality of 4%. At thoracotomy, mediastinal lymph node dissection was routinely performed, and the postsurgical stage was T3 N0 M0 in 53%, T3 N1 M0 in 13%, and T3 N2 M0 in 34%. Extrapleural resection was performed in 66 patients. En bloc resection of chest wall and lung was performed in 45 patients with an operative mortality of 2%. Complete resection of tumor was possible in 77 patients (62%). Extension of tumor beyond the parietal pleura significantly decreased resectability. The median survival of 48 patients having incomplete resection was 9 months, despite perioperative interstitial and external radiation. The actuarial 5 year survival rate (Kaplan-Meier) of 77 patients having complete resection was 40%. This percentage was not significantly influenced by the patient's age or sex or by tumor size or histologic type. Lymphatic metastases significantly reduced survival, with a 5 year actuarial survival rate of 56% for patients with T3 N0 M0 disease and 21% for those with T3 N1 M0 or T3 N2 M0 disease (p = 0.005). The extent of tumor invasion of the chest wall appeared to influence survival, but in the absence of lymphatic metastases the difference at 5 years was not significant. Complete resection offers a significant chance for long-term survival in lung cancer directly extending into parietal pleura and chest wall. Extrapleural resection or en bloc chest wall resection can be performed with a low operative mortality and an expected 5 year survival in excess of 50% in the absence of lymphatic metastases.     

Surgery and the management of peripheral lung tumors adherent to the parietal pleura.

Among 37 patients with peripheral T3 lung lesions, preoperative clinical and imaging evidence was suggestive of T3 disease in 28 and of T2 disease in nine. Intraoperatively, the T2 designation was changed to T3 on the basis of adherence of the tumor to the parietal pleura. All had mediastinoscopy followed by resection and complete lymph node dissection. There were 17 lobectomies and 20 pneumonectomies. The chest wall was resected in continuity with the lung in 21 patients, and in 16 only an extrapleural resection was done. Follow-up was completed in all patients (range 2 to 14 years, median 7 years). The 5-year actuarial survival rate for all patients was 30%. As expected, the presence of lymph node metastasis affected the 5-year actuarial survival rate: N0 = 41%; N1 = 29%, and N2 = 0%. Histologic examination of the resected specimen confirmed a T3 lesion in 30 patients. The tumor was removed completely in 100% of patients whose chest wall was resected in continuity with the lung but in only 31% in whom an extrapleural resection was done. In the absence of lymph node metastasis, the 5-year survival rate of patients after en bloc resection of the chest wall was 50% compared with 33% for those with extrapleural resection (p less than 0.05). The finding of a peripheral lung tumor adherent to the parietal pleura indicates, in most instances, extension through the parietal pleura. When tumor is firmly adherent to the parietal pleura, an en bloc resection of the chest wall rather than an extrapleural dissection should be performed. This assures complete tumor removal and improves the probability of long-term survival.     

Resection of chest wall invasion in patients with non-small cell lung cancer

Objective: The treatment of patients with non-small cell lung cancer invading the parietal pleura or chest wall is still debated. It is unsolved whether the depth of chest wall involvement or the type of resection (extrapleural or en bloc) affects long-term survival. Methods: design, retrospective analysis; setting, Hyogo Medical Center for Adults, patients: the 97 patients who underwent surgical resection for non-small cell lung cancer involving the parietal pleura or chest wall between 1985 and 1997 were reviewed. Results: Of the 97 patients, 76 had apparently complete resection, 21 had incomplete resection. The overall 5-year survival of completely resected patients was 34.2%, and that of incompletely resected patients was 14.3% (P=0.0489). In complete resection cases, the chest wall involvement was limited to the parietal pleura in 40, extended into the subpleural soft tissues in 10, and extended into the ribs in 26. The 5-year survivals were 32.5, 30.0 and 38.5%, respectively (no significant difference). The 5-year survival of completely resected patients with T3 N0 M0 disease was 44.2%, T3 N1 M0 disease 40.0%, and T3N2 M0 disease 6.2% (P=0.0019). The 5-year survival of completely resected patients with extrapleural resections was 30.0%, that of en bloc resections 38.9% (no significant difference). Conclusions: Survival of patients with lung cancer invading the chest wall or parietal pleura after resection is highly dependent on the completeness of resection and the extent of nodal involvement, but not so much on the depth of chest wall invasion or type of resection.     

Surgical treatment of Pancoast tumours.

Due to its localisation in the apex of the lung with invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, a superior sulcus tumour causes characteristic symptoms, like arm or shoulder pain or Horner's syndrome. If rib invasion is the only feature, lysis of the rib must be evident on the chest radiograph; otherwise the tumour cannot be defined as a Pancoast tumour. It is important to adequately stage the tumour, because staging significantly influences survival. Survival is better for T3 than T4 tumours and mediastinal lymph node involvement has been found to be a negative prognostic factor. Also Horner's syndrome and incompleteness of resection worsen survival. The management of superior sulcus tumours has evolved over the past 50 years. Before 1950 it was considered to be inoperable and uniformly fatal. Shaw and Paulson introduced combined modality treatment and for many years, this combination of radiotherapy and surgery was the treatment of choice with a mean 5-year survival of approximately 30%. Postoperative radiotherapy or brachytherapy does not improve survival in patients with complete or incomplete resection. The tumour can be resected through the classic posterior Shaw-Paulson approach or the newer anterior transcervical approach, introduced by Dartevelle. This method facilitates better exposure of the extreme apex of the lung, brachial plexus and subclavian vessels. Regarding the extent of pulmonary resection, en bloc resection of the involved ribs with a lobectomy is recommended. Recent multimodality studies, involving chemoradiotherapy and surgical resection, show promising results regarding completeness of resection, local recurrence and survival, provided that appropriate staging has been carried out. However, careful patient selection and adequate perioperative management with protection of the bronchial stump or anastomosis are important to achieve reasonable rates of morbidity and mortality. As brain metastases remain one of the most common forms of relapse, further studies are needed to examine the role of prophylactic cranial irradiation in patients with complete resection. Also the addition of other chemotherapy agents or biologic agents such as angiogenesis inhibitors or tyrosine kinase inhibitors gives a new perspective in the treatment of Pancoast tumours.     

Extent of chest wall invasion and survival in patients with lung cancer.

BACKGROUND: The long-term survival after operation of patients with lung cancer involving the chest wall is known to be related to regional nodal involvement and completeness of resection, but it is not known whether the depth of chest wall involvement or the type of resection (extrapleural or en bloc) affects either the rate of local recurrence or survival. METHODS: We retrospectively reviewed the Memorial Sloan-Kettering Cancer Center experience between 1974 and 1993 of 334 patients undergoing surgical exploration for lung cancer involving the chest wall or parietal pleura. RESULTS: Of 334 patients who underwent exploration, 175 had apparently complete (R0) resections, 94 had incomplete (R1 or R2) resections, and 65 underwent exploration without resection. The overall 5-year survival of R0 patients was 32%, of R1 or R2 patients 4%, and of patients undergoing exploration without resection 0%. In the patients undergoing R0 resections, the extent of chest wall involvement was limited to the parietal pleura in 80 patients, and extended into the ribs or soft tissues in 95. The 5-year survival of R0 patients with T3 N0 M0 disease was 49%, T3 N1 M0 disease 27%, and T3 N2 M0 disease 15% (p < 0.0003). Independent of lymph node involvement, a survival advantage was observed in R0 patients if the chest wall involvement was limited to parietal pleura only, rather than invading into the chest wall musculature or ribs. CONCLUSIONS: Survival of patients with lung cancer invading the chest wall after resection with curative intent is highly dependent on the extent of nodal involvement and the completeness of resection, and much less so on the depth of chest wall invasion.     

En bloc resection for T3 bronchogenic carcinoma with chest wall invasion

From January 1960 to January 1986, 77 patients with lung cancer invading the chest wall underwent operations in the Department of Thoracic Surgery at the University of Rome. Chest pain, alone or with other symptoms, was the presenting complaint in 52 patients (67%). All patients underwent thoracotomy (25 pneumonectomy, 5 bilobectomy, 23 lobectomy, 2 wedge resection, 22 no pulmonary resection), with an operative mortality of 7.8%. At thoracotomy, mediastinal lymph node dissection was performed in 36 cases; after the operation 10 patients were classified as T3 N0 M0, 11 as T3 N1 M0, 15 as T3 N2 M0; 19 patients (34.5%) were staged T3 Nx M0 because mediastinal dissection was not performed. En bloc resection of the chest wall was performed on 37 patients. The actuarial 5-year survival of 55 patients following potentially curative resection was 15%. Five-year survival was 22% for N0, 12% for N1 and 8% for N2 patients. Five-year survival for squamous cell, large cell, and adenocarcinoma was 22%, 10% and 14%, respectively. T3 N0 M0 patients with squamous cell carcinoma had a 5-year survival of 32%. Pain relief was achieved in 45% of our patients. Resection of pulmonary parenchyma and part of the thoracic wall for lung cancer yields palliation of pain in a fairly large number of patients and may result in long-term survival in selected cases.     

Non-small cell lung cancer invading the chest wall

Non-Small cell lung cancer invading the chest wall represents an advanced stage of the disease. Chest wall resection may be achieved in up to 100% of the patients, and the ensuing defect requires to be reconstructed in 40% to 64% of cases. Once a surgical challenge, chest wall resection is no longer a technical problem and en bloc chest wall and lung resections regularly provide good results. However, survival rates are jeopardized by incompleteness of the resection and mediastinal lymph node involvement. Nowadays, the challenge is represented by the use of the other nonsurgical modalities (chemotherapy and radiation therapy) to increase the chance of performing a complete resection, the need to achieve a better control of probable lymphatic or hematogenous spread, and the reduction of the recurrence rate.     

Treatment of bronchogenic carcinoma with chest wall invasion

En bloc resection of chest wall and lung for primary non-small cell bronchogenic carcinoma with chest wall invasion, although often associated with a significant operative mortality, can be performed with a reasonable expectation of long-term survival if lymph nodes are not metastatically involved. Older age appears to decrease long-term survival, but age alone should not abrogate surgical resection. Non-small cell carcinoma cell type, tumor size, depth of chest wall invasion, and extent of chest wall or lung resection do not significantly influence survival.     

Surgical treatment of T3 lung cancer invading the chest wall

Lung tumors invading the chest wall are classed as belonging to the T3 group and are considered potentially resectable. Their management, however, is controversial, and extrapleural resection, when possible, is preferred to en bloc resection which is regarded as a far more invasive and dangerous operation. Five year survival rates for completely resected cases range in the literature from 25 to 35%, but survival rates are much worse if lymph node metastases are present. These poor outcomes have prompted the development of combined surgical approaches: preoperative radiation therapy, with or without chemotherapy, has been used with an improvement in resectability rates, but only modest results in terms of median survival; in a number of case series, increased operative morbidity and mortality have been reported with this approach. The present report relates to 122 patients treated by en bloc (20 cases) or extrapleural (102 cases) resection, 31 of whom also received neoadjuvant treatment. The operative mortality was 4.6%. Median survival was 17 months after en bloc resection and 19 months after extrapleural resection. Though no statistically significant difference was found, extrapleural resection would appear to yield better results than the en bloc procedure.     

Preoperative staging of carcinoma of the bronchus: can computed tomographic scanning reliably identify stage III tumours?

BACKGROUND--The aim of preoperative computed tomographic (CT) assessment of patients with carcinoma of the bronchus is to stage the tumour accurately, and forewarn the surgeon of any possible local extrapulmonary extension of tumour in patients considered to have potentially resectable disease. The ability of CT scanning to differentiate between conventionally resectable lung cancer (TNM stages I and II), locally advanced but resectable lung cancer (TNM stage IIIa), and locally advanced but unresectable lung cancer (TNM stage IIIb) was determined in a group of patients accepted for surgery. METHODS--Computed tomographic scans of 110 patients who underwent thoracotomy for intended resection of carcinoma of the bronchus, including 52 cases with stage III and 58 cases with stage I or II disease, were reviewed and the CT features and radiological interpretations correlated with the surgical and pathological findings. RESULTS--Thirteen CT scans were judged not to have been of diagnostic quality: of the remaining 97 cases 45 had stage III lung cancer, of whom 30 had successful resections, and 52 had stage I or stage II tumours. There was no difference in the frequencies of CT observations--including contiguity of tumour and mediastinum or chest wall, apparent mediastinal or chest wall invasion, proximity of tumour to the carina, mediastinal nodal enlargement, pulmonary collapse or consolidation and pleural effusion--in patients with stage I/II disease and patients with stage III disease. Similar results were found when the same observations were compared in all patients with resected disease and those with unresectable tumour. Sensitivity and specificity of CT was 27% and 96% respectively for tumour unresectability, 50% and 89% for mediastinal invasion, 14% and 99% for chest wall invasion, and 61% and 76% for mediastinal nodal metastases. Only 19 of 45 stage III tumours were correctly identified as being stage III and resectable or unresectable. CONCLUSIONS--In patients being considered for thoracotomy for resection of lung cancer, CT scanning used as the sole method of staging is of limited value for differentiating between stage I/II and stage III tumours. Patients should not be denied the opportunity for curative surgery on the basis of equivocal CT signs.     

Intraoperative diagnosis and treatment of parathyroid cancer and atypical parathyroid adenoma

BACKGROUND: Distinction of parathyroid cancer from atypical parathyroid adenoma (APA) at operation is difficult. The aim of this study was to determine whether parathyroid cancer and APA have different operative findings and long-term outcomes. METHODS: A retrospective review was undertaken of patients with suspicious or malignant parathyroid tumours treated between 1974 and 2005. Parathyroid cancer was defined as a lesion with vascular or tissue invasion, and APA as a neoplasm with broad fibrous bands, trabecular growth, mitosis and nuclear atypia. RESULTS: Twenty-seven patients with suspicious or malignant parathyroid tumours were identified. After histological review, parathyroid cancer was confirmed in 11 patients (group 1) and 16 tumours were classified as APA (group 2). The clinical presentation and operative findings of the two types of tumour were indistinguishable. At initial surgery, seven patients in group 1 underwent en bloc resection, and four had parathyroidectomy. Four of the seven patients who had en bloc resection had recurrences. No recurrences were observed in the other seven patients in group 1 at a median follow-up of 65 months. In group 2, eight patients had en bloc resection and eight had parathyroidectomy; no patient had recurrence at a median follow-up of 91 months. CONCLUSION: Operative findings cannot distinguish APA from parathyroid cancer reliably. Without evidence of macroscopic local invasion, the value of en bloc resection at initial surgery remains debatable.     

Results of en bloc resection for bronchogenic carcinoma with chest wall invasion

OBJECTIVE: Lung cancer invading the chest wall without lymph node metastasis has recently been downstaged to stage IIb. To validate this reclassification, we reviewed our experience with en bloc lung and chest wall resection for bronchogenic carcinoma. METHODS: From February 1985 to November 1999, 95 en bloc lung and chest wall resections were performed on 94 patients (62 men and 32 women). The median age was 66 years (range, 38-93 years). Pancoast tumors were excluded. Factors that may affect survival were analyzed with univariate analysis, and factors found to be significant univariately were analyzed multivariately to determine whether the significant association remained after adjusting for other significant factors. RESULTS: Presenting symptoms included chest wall pain in 42 patients, cough in 17 patients, and "other" in 16 patients. Twenty patients were asymptomatic. Ninety-two patients were current or former smokers (median pack-years, 50; range, 8-150 pack-years). Seventy-five lobectomies, 12 pneumonectomies, 5 bilobectomies, 2 wedge excisions, and 1 segmentectomy were performed. The number of ribs resected ranged from 1 to 5 (median, 3). Sixty-one patients required chest wall reconstruction (prostheses in 60 and bovine pericardium in 1). Operative morbidity and mortality were 44.2% and 6.3%, respectively. Sixty-five cancers were classified as T3 N0 M0, 16 as T3 N1 M0, and 14 as T3 N2 M0. Squamous cell carcinoma was present in 56 tumors, adenocarcinoma in 25, large cell carcinoma in 11, and "other" in 3. Follow-up was complete in 86 (96.6%) of 89 operative survivors and ranged from 1 month to 15 years (median, 19 months). Overall 5-year actuarial survival was 38.7%. Five-year survival for patients with stage IIb disease (T3 N0 M0) was 44.3% compared with only 26.3% for those with stage IIIa disease (T3 N1 M0 or T3 N2 M0, P =.0082). Women had a better 5-year survival than men (52.9% vs 31.0%, P =.0122). The best 5-year survival was observed in women with stage IIb disease (61.2%). All other variables (age, tumor size, histopathology, forced expiratory volume in 1 second, extent of operation, depth of invasion, and adjuvant therapy) did not significantly affect survival. CONCLUSIONS: En bloc resection of lung cancer invading the chest wall is safe but associated with significant morbidity. Long-term survival is stage and sex dependent. The best survival is observed in women who have T3 N0 M0 disease (stage IIb).     

En bloc (non-chest wall) resection for bronchogenic carcinoma with parietal fixation. Factors affecting survival

Seventy-three patients (57 men and 16 women) underwent en bloc resection of lung and attached parietes between 1970 and 1982. All patients had documented malignant pleural invasion. Chest wall parietal pleura was invaded in 33 patients, pericardium in 14, phrenic or vagus nerve in nine, left atrium in five, superior vena cava in four, esophagus in two, diaphragm in one, and multiple structures in five. No patient underwent chest wall resection. Parietal pleurectomy was performed in all patients with involvement of the chest wall parietal pleura; 37 lobectomies and 36 pneumonectomies were performed. Operative mortality was 12.3%. The actuarial overall 5 year survival rate (Kaplan-Meier method) was 39.7%. We conclude that en bloc resection for primary bronchogenic carcinoma with invasion of adjacent intrathoracic structures, although associated with a significant mortality, can be performed with a reasonable likelihood of long-term survival.     

Superior sulcus lung tumors. Results of combined treatment (irradiation and radical resection)

Twenty-one patients underwent combined therapy (irradiation and radical resection) for a Pancoast tumor at the Massachusetts General Hospital between 1976 and 1985. All patients underwent en bloc removal of the apical chest wall and underlying lung. In addition four patients required subclavian artery resection, and in five patients a portion of the vertebral body was resected. There were three operative deaths. Median survival was 24 months and actuarial survival rate was 55% at 3 years and 27% at 5 years. Long-term palliation of pain was achieved in 72% of the patients. Involvement of the subclavian artery, vertebral body, or rib did not preclude long-term survival. Computed tomographic scanning in these patients is often indeterminate regarding invasion of chest wall structures but is more helpful than plain films alone. When compared to recent series in which irradiation alone was used, the combined approach appears to produce better results.     

Results of surgical treatment of T4 non-small cell lung cancer

Objective: Because of location and invasion of surrounding structures, the role of surgical treatment for T4 tumors remains unclear. Extended resections carry a high mortality and should be restricted for selected patients. This study clarifies the selection process in non-small cell T4 tumors with invasion of the mediastinum, recurrent nerve, heart, great vessels, trachea, esophagus, vertebral body, and carina, or with malignant pleural effusion. Methods: From 1977 through 1993, 89 patients underwent resection for primary non-small cell T4 carcinomas. Resection was regarded as complete in 34 patients (38.2%) and incomplete in 55 patients (61.8%). Actuarial survival time was calculated and risk factors for late death were identified. Results: Overall hospital mortality was 19.1% (n=17). Mean 5-year survival was 23.6% for all hospital survivors, 46.2% for patients with complete resection and 10.9% for patients with incomplete resection (P=0.0009). In patients with complete resection, mean 5-year survival for patients with invasion of great vessels was 35.7%, whereas mean 5-year survival for invasion of other structures was 58.3% (P=0.05). Age, mediastinal lymph node involvement, type of operative procedure, and postoperative radiotherapy did not significantly influence survival. Conclusion: In certain T4 tumors complete resection is possible, resulting in good mean 5-year survival especially for tumors with invasion of the trachea or carina. High hospital mortality makes careful patient selection imperative.     

Surgical Treatment of Superior Sulcus Tumors

Purpose To access the clinical outcome of patients with superior sulcus tumor.Methods We reviewed the records of 16 patients who underwent surgery for a superior sulcus tumor between 1988 and 2003, focusing on the type of surgery.Results All 16 patients underwent en bloc lung and chest wall resection, which was done as pneumonectomy in 1 patient and lobectomy in 15. Complete resection was achieved in 11 patients, but incomplete resection was done in 5 patients because microscopic examination revealed positive surgical margins. Eight patients underwent partial vertebrectomy and 1 patient had combined resection of the subclavian artery. There was no postoperative mortality. All patients received pre- or postoperative adjuvant therapy, or both. The overall 5-year survival rate was 31.0%. The 5-year survival rate was higher after complete resection than after incomplete resection (59.3% vs 0%, P = 0.08). Patients who underwent complete resection for vertebral invasion and those who did not had 5-year survival rates of 66.7% and 0%, respectively (P = 0.17). Patients who underwent preoperative induction therapy followed by complete resection and those who did not had 5-year survival rates of 80% and 0%, respectively (P = 0.009).Conclusion Although superior sulcus tumors are still complex, preoperative induction therapy followed by complete resection seemed effective for prolonging survival.     

Characteristics and prognosis of resected T3 non-small cell lung cancer

BACKGROUND: T3 tumors can be divided into several subgroups depending on the type of anatomical structure invaded: chest wall, mediastinal pleura, or main bronchus. The aim of this study was to analyze the characteristics and prognosis of each subgroup of T3 tumors. METHODS: The results of surgical treatment were retrospectively analyzed for 261 patients with T3 non-small cell lung cancer invading either the mediastinal pleura or parietal pericardium by direct extension (mediastinal pT3, n = 68), or main bronchus (bronchial pT3, n = 68), or chest wall (chest wall pT3, n = 125) that were operated on between 1984 and 1996. Complete resection including radical mediastinal lymph node dissection was intended in all patients. One patient had segmentectomy, 91 had lobectomy (34.9%), and 169 had pneumonectomy (64.8%). One hundred and fifty-eight patients received adjuvant radiation therapy and 7 patients received both adjuvant chemotherapy and radiation therapy. Actuarial survival curves were drawn using the Kaplan-Meier method and risk factors for late death were identified. RESULTS: In-hospital mortality was 6.1%. Follow-up was 98% complete. Global 5-year survival was 28%, with survival being not significantly different among the three subgroups: 34.9%, 30.6%, and 22.5% (p = 0.19) in the bronchial pT3, mediastinal pT3, and chest wall pT3 subgroups, respectively. Resection margins were microscopically invaded in 33 patients (12.6%). Seventy-four patients had N1 involvement (28.4%) and 78 patients had N2 involvement (29.8%). N0 involvement was more prevalent in the chest wall pT3 subgroup, whereas N1 involvement was more prevalent in the bronchial pT3 subgroup and N2 involvement was more prevalent among patients with mediastinal invasion. Pathologic factors influencing the 5-year survival were tumor size (p = 0.03) and N involvement (p = 0.003). Histology, type of surgical resection (lobectomy versus pneumonectomy), and use of adjuvant therapy did not influence survival significantly. CONCLUSIONS: Five-year survival was not significantly different among the three subgroups of pT3 non-small cell lung cancer, although bronchial pT3 tumors tended to have a better prognosis and chest wall pT3 tumors tended to have a worse prognosis. The pathologic characteristics of each pT3 subgroup seems different. Further research is warranted to explore the pathologic and biological factors influencing prognosis for each pT3 subgroup.     

En bloc partial vertebrectomy for lung cancer invading the spine after induction chemoradiotherapy.

OBJECTIVE: The optimal surgical treatment for non-small cell lung cancer (NSCLC) with vertebral body invasion remains both controversial and challenging. We reviewed our experiences of NSCLC with vertebral body invasion, in which we have performed induction chemoradiotherapy followed by lung resection with en bloc partial vertebrectomy. METHODS: Six NSCLC patients with vertebral invasion underwent an operation following chemoradiotherapy from January 2001 to July 2006. Vertebral invasion was evaluated by the chest CT and MRI findings. Either carboplatin-paclitaxel (n=3) or carboplatin-docetaxel (n=3) was used. Two cycles of chemotherapy were performed with concurrent radiation (50 Gy) treatment. RESULTS: In all of the six cases, a complete resection with en bloc partial vertebrectomy was performed with no operative mortality. The histological complete response rate and major response rate were 16.7% (1/6) and 83.3% (5/6), respectively. The 5-year overall survival rate was 67.7%. In addition, no local failure was observed after surgery. CONCLUSIONS: Surgery after chemoradiotherapy (carboplatin/paclitaxel or docetaxel and 50 Gy radiation) for NSCLC with vertebral invasion could thus be performed with acceptable morbidity.