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Shea GKH, Kwan KYH. Management of Metastatic Spinal Disease - A Practical Approach. Global Spine J 2024:21925682231173646. [PMID: 39069670 DOI: 10.1177/21925682231173646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/30/2024] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE This review presents a comprehensive approach to the management of spinal metastases. METHODS N/A. RESULTS The wide spectrum of clinical presentation in spinal metastases necessitates a personalized approach to treatment planning. This includes a comprehensive diagnostic workup, oncological management, palliation of symptoms, and surgical intervention if appropriate. A systematic and multidisciplinary approach allows optimal shared decision making to reach an evidence-informed and value-congruent treatment plan for the patient. We highlight how advances in stereotactic body radiotherapy (SBRT) and separation surgery may be incorporated into clinical management from a spine surgeon's perspective. CONCLUSION This review summarizes the approach and management of spinal metastases, its outcomes and complications.
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Affiliation(s)
- Graham Ka Hon Shea
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong
| | - Kenny Yat Hong Kwan
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong
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2
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Unal S, Feller R, Stadhouder A, Heineman D, Jiya TU, van Dorp M, Bahce I, Braun J, Senan S, Dahele M, Dickhoff C. Superior Sulcus Tumors Invading the Spine: Multimodal Treatment Outcomes From the Preimmunotherapy Era. JTO Clin Res Rep 2023; 4:100582. [PMID: 38046379 PMCID: PMC10689281 DOI: 10.1016/j.jtocrr.2023.100582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction Curative-intent treatment of superior sulcus tumors (SSTs) of the lung invading the spine presents considerable challenges. We retrospectively studied outcomes in a single center, uniformly staged patient cohort treated with induction concurrent chemoradiotherapy followed by surgical resection (trimodality therapy). Methods An institutional surgical database from the period between 2002 and 2021 was accessed to identify SSTs in which the resection included removal of at least part of the vertebral body. All patients were staged using fluorodeoxyglucose positron emission tomography (/computed tomography), computed tomography scan of the chest/upper abdomen, and brain imaging. Surgical morbidity was assessed using the Clavien-Dindo classification. Overall and disease-free survival were calculated using the Kaplan-Meier method. Results A total of 18 patients were included: 8 complete and 10 partial vertebrectomies were performed, with six of the eight complete vertebrectomies involving two vertebral levels, resulting in Complete surgical resection (R0) in 94%. Nine patients had a 1-day procedure, and nine were staged over 2 days. The median follow-up was 30 months (interquartile range 11-57). The 90-day postoperative morbidity was 44% (grade III/IV), with no 90-day surgery-related mortality. There were 83% who had a major pathologic response, associated with improved survival (p = 0.044). The 5-year overall and disease-free survival were 55% and 40%, respectively. Disease progression occurred in 10 patients, comprising locoregional recurrences in two and distant metastases in eight patients. Conclusions Multimodality treatment in selected patients with a superior sulcus tumor invading the spine is safe and results in good survival. Such patients should be referred to expert centers. Future research should focus on improving distant control (e.g. [neo]adjuvant immunotherapy).
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Affiliation(s)
- Semih Unal
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ricardo Feller
- Department of Neurosurgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Agnita Stadhouder
- Department of Orthopedic Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - David.J. Heineman
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | | | - Martijn van Dorp
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
| | - Idris Bahce
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Suresh Senan
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Max Dahele
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Department of Radiation Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Chris Dickhoff
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
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Etienne H, Kalt F, Park S, Opitz I. The oncologic efficacy of extended resections for lung cancer. J Surg Oncol 2023; 127:296-307. [PMID: 36630100 DOI: 10.1002/jso.27183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 01/12/2023]
Abstract
Extended lung resections for T3-T4 non-small-cell lung cancer remain challenging. Multimodal management is mandatory in multidisciplinary tumor boards, and here the determination of resectability is key. Long-term oncologic efficacy depends mostly on complete resection (R0) and the extent of N2 disease. The development of novel innovative treatments (targeted therapy and immune checkpoint inhibitors) sets interesting perspectives to reinforce current therapeutic options in the induction and adjuvant setting.
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Affiliation(s)
- Harry Etienne
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Fabian Kalt
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Samina Park
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
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Inci I. Extended Pulmonary Resection for T4 Non-Small Cell Lung Cancer. PRAXIS 2023; 112:103-110. [PMID: 36722106 DOI: 10.1024/1661-8157/a003991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
T4 non-small cell lung cancer is a locally advanced disease with poor prognosis. The operation can be challenging even for an experienced surgeon. N2 disease has been shown repeatedly as a risk factor for poor outcome, and these patients should not be candidates for surgical treatment. Surgery for locally advanced T4 tumors without mediastinal lymph node involvement (T4N0 and T4N1) has been demonstrated to result in good outcomes in carefully selected patients. Patients with T4N0-1M0 should be rejected for surgery only after consulting an expert surgical center. As with other stages, the decision for resectability and surgery should be made by a multidisciplinary team.
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Affiliation(s)
- Ilhan Inci
- Klinik Hirslanden, Chirurgisches Zentrum Zürich, Thoracic Surgery, Zurich, Switzerland
- School of Medicine, University of Zurich, Zurich, Switzerland
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5
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Evolution of the Surgical Management of Lung Cancer Invading the Spine: A Single Center Experience. Curr Oncol 2022; 29:3061-3071. [PMID: 35621638 PMCID: PMC9139927 DOI: 10.3390/curroncol29050248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/15/2022] [Accepted: 04/19/2022] [Indexed: 11/16/2022] Open
Abstract
For patients with locally advanced non-small cell lung cancer invading the spine, induction chemoradiotherapy combined with radical en bloc resection is the key to obtaining long-term survival. With time, our operative technique evolved to a two-step surgery as we experienced numerous perioperative complications during one step surgery. The aim of our study was to assess postoperative morbimortality and long-term survival of both techniques. We retrospectively reviewed all patients who underwent en bloc resection for lung cancer invading the spine between October 2012 and June 2020. Every patient underwent induction therapy. Sixteen patients were included: nine patients were operated on with one step surgery, seven patients were operated on with two step interventions. Twenty-five percent of patients had major perioperative complications and 56.2% of patients had major post-operative complications. Patients in the “one step” group tended to have more perioperative complications whereas patients in the “two step” group tended to have more post-operative complications. Overall 3-year survival was 40% in the one-step and 86% in the two-step surgery group. Although our practice has been improved by two-step interventions, post-operative morbidity remains significant. As long term survivals are encouraging, this type of treatment should still be proposed for highly selected patients, in specialized centers.
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Hireche K, Moqaddam M, Lonjon N, Marty-Ané C, Solovei L, Ozdemir BA, Canaud L, Alric P. Combined video-assisted thoracoscopy surgery and posterior midline incision for en bloc resection of non-small-cell lung cancer invading the spine. Interact Cardiovasc Thorac Surg 2022; 34:74-80. [PMID: 34999810 PMCID: PMC8932506 DOI: 10.1093/icvts/ivab215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This article aims to evaluate the feasibility and safety of a hybrid video-assisted thoracic surgery (VATS) approach to achieve en bloc lobectomy and spinal resection for non-small-cell lung cancer (NSCLC). METHODS Between October 2015 and November 2020, 10 patients underwent VATS anatomical lobectomy and en bloc chest wall and spinal resection through a limited posterior midline incision as a single operation for T4 (vertebral involvement) lung cancer. Nine patients had Pancoast syndrome without vascular involvement and 1 patient had NSCLC of the right lower lobe with invasion of T9 and T10. RESULTS There were 5 men and 5 women. The mean age was 61 years (range: 47-74 years). Induction treatment was administered to 9 patients (90%). The average operative time was 315.5 min (range: 250-375 min). The average blood loss was 665 ml (range: 100-2500 ml). Spinal resection was hemivertebrectomy in 6 patients and wedge corpectomy in 4 patients. Complete resection (R0) was achieved in all patients. The average hospitalization stay was 14 days (range: 6-50 days). There was no in-hospital mortality. The mean follow-up was 32.3 months (range: 6-66 months). Six patients (60%) are alive without recurrence. CONCLUSIONS VATS is feasible and safe to achieve en bloc resection of NSCLC inviding the spine without compromising oncological efficacy. Further experience and longer follow-up are needed to determine if this approach provides any advantages over thoracotomy.
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Affiliation(s)
- Kheira Hireche
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Mathieu Moqaddam
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Nicolas Lonjon
- Department of Neurosurgery, Gui de Chauliac Hospital, Montpellier, France
- PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Charles Marty-Ané
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Laurence Solovei
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Baris Ata Ozdemir
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- University of Bristol, Bristol, UK
| | - Ludovic Canaud
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Pierre Alric
- Department of Thoracic and Vascular Surgery, Arnaud de Villeneuve Hospital, Montpellier, France
- PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
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7
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Tfayli AH, Sfeir PM, Youssef BY, Khuri FR. Locally advanced lung cancer. CA Cancer J Clin 2021; 71:461-465. [PMID: 34491576 DOI: 10.3322/caac.21698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/10/2021] [Accepted: 08/10/2021] [Indexed: 12/25/2022] Open
Affiliation(s)
- Arafat H Tfayli
- Department of Internal Medicine, Division of Hematology/Oncology, American University of Beirut, Beirut, Lebanon
| | - Pierre M Sfeir
- Department of Surgery, American University of Beirut, Beirut, Lebanon
| | - Bassem Y Youssef
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Fadlo R Khuri
- President, American University of Beirut, Beirut, Lebanon
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8
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Hexiao T, Yuquan B, Lecai X, Yanhong W, Li S, Weidong H, Ming X, Xuefeng Z, Gaofeng P, Li Z, Minglin Z, Zheng T, Zetian Y, Xiao Z, Yi C, Lanuti M, Jinping Z. Knockdown of CENPF inhibits the progression of lung adenocarcinoma mediated by ERβ2/5 pathway. Aging (Albany NY) 2021; 13:2604-2625. [PMID: 33428600 PMCID: PMC7880349 DOI: 10.18632/aging.202303] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 09/05/2020] [Indexed: 01/21/2023]
Abstract
Many studies have reported that estrogen (E2) promotes lung cancer by binding to nuclear estrogen receptors (ER), and altering ER related nuclear protein expressions. With the GEO database analysis, Human centromere protein F (CENPF) is highly expressed in lung adenocarcinoma (LUAD), and the co-expression of CENPF and ERβ was found in the nucleus of LUAD cells through immunofluorescence. We identified the nuclear protein CENPF and explored its relationship with the ER pathway. CENPF and ERβ2/5 were related with T stage and poor prognosis (P<0.05). CENPF knockout significantly inhibited LUAD cell growth, the tumor growth of mice and the expression of ERβ2/5 (P<0.05). The protein expression of CENPF and ERβ2/5 in the CENPF-Knockdown+Fulvestrant group was lower than CENPF- Negative Control +Fulvestrant group (P=0.002, 0.004, 0.001) in A549 cells. The tumor size and weight of the CENPF-Knockdown+Fulvestrant group were significantly lower than CENPF- Negative Control +Fulvestrant group (P=0.001, 0.039) in nude mice. All the results indicated that both CENPF and ERβ2/5 play important roles in the progression of LUAD, and knockdown CENPF can inhibit the progression of LUAD by inhibiting the expression of ER2/5. Thus, the development of inhibitors against ERβ2/5 and CENPF remained more effective in improving the therapeutic effect of LUAD.
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Affiliation(s)
- Tang Hexiao
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Bai Yuquan
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiong Lecai
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Wei Yanhong
- Department of Geriatrics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shen Li
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Hu Weidong
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xu Ming
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhou Xuefeng
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Pan Gaofeng
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhang Li
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhu Minglin
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Tang Zheng
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yang Zetian
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zhou Xiao
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Cai Yi
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Michael Lanuti
- Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Zhao Jinping
- Department of Thoracic Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
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9
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Loi M, Mazzella A, Desideri I, Fournel L, Hamelin EC, Icard P, Bobbio A, Alifano M. Chest wall resection and reconstruction for lung cancer: surgical techniques and example of integrated multimodality approach. J Thorac Dis 2020; 12:22-30. [PMID: 32055420 DOI: 10.21037/jtd.2019.07.81] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Mauro Loi
- Department of Thoracic Surgery, Paris-Center University Hospital, AP-HP, Paris Descartes University, Paris, France.,Department of Radiotherapy, Hospital Tenon, Paris, France
| | - Antonio Mazzella
- Department of Thoracic Surgery, Paris-Center University Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Isacco Desideri
- Department of Radiotherapy, Università di Firenze, Firenze, Italy
| | - Ludovic Fournel
- Department of Thoracic Surgery, Paris-Center University Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Emelyne Canny Hamelin
- Department of Thoracic Surgery, Paris-Center University Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Philippe Icard
- Department of Thoracic Surgery, Paris-Center University Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Antonio Bobbio
- Department of Thoracic Surgery, Paris-Center University Hospital, AP-HP, Paris Descartes University, Paris, France
| | - Marco Alifano
- Department of Thoracic Surgery, Paris-Center University Hospital, AP-HP, Paris Descartes University, Paris, France
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En Bloc Resection of Thoracic Tumors Invading the Spine: A Single-Center Experience. Ann Thorac Surg 2019; 108:227-234. [PMID: 30885851 DOI: 10.1016/j.athoracsur.2019.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Vertebral involvement by a thoracic tumor has long been considered as a limit to surgical treatment, and despite advances, such an invasive operation remains controversial. The aim of this study was to characterize a single-center cohort and to evaluate the outcome, focusing on survival and complications. METHODS We retrospectively reviewed the data of all patients operated on for tumors involving the thoracic spine in an 8-year period. En bloc resection was generally performed by a double team involving thoracic and orthopedic surgeons. Distant follow-up was recorded for oncologic and functional analysis. RESULTS There were 31 patients operated on. An induction therapy was administered in 20 patients. Spinal resection (mostly including ≥2 vertebral levels) was combined with lobectomy in 48.3% of the patients, and osteosynthesis was required in 22 patients. We observed no in-hospital death and a major complications rate of 32.3%, including 5 patients with early neurologic complications. There were 61.3% primary lung carcinomas, 12.9% extrapulmonary primaries, 9.7% metastases, and 16.1% benign tumors. Mean follow-up was 32.1 months. The 5-year overall survival rate was 81.3% in the entire cohort and 75.0% in patients with a malignant tumor. Occurrence of an early postoperative major complication was the only factor significantly associated with shorter overall survival (p = 0.03). The 5-year disease-free survival rate was 37.0% in malignancies. Delayed complications occurred in 35.5% of patients, including persistent neurologic deficit in 12.9%, instrumentation migration in 19.4%, and local infection in 12.9%. CONCLUSIONS En bloc resection of spinal thoracic tumors offers long-term survival and few recurrences in highly selected patients but is associated with significant delayed mechanical or infectious complications.
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Ng S, Boetto J, Poulen G, Berthet JP, Marty-Ane C, Lonjon N. Partial Vertebrectomies without Instrumented Stabilization During En Bloc Resection of Primary Bronchogenic Carcinomas Invading the Spine: Feasibility Study and Results on Spine Balance. World Neurosurg 2019; 122:e1542-e1550. [DOI: 10.1016/j.wneu.2018.11.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/11/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
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Ilonen I, Jones DR. Initial extended resection or neoadjuvant therapy for T4 non-small cell lung cancer-What is the evidence? ACTA ACUST UNITED AC 2018; 2. [PMID: 30498811 DOI: 10.21037/shc.2018.09.08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Locally advanced non-small cell lung cancer (NSCLC) tumors that invade surrounding structures within the chest (T4) are a heterogeneous group, and, as such, there are no straightforward guidelines for their management. Advances in imaging, invasive mediastinal staging, and neoadjuvant therapies have expanded the role of surgery with curative intent for this patient group and have also diminished the rate of explorative thoracotomies. Unlike for T4 superior sulcus tumors, the use of neoadjuvant therapy for central T4 tumors is not clearly defined. The most important determinants of a successful outcome after surgery are achieving an R0 resection and avoiding incidental pathologic N2 disease. Use of neoadjuvant therapy in this setting may yield better outcomes after surgery, as both of these variables can be altered if the tumor responds to neoadjuvant therapy. Moreover, response to induction therapy has been shown to have prognostic value.
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Affiliation(s)
- Ilkka Ilonen
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David R Jones
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Sato S, Goto T, Koike T, Okamoto T, Shoji H, Ohashi M, Watanabe K, Tsuchida M. One-stage surgery in combination with thoracic endovascular grafting and resection of T4 lung cancer invading the thoracic aorta and spine. J Thorac Dis 2017; 9:E1009-E1012. [PMID: 29268560 DOI: 10.21037/jtd.2017.10.101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A novel strategy of one-stage surgery in combination with thoracic endovascular grafting and resection for T4 lung cancer invading the thoracic aorta and spine is described. A 56-year-old man with locally advanced lung cancer infiltrating the aortic wall and spine underwent neoadjuvant chemotherapy and thoracic irradiation, followed by en bloc resection of the aortic wall and spine with thoracic endovascular grafting. He developed postoperative chylothorax, but there were no stent graft-related events. After 3 months, computed tomography (CT) did not show aortic stent graft stenosis, migration, or deformation.
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Affiliation(s)
- Seijiro Sato
- Division of Thoracic and Cardiovascular Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tatsuya Goto
- Division of Thoracic and Cardiovascular Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Terumoto Koike
- Division of Thoracic and Cardiovascular Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takeshi Okamoto
- Division of Thoracic and Cardiovascular Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hirokazu Shoji
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Masayuki Ohashi
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kei Watanabe
- Division of Orthopedic Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Masanori Tsuchida
- Division of Thoracic and Cardiovascular Surgery, Department of Regenerative and Transplant Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Mody GN, Bravo Iñiguez C, Armstrong K, Perez Martinez M, Ferrone M, Bono C, Chi JH, Wee JO, Lebenthal A, Swanson SJ, Colson YL, Bueno R, Jaklitsch MT. Early Surgical Outcomes of En Bloc Resection Requiring Vertebrectomy for Malignancy Invading the Thoracic Spine. Ann Thorac Surg 2016; 101:231-6; discussion 236-7. [DOI: 10.1016/j.athoracsur.2015.05.113] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 05/11/2015] [Accepted: 05/15/2015] [Indexed: 11/16/2022]
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15
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[Intrapericardial Vessel Management for Lung Cancer Surgery]. J UOEH 2015; 37:191-4. [PMID: 26370042 DOI: 10.7888/juoeh.37.191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Intrapericardial vessel management is one of the necessary techniques for respiratory surgeons. We collected cases that had undergone intrapericardial vessel management for lung cancer, and herein discuss the practical performance and safety of this treatment method. We identified 23 (5.6%) of 413 patients who had undergone lung cancer surgery during the 30-month period from January 2011 to June 2013 at our institution. Twenty cases had large sized tumors near the hilum. Three cases demonstrated severe adhesion in the intrathoracic region due to a previous operation. The lung cancer staging was stage ⅠA in 1 case, stage ⅠB in 4 cases, stage ⅡB in 5 cases, stage ⅢA in 11 cases, stage ⅢB in 1 case, and stage Ⅳ in 1 case. We performed lobectomy in 11 cases, bilobectomy in 6 cases, and pneumonectomy in 6 cases. The average operation time was 366 minutes (137-965). Post operative complications were observed in five cases, including two cases of air-leakage and three cases of arrhythmia. All cases were able to walk on foot at discharge. It is important to clearly understand intrapericardial anatomy in order to carry out successful intrapericadial vessel management.
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Surgical management of locally advanced lung cancer. Gen Thorac Cardiovasc Surg 2014; 62:522-30. [DOI: 10.1007/s11748-014-0425-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Indexed: 11/25/2022]
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Thoracic aortic endografting facilitates the resection of tumors infiltrating the aorta. J Thorac Cardiovasc Surg 2014; 147:1178-82; discussion 1182. [DOI: 10.1016/j.jtcvs.2013.12.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/18/2013] [Accepted: 12/09/2013] [Indexed: 11/20/2022]
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Long-Term Outcome after En Bloc Resection of Non–Small-Cell Lung Cancer Invading the Pulmonary Sulcus and Spine. J Thorac Oncol 2013; 8:1538-44. [DOI: 10.1097/01.jto.0000437419.31348.a4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kozower BD, Larner JM, Detterbeck FC, Jones DR. Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e369S-e399S. [PMID: 23649447 DOI: 10.1378/chest.12-2362] [Citation(s) in RCA: 244] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement. METHODS The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians. RESULTS In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered. CONCLUSIONS Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.
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Affiliation(s)
- Benjamin D Kozower
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA
| | - James M Larner
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Frank C Detterbeck
- Division of Thoracic Surgery, Yale University School of Medicine, New Haven, CT
| | - David R Jones
- Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA.
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Deslauriers J, Tronc F, Fortin D. Management of tumors involving the chest wall including pancoast tumors and tumors invading the spine. Thorac Surg Clin 2013; 23:313-25. [PMID: 23931015 DOI: 10.1016/j.thorsurg.2013.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Bronchogenic carcinomas involving the chest wall include tumors invading the ribs and spine, as well as Pancoast tumors. In the past, such neoplasms were considered to be incurable, but with new multimodality regimens, including induction chemoradiation followed by surgery, they can now be completely resected and patients can benefit from prolonged survival. The most important prognostic factors are the completeness of resection and the pathologic nodal status.
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Affiliation(s)
- Jean Deslauriers
- Division of Thoracic Surgery, Institut universitaire de cardiologie et de pneumologie de Québec (IUCPQ), Laval University, 2725 chemin Sainte-Foy, L-3540, Quebec City, Quebec G1V 4G5, Canada.
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Stoker GE, Buchowski JM, Kelly MP, Meyers BF, Patterson GA. Video-assisted thoracoscopic surgery with posterior spinal reconstruction for the resection of upper lobe lung tumors involving the spine. Spine J 2013; 13:68-76. [PMID: 23295033 DOI: 10.1016/j.spinee.2012.11.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 08/11/2012] [Accepted: 11/16/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Video-assisted thoracoscopic surgery (VATS) is associated with less morbidity and recovery time compared with traditional open thoracotomy (OT) for the resection of early stage non-small cell lung cancer (NSCLC). Local invasion of NSCLC into adjacent vertebrae confers a TNM T status of T4. Anatomical lobectomy by VATS with simultaneous posterior spinal reconstruction (PSR), as a single procedure, offers advantages to selected patients judged as suitable candidates for resection. PURPOSE To report the preliminary results of a novel, multidisciplinary surgical technique for the treatment of upper lobe lung cancers with direct extension to the spine. STUDY DESIGN Consecutive case series. PATIENT SAMPLE Eight adults who underwent PSR with either VATS or OT for the treatment of a T4 (vertebral body invasion) NSCLC. OUTCOME MEASURES Total operative time, estimated blood loss, length of hospital stay, postoperative tumor recurrence and metastasis, survival, reoperations, and any other intraoperative or postoperative complication. METHODS Eight consecutive patients who underwent instrumented PSR with corpectomy for the treatment of an upper lobe NSCLC at a single institution were identified. Either VATS (n=4) or OT (n=4) was performed at the time of the reconstruction in each patient. All tumors were stage III NSCLC without metastasis. RESULTS Patients who underwent VATS and OT were aged 54±11 and 54±2.9 years, respectively. Mean operative time and blood loss were similar between the groups: VATS: 367±117 minutes versus OT: 518±264 minutes; VATS: 813±463 mL versus OT: 1,250±1,500 mL. Mean follow-up was 16±13 months after surgery. Complications occurred in all eight patients. One OT patient had wound dehiscence requiring a tissue flap, and another suffered from a septic shock. No wound complications developed after VATS. Death secondary to tumor recurrence occurred once in each group. For the six surviving patients, 23±15 months (range, 4.5-43 months) have elapsed since surgery. CONCLUSIONS Video-assisted thoracoscopic surgery with PSR is a novel and viable method for the complete resection of T4 NSCLC.
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Affiliation(s)
- Geoffrey E Stoker
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 S. Euclid Ave., West Pavilion Suite 11300, Campus Box 8233, St. Louis, MO 63110, USA
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de Perrot M, Rampersaud R. Surgical approaches to apical thoracic malignancies. J Thorac Cardiovasc Surg 2012; 144:72-80. [DOI: 10.1016/j.jtcvs.2012.03.049] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 03/14/2012] [Accepted: 03/19/2012] [Indexed: 12/01/2022]
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Isobe K, Hata Y, Sakaguchi S, Sato F, Takahashi S, Sato K, Sano G, Sugino K, Sakamoto S, Takai Y, Mitsuda A, Terahara A, Shibuya K, Takagi K, Homma S. Pathological response and prognosis of stage III non-small cell lung cancer patients treated with induction chemoradiation. Asia Pac J Clin Oncol 2012; 8:260-6. [PMID: 22897895 DOI: 10.1111/j.1743-7563.2012.01529.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM The aim of this study was to clarify the relationship between pathological effects and the prognosis of patients with stage III non-small cell lung cancer (NSCLC) treated with induction chemoradiation. METHODS Patients who were untreated and potentially resectable with stage III NSCLC were enrolled. They received carboplatin and docetaxel with concurrent radiotherapy (5 × 2 Gy/week with a total dose of 40 Gy) followed by surgery. We assessed the relationship between the pathological effect (Ef) (Ef 1: slight pathological response, Ef 2: moderate pathological response, Ef 3: complete pathological response) and prognosis. RESULTS In all, 30 patients with stage III NSCLC (24 men and 6 women, mean age 60.7 years, 17 with adenocarcinomas and 13 with squamous cell carcinomas, 21 with clinical stage IIIA and nine with stage IIIB) participated in the trial and underwent induction chemoradiation. A total of 27 patients (90%) with complete response, partial response and stable disease had surgical resection. The pathological effect was Ef 1 and Ef 2 in 10 patients each, and Ef 3 in seven patients. Median survival was 10.9 months in patients with Ef 1 and 49.6 months in patients with Ef 2. Six out of seven Ef 3 patients are alive at the time of writing with a mean survival of 77.1 months (14-104 months). There was a significant difference in overall survival based on pathological effect rating (P = 0.0036). CONCLUSION The Ef rating was well correlated with prognosis after induction chemoradiation.
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Affiliation(s)
- Kazutoshi Isobe
- Department of Respiratory Medicine, Toho University Omori Medical Center, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, Japan.
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Fadel E, Missenard G, Court C, Mercier O, Mussot S, Fabre D, Dartevelle P. Long-Term Outcomes of En Bloc Resection of Non-Small Cell Lung Cancer Invading the Thoracic Inlet and Spine. Ann Thorac Surg 2011; 92:1024-30; discussion 1030. [DOI: 10.1016/j.athoracsur.2011.04.100] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 04/12/2011] [Accepted: 04/15/2011] [Indexed: 10/17/2022]
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Abstract
OBJECTIVE In 2009, a new TNM staging system was published by the International Union Against Cancer and the American Joint Committee on Cancer. The new edition will encompass non-small cell lung cancer, small cell lung cancer, and bronchopulmonary carcinoids. This article will review many important changes that have been made in the revised staging system. CONCLUSION It is important that radiologists learn the new system and understand the reasons for the changes to provide more accurate clinical staging.
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What is the role for surgery in patients with stage III non-small cell lung cancer? Curr Opin Pulm Med 2009; 15:295-302. [PMID: 19465855 DOI: 10.1097/mcp.0b013e32832cbefc] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Locally advanced non-small cell lung cancer (NSCLC) represents a therapeutic challenge. Although combined modality has become the standard treatment in stage III NSCLC, the role of surgery in it remains controversial. This review will address recent evidence on the potential role of surgery in either superior sulcus tumors, T4N0-1 tumors with central extension multifocal tumors with nodule(s) in the same lobe, or stage III disease with mediastinal lymph node involvement. RECENT FINDINGS Two recent phase 2 trials, exploring surgical resection preceded by induction chemoradiotherapy for tumors of the superior sulcus, have reported an impressive survival with acceptable mortality rate. They confirm the outcome observed in other prospective and retrospective series for T3-4N0-1. For subsets of T4 NSCLC with central extension or with satellite nodule(s) in the primary lobe, cumulative data suggest that these tumors behave differently than other stage IIIB tumors and might benefit from upfront surgery, possibly followed by postoperative chemotherapy and/or radiotherapy. Whenever clinical mediastinal lymph node invasion is present, surgery after induction treatment is not proven superior to radiotherapy, and is best restricted to clinical trials. SUMMARY Combined modality treatment is the standard of care for locally advanced NSCLC and the optimal role for surgery remains a challenging issue for the clinicians.
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