Factors affecting long-term survival after en-bloc resection of lung cancer invading the chest wall

En bloc chest wall resection in locally advanced cT3N2 (stage IIIB) lung cancer involving the chest wall: Revisiting guidelines

Objectives

Current National Comprehensive Cancer Network guidelines recommend definitive chemoradiation rather than surgery for patients with locally advanced clinical stage T3 and N2 (stage IIIB) lung cancer involving the chest wall. The data supporting this recommendation are controversial. We studied whether surgery confers a survival advantage over definitive chemoradiation in the National Cancer Database.

Methods

We identified all patients with clinical stage T3 and N2 lung cancer in the National Cancer Database from 2004 to 2017 who underwent a lobectomy with en bloc chest wall resection and compared them with patients with clinical stage T3 and N2 lung cancer who had definitive chemoradiation. We used propensity score matching to minimize confounding by indication while excluding patients with tumors in the upper lobes to exclude Pancoast tumors. We used 1:1 propensity score matching and Kaplan-Meir survival analyses to estimate associations.

Results

Of 4467 patients meeting all inclusion/exclusion criteria, 210 (4.49%) had an en bloc chest wall resection. Patients undergoing surgical resection were younger (mean age = 60.3 ± 10.3 years vs 67.5 ± 10.4 years; P < .001) and had more adenocarcinoma (59.0% vs 44.5%; P < .001) but were otherwise similar in terms of sex (37.1% female vs 42.0%; P = .167) and race (Whites 84.3% vs 84.0%; P = .276) compared with the definitive chemoradiation group. After resection, there was an unadjusted 30- and 90-day mortality rate of 3.3% and 9.5%, respectively. A substantial survival benefit with surgical resection persisted after propensity score matching (log-rank P < .001).

Conclusions

In this large observational study, we found that in select patients, en bloc chest wall resection for locally advanced clinical stage T3 and N2 lung cancer was associated with improved survival compared with definitive chemoradiation. National Comprehensive Cancer Network guidelines should be revisited.

New perspectives in prosthetic reconstruction in chest wall resection

The extension of chest wall resection for the treatment of primary and secondary tumours is still widely debated. The reconstructive strategy after extensive surgery is challenging as well as chest wall demolition itself. Reconstructive surgery aims to avoid respiratory failure and to guarantee intra-thoracic organs protection. The purpose of this review is to analyse the literature on this issue focusing on the planning strategy for chest wall reconstruction. This is a narrative review, reporting data from the most interesting studies on chest wall demolition and reconstruction. Representative surgical series on chest wall thoracic surgery were selected and described. We focused to identify the best reconstructive strategies analyzing employed materials, techniques of reconstruction, morbidity and mortality. Nowadays the new "bio-mimetic" materials in "rigid" and "non-rigid" chest wall systems reconstructive represent new horizons for the treatment of challenging thoracic diseases. Further prospective studies are warranted to identify new materials enhancing thoracic function after major thoracic excisions.

Multimodality therapy for lung cancer invading the chest wall: A study of the French EPITHOR database

OBJECTIVES

According to a nation-based study, we intend to report the data of the patients operated on for lung cancer invading the chest wall, taking into consideration the completion of induction chemotherapy (Ind_CT), induction radiochemotherapy (Ind_RCT) or no induction therapy (0_Ind).

MATERIALS AND METHODS

All patients with a primary lung cancer invading the chest wall who underwent radical resection from 2004 to 2019 were included. Superior sulcus tumors were excluded.

RESULTS

Overall, 688 patients were included: 522 operated without induction therapy, 101 with Ind_CT and 65 with Ind_RCT. Postoperative 90-day mortality was 10.7% in the 0_Ind group, 5.0% in the Ind_CT group, 7.7% in the Ind_RCT group (p = 0.17). Incomplete resection rate was 14.0% in the 0_Ind group, 6.9% in the Ind_CT group, 6.2% in the Ind_RCT group (p = 0.04). In the 0_Ind group, 70% of the patients received adjuvant therapies. Overall survival (OS) analysis disclosed the best long-term outcomes in the Ind_RCT group (5-year OS probability: 56.5% versus 40.0% and 40.5% for 0_Ind and Ind_CT groups, respectively; p = 0.035). At multivariable analysis, Ind_RCT (HR = 0.571; p = 0.008), age > 60 years old (HR = 1,373; p = 0.005), male sex (HR = 1.710; p < 0.001), pneumonectomy (HR = 1.368; p = 0.025), pN2 status (HR = 1.981; p < 0.001), ≥3 resected ribs (HR = 1.329; p = 0.019), incomplete resection (HR = 2.284; p < 0.001) and lack of adjuvant therapy (HR = 1.959; p < 0.001) were associated with OS. Ind_CT was not associated with survival (HR = 0.848; p = 0.257).

CONCLUSION

Induction chemoradiation therapy seems to improve survival. Therefore, the present results should be confirmed by a prospective randomized trial testing the benefit of induction radiochemotherapy for NSCLC invading the chest wall.

Prognostic relevance of rib invasion and modification of T description for resected NSCLC patients: A propensity score matching analysis of the SEER database

Introduction

The impact of rib invasion on the non-small cell lung cancer (NSCLC) T classifications remains unclear. Our study aims to verify the impact of rib invasion on survival in patients with NSCLC through multicenter data from the Surveillance, Epidemiology, and End Results (SEER) database, and proposed a more appropriate pT for the forthcoming 9^th tumor-node-metastasis (TNM) classifications.

Method

The SEER database was used to collect T_2b-4N_0-2M₀ NSCLC cases from the period of 2010-2015 according to the 7^th TNM classification system. Subsequently, the T classification was restaged according to the 8^th TNM classification system based on the following codes: tumor size and tumor extension. Cases with T1-2 disease and incomplete clinicopathological information were excluded. Finally, 6479 T3 and T4 NSCLC patients were included in the present study and divided into a rib invasion group (n = 131), other pT3 group (n = 3835), and pT4 group (n = 2513). Propensity-score matching (PSM) balanced the known confounders of the prognosis, resulting in two sets (rib invasion group vs. other pT3 and pT4 group). Overall survival (OS) and cancer-specific survival (CSS) were investigated using Kaplan-Meier survival curves, and predictive factors of OS and CSS were assessed by Cox regression.

Result

Survival outcomes of the rib invasion group were worse than the other pT3 group (OS: 40.5% vs. 46.5%, p = 0.035; CSS: 49.2% vs. 55.5%, p = 0.047), but comparable to the pT4 group (OS: 40.5% vs. 39.9%, p = 0.876; CSS: 49.2% vs. 46.3%, p = 0.659). Similar results were obtained after PSM. Multivariate analyses for all patients revealed that age at diagnosis, gender, N stage, T stage, surgical modalities, and adjuvant therapy had a predictive value for the prognosis.

Conclusion

The rib invasion group had a worse prognosis than the other pT3 groups, but was similar to the pT4 group. Our recommendation is to change the classification of rib invasion to pT4 disease and further validate this in the forthcoming 9^th TNM classification.

The Difference and Significance of Parietal Pleura Invasion and Rib Invasion in Pathological T Classification With Non-Small Cell Lung Cancer

Objective

This study was to explore the difference and significance of parietal pleura invasion and rib invasion in pathological T classification with non-small cell lung cancer.

Methods

A total of 8681 patients after lung resection were selected to perform analyses. Multivariable Cox analysis was used to identify the mortality differences in patients between parietal pleura invasion and rib invasion. Eligible patients with chest wall invasion were re-categorized according to the prognosis. Cancer-specific survival curves for different pathological T (pT) classifications were presented.

Results

There were 466 patients considered parietal pleura invasion, and 237 patients served as rib invasion. Cases with rib invasion had poorer survival than those with the invasion of parietal pleura (adjusted hazard ratio [HR]= 1.627, P =0.004). In the cohort for parietal pleura invasion, patients with tumor size ≤5cm reached more satisfactory survival outcomes than patients with tumor size >5cm (unadjusted HR =1.598, P =0.006). However, there was no predictive difference in the cohort of rib invasion. The results of the multivariable analysis revealed that the mortality with parietal pleura invasion plus tumor size ≤5cm were similar to patients with classification pT3 (P =0.761), and patients for parietal pleura invasion plus tumor size >5cm and pT4 had no stratified survival outcome (P =0.809). Patients identified as rib invasion had a poorer prognosis than patients for pT4 (P =0.037).

Conclusions

Rib invasion has a poorer prognosis than pT4. Patients with parietal pleura invasion and tumor size with 5.1-7.0cm could be appropriately up-classified from pT3 to pT4.

Prognostic factors following complete resection of non-superior sulcus lung cancer invading the chest wall

OBJECTIVES

Locally advanced non-small-cell lung cancer (NSCLC) with chest wall invasion carries a high risk of recurrence and portends poor survival (30-40% and 20-50%, respectively). No studies have identified prognostic factors in patients who underwent R0 resection for non-superior sulcus NSCLC.

METHODS

A retrospective review was conducted for all chest wall resections for NSCLC from 2004 to 2018. Patients with superior sulcus tumours, partial (<1 rib) or incomplete (R1/R2) resection or distant metastasis were excluded. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Cox proportional hazards modelling was used to determine factors associated with DFS and OS.

RESULTS

A total of 100 patients met inclusion criteria. Seventy-three (73%) patients underwent induction therapy, and all but 12 (16%) patients experienced a partial radiological response. A median of 3 ribs was resected (range 1-7), and 67 (67%) patients underwent chest wall reconstruction. The 5-year DFS and OS were 36% and 45%, respectively. Pathological N2 status [hazard ratio (HR) 3.12, confidence interval (CI) 1.56-6.25; P = 0.001], intraoperative blood transfusion (HR 2.24, CI 1.28-3.92; P = 0.005) and preoperative forced vital capacity (per % forced vital capacity, HR 0.97, CI 0.96-0.99; P = 0.013) were associated with DFS. Increasing pathological stage, lack of radiological response to induction therapy (HR 7.35, CI 2.35-22.99; P = 0.001) and cardiovascular comorbidity (HR 2.43, CI 1.36-4.36; P = 0.003) were associated with OS.

CONCLUSIONS

We demonstrate that blood transfusion and forced vital capacity are associated with DFS after R0 resection for non-superior sulcus NSCLC, while radiological response to induction therapy greatly influences OS. We confirm that pathological nodal status and pathological stage are reproducible determinants of DFS and OS, respectively.

En bloc resection of a T4B stage cancer of the hepatic flexure of the colon invading the liver, gall bladder, and pancreas/duodenum: A case report

A T4B hepatic flexure of colon cancer that had invaded the liver, gall bladder, and pancreas/duodenum was removed through a D3 expanded right hemicolectomy + pancreaticoduodenectomy +sectional VI and VII hepatic segmentectomy.

Treatment of T3N0 non-small cell lung cancer with chest wall invasion using stereotactic body radiotherapy

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The role of SBRT for T3N0 lung cancer invading the chest wall is unknown.

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We treated 12 patients with T3N0 chest wall-invading lung cancer with SBRT.

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Local control was excellent and no grade 3+ toxicity was observed.

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Pre-treatment chest wall pain was relieved after SBRT in most patients.

Objectives

Chest wall invasion (CWI) is observed in 5% of localized non-small cell lung cancer (NSCLC). The role of stereotactic body radiotherapy (SBRT) in these patients is unknown. We investigate the safety and efficacy of SBRT in patients with T3N0 NSCLC due to CWI.

Methods

Patients with T3N0 NSCLC due to CWI were identified using a prospective registry. CWI was defined as radiographic evidence of soft tissue invasion or bony destruction. We excluded patients with recurrent or metastatic disease. All patients were treated with definitive SBRT. Prescribed dose was 50 Gy in 5 fractions for most patients. Kaplan-Meier analysis was used to estimate survival outcomes.

Results

We identified 12 patients treated between 2006 and 2017. Median age was 70 (range, 58–85). Median tumor diameter was 3.0 cm (range, 0.9–7.2). Median survival was 12.0 months (range, 2.4–63). At a median follow-up of 8.9 months (range, 2.1–63), 1-year primary tumor control was 89%, involved lobar control was 89%, local–regional control was 82%, distant control was 91%, and survival was 63%. Of the 4 patients with pre-treatment chest wall pain, 3 reported improvement after SBRT. Two patients reported new grade 1–2 chest wall pain. No grade 3+ toxicity was reported, with 1 patient experiencing grade 1 skin toxicity and 3 patients experiencing grade 1–2 radiation pneumonitis.

Conclusions

SBRT for CWI NSCLC is safe, with high early tumor control and low treatment-related toxicity. Most patients with pre-treatment chest wall pain experienced relief after SBRT, with no grade 3+ toxicity observed.

Video-assisted thoracoscopic surgery lobectomy with chest wall resection

Lung cancer presents with chest wall invasion in 5-8% of patients, which imparts some treatment challenges. Surgical resection is currently the standard of care, and there are some controversies regarding the best approach. Published series and case reports confirm the safety and feasibility of video-assisted thoracoscopic surgery (VATS) in highly complex surgical cases including lobectomy with chest wall resection of locally advanced lung cancer. In this article, we present the clinical indications of locally advanced lung cancer that infiltrates the chest wall, the modalities for and importance of accurately staging lung cancers with chest wall invasion, and the technical aspects of accomplishing a safe and oncologically sound extended resection through VATS.

Adjuvant Chemotherapy Does Not Improve Survival for Lung Cancer With Chest Wall Invasion

BACKGROUND

The National Comprehensive Cancer Network recommends adjuvant chemotherapy (AC) for patients with completely resected (R0) pT3N0M0 non-small cell lung cancer (NSCLC) with chest wall invasion. There is minimal evidence to support this recommendation. We aimed to determine whether there is a survival benefit with AC and if so whether it depends on tumor size.

METHODS

Patients who had undergone R0 resection for pT3N0M0 NSCLC with chest wall invasion were identified in the National Cancer Data Base from 2008 to 2012. Multivariable Cox proportional hazards modeling was used to determine independent predictors of overall mortality.

RESULTS

Of 247 patients, 92 (37.3%) received AC. The median tumor size without AC was 42 mm (interquartile range [IQR], 30 to 60 mm) and with AC was 56 mm (IQR, 40 to 70 mm; p = 0.003). Median follow-up was 21.7 months (IQR, 10.6 to 29.1 months). There was no difference in AC based on tumor grade, but the 3-year overall survival for those with well-differentiated or moderately differentiated tumors was 68% versus 55% in those with poorly differentiated or undifferentiated tumors. Three-year overall survival for the entire cohort was 59%. There was no difference in overall survival between those who received AC and those who did not. The only significant predictor of mortality in both univariable and multivariable analyses was poorly or undifferentiated tumor grade.

CONCLUSIONS

For patients with pT3N0M0 NSCLC with chest wall invasion there is no survival benefit with AC, regardless of tumor size or grade, after R0 resection. Poorly differentiated or undifferentiated tumor grade is an independent predictor of mortality.

Surgical Management of Lung Cancer Involving the Chest Wall

The prevalence of chest wall invasion by non-small cell lung cancer is < 10% in published surgical series. The role of radiation or chemotherapy around the complete resection of lung cancer invading the chest wall, excluding the superior sulcus of the chest, is poorly defined. Survival of patients with lung cancer invading the chest wall is dependent on lymph node involvement and completeness of en-bloc resection. In some patients harboring T3N0 disease, 5-year survival in excess of 50% can be achieved. Offering en-bloc resection of lung cancer invading chest wall to patients with T3N1 or T3N2 disease is controversial.

Adjuvant Chemotherapy Is Associated With Improved Survival in Locally Invasive Node Negative Non-Small Cell Lung Cancer

BACKGROUND

The objectives of this study are to explore factors that are associated with use of adjuvant chemotherapy and to evaluate its impact on overall survival in node-negative patients who undergo lung and chest wall resection for non-small cell lung cancer (NSCLC).

METHODS

Patients who underwent concomitant lung and chest wall resection for NSCLC were abstracted from the National Cancer Database. Clinical, pathologic, treatment, and follow-up data were obtained. Patients with pathologic nodal metastases or patients who received any radiation treatment were excluded, and the cohort was dichotomized based on administration of adjuvant postoperative chemotherapy.

RESULTS

Between 1998 and 2010, 824 patients met the inclusion criteria. This cohort exclusively consisted of pT3 N0 patients who did not receive any induction treatment or adjuvant radiation treatment. Adjuvant chemotherapy was administered to 255 patients (31%). Patients in the chemotherapy group were younger and had shorter inpatient length of stay. Both groups had similar comorbidities, tumor size, unplanned readmission rate, and incomplete resection rate. In multivariable analysis, younger age and shorter length of stay were associated with a greater likelihood of receiving adjuvant chemotherapy. Adjuvant chemotherapy was associated with improved survival (hazard ratio 0.74, 95% CI: 0.6 to 0.9), whereas increasing age, white race, length of inpatient stay, tumor size, and residual tumor were independently associated with greater risk of death.

CONCLUSIONS

Patients who undergo lobectomy with chest wall resection for locally advanced NSCLC should be strongly considered for postoperative adjuvant chemotherapy even in the absence of nodal disease. Actual selection of patients for adjuvant chemotherapy is affected by perioperative factors.

Patterns of Failure After Surgery for Non-Small-cell Lung Cancer Invading the Chest Wall

INTRODUCTION

The patterns of failure after resection of non-small-cell lung cancer (NSCLC) invading the chest wall are not well documented, and the role of adjuvant radiation therapy (RT) is unclear, prompting the present analysis.

MATERIALS AND METHODS

The present institutional review board-approved study evaluated patients who had undergone surgery from 1995 to 2014 for localized NSCLC invading the chest wall. Patients with superior sulcus tumors were excluded. The clinical outcomes were estimated using the Kaplan-Meier method and compared using a log-rank test. The prognostic factors were assessed using a multivariate analysis, and the patterns of failure were scored.

RESULTS

Seventy-four patients were evaluated. Most patients had undergone lobectomy or pneumonectomy (85%) with en bloc chest wall resection (80%) and had pathologically node negative findings (81%). The surgical margins were positive in 10 patients (14%) and most commonly involved the chest wall (7 of 10). Adjuvant treatment included RT in 21 (28%) and chemotherapy in 28 (38%). A total of 24 local recurrences developed. The chest wall was a component of local disease recurrence in 19 of 24 cases (79%). The local control rate at 5 years for the entire population was 60% (95% confidence interval, 46%-74%). The local control rate was 74% with adjuvant RT versus 55% without RT (P = .43). On multivariate analysis, only resection less than lobectomy or pneumonectomy was associated with worse local control. The overall survival rate was 38% with RT versus 34% without RT (P = .59).

CONCLUSION

Positive surgical margins and local disease recurrence were common after resection of NSCLC invading the chest wall. The primary pattern of failure was local recurrence in the chest wall. Adjuvant RT was not associated with improved local control or survival.

Primary lung tumors invading the chest wall

Chest wall (CW) involvement occurs in approximately 5% of all primary lung neoplasms. According to the most recent TNM classification, lung tumors invading CW are classified as T3, and they represent approximately 45% of all T3 lung cancers. The most common clinical symptom at presentation is chest pain (>60%), which is highly specific of CW infiltration (>90%). Dyspnoea and hemoptysis are also described, especially in case of large lesions. A realistic chance to cure locally advanced tumors invading CW is a surgical resection, consisting in the excision of the primary lung cancer along with the involved CW (sometimes an "en-bloc" resection) and an appropriate lymph-nodal dissection. However, such patients are at high-risk of facing postoperative complications; prognosis mainly depends on: (I) the completeness of resection; and (II) the lymph-nodal involvement. Hence, due to these reasons (incidence, symptoms, prognosis, post-operative complications), such category of patients are to be carefully assessed preoperatively and if deemed practicable, surgery should be taken into consideration. In this view, the aim of this paper is to critically review the most recent series of lung tumors invading the CW, with a particular focus on patients' preoperative evaluation, surgical techniques, postoperative complications and overall outcome.

Role of Adjuvant Therapy for Node-Negative Lung Cancer Invading the Chest Wall

INTRODUCTION

The present study investigated the effect of adjuvant chemotherapy and radiation on survival among patients undergoing chest wall resection for T3N0 non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Patients with T3N0 NSCLC who underwent chest wall resection were identified in the National Cancer Data Base in 2004 to 2012. The cohort was divided into patients who had received adjuvant chemotherapy, radiation therapy, chemoradiation therapy, or no adjuvant treatment. Kaplan-Meier and log-rank tests were used to compare overall survival, and a bootstrapped Cox proportional hazards model was used to determine the significant contributors to survival. A subset analysis was performed with stratification by margin status and tumor size.

RESULTS

Of 759 patients identified, 42.0% underwent surgery alone, 23.3% underwent surgery followed by chemotherapy, 22.3% underwent surgery followed by chemoradiation therapy, and 12.3% underwent surgery followed by radiotherapy alone. Tumors > 4 cm benefited from adjuvant chemotherapy and radiation therapy in the multivariable analysis, and those ≤ 4 cm benefited only from adjuvant chemotherapy. The subgroup analysis by margin status identified that margin-positive patients with tumors > 4 cm benefited significantly from either adjuvant chemoradiation therapy or radiation therapy alone.

CONCLUSION

T3N0 NSCLC with chest wall invasion requires unique management compared with other stage IIB tumors. An important determinant of management is tumor size, with tumors ≤ 4 cm benefiting from adjuvant chemotherapy and tumors > 4 cm benefiting from adjuvant chemotherapy if margin negative and adjuvant chemoradiation therapy or radiotherapy if margin positive.

Number of Ribs Resected is Associated with Respiratory Complications Following Lobectomy with en bloc Chest Wall Resection

PURPOSE

Pulmonary lobectomy with en bloc chest wall resection is a common strategy for treating lung cancers invading the chest wall. We hypothesized a direct relationship exists between number of ribs resected and postoperative respiratory complications.

METHODS

An institutional database was queried for patients with non-small cell lung cancer that underwent lobectomy with en bloc chest wall resection between 2003 and 2014. Propensity matching was used to identify a cohort of patients who underwent lobectomy via thoracotomy without chest wall resection. Patients were propensity matched on age, gender, smoking history, FEV1, and DLCO. The relationship between number of ribs resected and postoperative respiratory complications (bronchoscopy, re-intubation, pneumonia, or tracheostomy) was examined.

RESULTS

Sixty-eight patients (34 chest wall resections; 34 without chest wall resection) were divided into 3 cohorts: cohort A = 0 ribs resected (n = 34), cohort B = 1-3 ribs resected (n = 24), and cohort C = 4-6 ribs resected (n = 10). Patient demographics were similar between cohorts. The 90-day mortality rate was 2.9 % (2/68) and did not vary between cohorts. On multivariate analysis, having 1-3 ribs resected (OR 19.29, 95 % CI (1.33, 280.72); p = 0.03), 4-6 ribs resected [OR 26.66, (1.48, 481.86); p = 0.03), and a lower DLCO (OR 0.91, (0.84, 0.99); p = 0.02) were associated with postoperative respiratory complications.

CONCLUSIONS

In patients undergoing lobectomy with en bloc chest wall resection for non-small cell lung cancer, the number of ribs resected is directly associated with incidence of postoperative respiratory complications.

Analysis of major known driver mutations and prognosis in resected adenosquamous lung carcinomas

INTRODUCTION

Genotyping for driver mutations is now routinely used to guide clinical care of patients with lung cancer. Adenosquamous lung carcinoma (AdSqLC) is a subtype of cancer that contains both adenocarcinoma and squamous cell carcinoma. However, the incidence, clinicopathologic characteristics, and prognostic implications of major driver mutations in AdSqLCs are not well established.

METHODS

Seventy-six resected AdSqLCs and 646 lung adenocarcinomas were screened for known genetic alterations involving EGFR, ERBB2, KRAS, BRAF, PIK3CA, AKT1, RET, and ALK. Tumors showing acinar, lepidic, micropapillary, or papillary growth in glandular component were classified as classical AdSqLC.

RESULTS

Of the 76 AdSqLCs, 43 (56.6%) harbored known mutant kinases, including 24 (31.6%) with EGFR mutations, eight (10.5%) with KRAS mutations, two (2.6%) with AKT1 (2.6%) mutations, one (1.3%) with ERBB2 insertion mutation, one (1.3%) with PIK3CA mutation, four (5.3%) with ALK fusions, and three (4%) with KIF5B-RET fusions. No mutation was found in BRAF. The mutational profiles and clinicopathologic characteristics of classical AdSqLC were strikingly similar to that of poorly differentiated adenocarcinoma. However, AdSqLCs with solid growth pattern in glandular component had high frequency of ALK or RET fusions and low EGFR mutation rate.

CONCLUSIONS

To our knowledge, this is the first comprehensive study investigating major oncogenic driver mutations in a large cohort of AdSqLC patients in a Chinese population. The findings suggest that it will be clinically valuable to investigate the growth pattern of glandular component in AdSqLCs.

Extended chest wall resection and reconstruction in the setting of lung cancer

Reconstruction of large chest wall defects after resection remains a significant undertaking. Obtaining a negative margin is of paramount importance for long-term survival. While reconstructing the chest wall, recreating a stable chest wall with adequate functional capacity and reasonable cosmesis are always the end goals. Morbidity from these procedures is significant, and mortality continues to hover around 5%. With continued advancement in reconstructive techniques and improved perioperative management, these procedures will continue to result in improved outcomes for patients.

[Treatment of lung cancer with chest wall invasion]

The aim of this study was to analyze chest wall invasion, the indication and multidisciplinary nature of treatment, the methods used for parietal reconstruction and the technical problems posed by this procedure in patients with lung cancer and chest wall invasion. Chest wall invasion from adjacent malignancies affects 5% of patients with a bronchogenic carcinoma. Preoperative determination of parietal invasion aids the planning of an appropriate therapeutic approach. Positron emission tomography combined with computed tomography (PET/CT) improves the study of T-factor and metastatic nodal involvement and distant metastases. As a rule, surgical treatment should attempt complete tumoral resection: lobectomy, resection of the parietal pleura and/or of the chest wall--ensuring tumor-free margins--and hilar and mediastinal lymphadenectomy. We also analyzed the distinct prognostic factors for survival, as well as the indication for induction or adjuvant therapy. Chest wall reconstruction involves recreating the most anatomical and physiological conditions possible in the chest cavity and surrounding muscles. The ideal reconstruction would achieve adequate parietal stability and coverage to preserve functionality, with the cosmetic result being an important, but secondary, consideration. Many materials are available for reconstruction and the choice of material should be individualized in each patient. A multidisciplinary team able to plan and perform the resection and subsequent reconstruction, oversee postoperative management and treat complications early is essential.

Outcomes after treatment of 17,378 patients with locally advanced (T3N0-2) non-small-cell lung cancer

OBJECTIVES

Treatment patterns and outcomes in a population-based database were examined to identify patients likely to benefit from surgical resection of locally advanced (T3N0-2) non-small-cell lung cancer (NSCLC).

METHODS

Factors predicting the use of surgery for patients with T3N0-2M0 NSCLC in the Surveillance, Epidemiology and End Results (SEER) database from 1988 to 2010 were assessed using a multivariable logistic regression model. Survival was analysed using the Kaplan-Meier approach and Cox proportional hazard models. Propensity matching was used to compare outcomes after surgery and outcomes in patients who refused surgery and underwent radiation therapy (RT).

RESULTS

Of 17 378 patients identified for study inclusion [8597 (50%) T3N0, 2304 (13%) T3N1 and 6477 (37%) T3N2], surgery was used in 7120 (41%). Only female sex and being married predicted the use of surgery, while older age, black race and N2 nodal disease predicted non-surgical management. Surgical patients overall had better long-term survival than non-surgical patients [odds ratio (OR) 0.42, 95% confidence interval (CI): 0.41-0.45, P < 0.001]. After propensity adjustment, patients who refused surgery and instead were treated with RT had significantly worse long-term survival than matched surgery patients (OR 0.65, 95% CI: 0.48-0.89, P = 0.0074). Sublobar resection and pneumonectomy predicted worse survival in patients who had surgery. Nodal disease also predicted worse survival after surgery, but surgery maintained an association with better overall survival compared with non-operative therapy among patients with both N1 (OR 0.53, P < 0.001) and N2 disease (OR 0.50, P < 0.001) in separate analyses stratified by nodal status. Older age also predicted worse survival after surgery, but patients older than 75 who were treated with surgery had significantly better long-term survival than non-operative patients (OR 0.49, 95% CI: 0.45-0.53, P < 0.001).

CONCLUSIONS

Surgery is used in a minority of patients with locally advanced NSCLC, but is associated with better survival than non-surgical treatment, even for patients older than 75 and patients with nodal disease. Given the very poor outcomes observed with non-operative management, surgical resection should be carefully considered in all patients with locally advanced NSCLC and should not necessarily be denied because of patient age or nodal disease.

Lung cancer with chest wall invasion: retrospective analysis comparing en-bloc resection and 'resection in bird cage'

Background

Invasion of the chest wall per se is not a contraindication for tumor resection in non-small cell lung cancer (NSCLC), provided there is no mediastinal lymph node or vital structure involvement. Although widely known to Brazilian surgeons, the ‘resection in bird cage’ technique has never been widely studied in terms of patient survival. Thus, the objective of this study was to evaluate the postoperative consequences and overall survival of extra-musculoperiosteal resection compared with en-bloc resection in NSCLC patients with invasion of the endothoracic fascia.

Methods

Between January 1990 and December 2009, 33 NSCLC patients with invasion of the thoracic wall who underwent pulmonary resection were retrospectively analyzed. Of the 33 patients evaluated, 20 patients underwent en-bloc resection and 13 underwent ‘resection in bird cage.’ For each patient, a retrospective case note review was made.

Results

The median age at surgery, gender, indication, rate of comorbidities, tumor size and the degree of uptake in the costal margin were similar for both groups. The rate of postoperative complications and the duration of hospitalization did not differ between the groups. Regarding the outcome variables, the disease-free interval, rate of local recurrence, metastasis-free time after surgery, overall mortality rate, mortality rate related to metastatic disease, duration following surgery in which deaths occurred, and overall survival were also similar between groups. The cumulative survival curves between the ‘resection in bird cage’ and en-bloc resection and between stages Ia + Ib and IIb + IIIa + IV were not significantly different (p = 0.68 and p = 0.64, respectively). The cumulative metastasis-free survival curves were not significantly different between the two types of surgery (p = 0.38).

Conclusions

In NSCLC patients with invasion of the endothoracic fascia, ‘resection in bird cage’ is a less aggressive procedure that yields similar results in terms of morbidity and mortality compared with en-bloc resection. Thus, ‘resection in bird cage’ meets the oncologic principles of resection and does not adversely affect the patients in terms of cure.

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

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.

Management of tumors involving the chest wall including pancoast tumors and tumors invading the spine

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.

Initial single-port thoracoscopy to reduce surgical trauma during open en bloc chest wall and pulmonary resection for locally invasive cancer

OBJECTIVES

En bloc pulmonary and chest wall resection is the preferred method of treatment for locally invasive lung carcinoma. However, it carries major trauma to the chest wall, especially in cases with chest wall involvement distant to the potential location of 'traditional' thoracotomies. We describe an alternative method of estimating the boundaries of chest wall resection employing video assisted thoracoscopic surgery (VATS) and hypodermic needles.

METHODS

VATS delineation of boundaries of chest wall involvement by lung cancer has been performed in six patients who gave written consent. In one case the single-port thoracoscopic examination revealed unexpected distant pleural metastases thus preventing from resection. The other 5 patients, three males and two females [median age of 60.5 (range 39 to 75) years] underwent en bloc anatomical lung resection in addition to chest wall excision and reconstruction for T3N0 lung cancer.

RESULTS

In these five cases the chest wall opening was restricted to the extent of the rib excision, and the pulmonary resection was performed via the existing chest wall opening without requiring extension of the thoracotomy or any rib spreading.

DISCUSSION

Minimally invasive techniques aid to delineate the boundaries of chest wall involvement of lung cancer and intraoperative staging. This helped tailoring the surgical approach and location of the thoracotomy, and prevented rib-spreading or additional thoracotomies in our cases.

The impact on quality of life after en-bloc resection for non-small-cell lung cancer involving the chest wall

BACKGROUND

  En-bloc resection for non-small cell lung cancer with chest-wall involvement may achieve a 5-year survival rate higher than 40%, but the impact on postoperative quality of life is not yet known.

METHODS

  Twenty-six patients undergoing en-bloc lung resections were included. Life quality ratings were assessed through a Short-Form 36 questionnaire preoperatively and at six, 12, 18 and 24 month follow-up visits. The degree of dyspnea, pain level, and flow-volume curves were also obtained at the same time periods. Changes occurring over time were analyzed by means of repeated-measure ANOVA.

RESULTS

  As a whole, the Physical Component Summary score declined six months postoperatively (P < 0.0001) and failed to improve thereafter. Patients with preoperative Forced Expiratory Volume in one second (FEV₁ ), <80% predicted (P = 0.029), resected ribs >2 (P = 0.03), and chest wall defect ≥50 cm² (P = 0.007) experienced a greater and lasting impairment. Net postoperative decrease in FVC (P = 0.02; r = 0.48) and dyspnea worsening (P = 0.03; r =-043 at six months, P = 0.05; r =-0.39 at 12 months) were also correlated with the extent of physical deterioration, whereas age (P = 0.92), gender (P = 0.51), type of resection (P = 0.71), and adjuvant therapy (P = 0.68) did not. The Physical Component Summary didn't change significantly in patients with high pain levels (VAS >7). The Mental Component Summary score increased slightly at six months, with no difference in any patients' subgroup.

CONCLUSIONS

  The extent of chest wall resection, preoperative FEV₁ , and postoperative decline in FVC were the main indicators of quality of life impairment after en-bloc resection for lung cancer. The impact upon quality of life should be considered in a cost-to-benefit ratio of planning this surgery in suboptimal candidates.

Induction chemoradiotherapy followed by surgical resection for clinical T3 or T4 locally advanced non-small cell lung cancer

Purpose

To examine the usefulness of trimodality therapy in patients with clinical T3 or T4 (cT3–4) locally advanced non–small cell lung cancer (LA-NSCLC).

Methods

Between 1997 and 2009, a total of 76 LA-NSCLC patients with cT3–4 underwent surgery. Among them, 36 patients underwent induction chemoradiotherapy with docetaxel and cisplatin plus concurrent radiation followed by surgery (IC group). The other 40 patients initially underwent surgery (IS group). The outcomes of the IC and IS groups were then investigated. To minimize possible biases caused by confounding treatment indications, we performed a retrospective cohort analysis by applying a propensity score (PS). Patients were divided into three groups according to PS tertiles, and comparisons between the IC and IS groups were made by PS tertile-stratified Cox proportional hazard models.

Results

For the entire cohort, which had a median follow-up duration of 48 months, the 3- and 5-year overall survival rates were 83.8 and 78.9%, respectively, in the IC group, versus 66.8 and 56.5%, respectively, in the IS group (P = 0.0092). After adjustments for potentially confounding variables, the IC group continued to have a significantly longer overall survival than the IS group (P = 0.0045). In addition, when the analysis was limited to 52 patients with cT3–4N0 or N1 disease, the IC group had a significantly longer overall survival than the IS group after adjustments for confounding variables (P = 0.019).

Conclusions

Our study indicates that trimodality therapy is highly effective in patients with cT3–4 LA-NSCLC.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-012-2302-x) contains supplementary material, which is available to authorized users.

Extensive resections: pancoast tumors, chest wall resections, en bloc vascular resections

Infiltration by lung tumor of adjacent anatomic structures including major vessels, main bronchi, and chest wall not only influences the oncologic severity of the disease but also increases the technical complexity of surgery, requiring extended resections and demanding reconstructive procedures. Completeness of resection represents in every case one of the main factors influencing the long-term outcome of patients. Technical and oncologic aspects of extended operations, including resection of Pancoast tumors and chest wall, bronchovascular sleeve resections, and en bloc resections of major thoracic vessels, are reported in this article.

Special Treatment Issues in Lung Cancer

BACKGROUND

This chapter of the guidelines addresses patients who have particular forms of non-small cell lung cancer that require special considerations. This includes patients with Pancoast tumors, T4N0,1M0 tumors, satellite nodules in the same lobe, synchronous and metachronous multiple primary lung cancers (MPLCs), solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, metaanalyses or large prospective studies of patients are not available. For ensuring that these guidelines were supported by the most current data available, publications that were appropriate to the topics covered in this chapter were obtained by performance of a literature search of the MEDLINE computerized database. When possible, we also referenced other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method (see "Methodology for Lung Cancer Evidence Review and Guideline Development" chapter), and reviewed by all members of the lung cancer panel before approval by the Thoracic Oncology NetWork, Health and Science Policy Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach seems to be optimal, involving chemoradiotherapy and surgical resection, provided appropriate staging has been conducted. Patients with central T4 tumors that do not have mediastinal node involvement are uncommon. Such patients, however, seem to benefit from resection as part of the treatment as opposed to chemoradiotherapy alone when carefully staged and selected. Patients with a satellite lesion in the same lobe as the primary tumor have a good prognosis and require no modification of the approach to evaluation and treatment than what would be dictated by the primary tumor alone. However, it is difficult to know how best to treat patients with a focus of the same type of cancer in a different lobe. Although MPLCs do occur, the survival results after resection for either a synchronous presentation or a metachronous presentation with an interval of < 4 years between tumors are variable and generally poor, suggesting that many of these patients may have had a pulmonary metastasis rather than a second primary lung cancer. A thorough and careful evaluation of these patients is warranted to try to differentiate between patients with a metastasis and a second primary lung cancer, although criteria to distinguish them have not been defined. Selected patients with a solitary focus of metastatic disease in the brain or adrenal gland seem to benefit substantially from resection. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, as long as tumors can be completely resected and there is absence of N2 nodal involvement, primary surgical treatment should be considered.

CONCLUSIONS

Carefully selected patients may benefit from an aggressive surgical approach.

Comparison of mersilene mesh-methyl metacrylate sandwich and polytetrafluoroethylene grafts for chest wall reconstruction

We report the outcomes of patients who underwent reconstruction with Mersilene mesh-methyl methacrylate (MM-MM) sandwich and polytetrafluoroethylene (PTFE) grafts after a large chest wall resection. Between June 1990 and September 2001, 59 consecutive patients (37 men, 22 women; mean age, 48.1 +/- 11.8 years; range 22-74 years) underwent large chest wall resection (greater than 5 cm diameter) and reconstruction with prosthetic material in our department. Twenty-one patients (33%) underwent reconstruction with a PTFE graft (group 2) between 1990 and 1994, and 38 patients (67%) underwent reconstruction with an MM-MM sandwich graft (group 1) between 1994 and 2001. Operative morbidity ratios were 5.2% (2/38) in group 1 and 24% (5/21) in group 2 (p = .036). The paradoxical respiration ratio was significantly higher (p = .018) in group 2 (5/21: 24%) than it was in group 1 (1/38: 2.6%). The operative mortality ratio was 4.5% (1/21) in group 2 and 0% in group 1. Mean hospital stay was 10.6 days (range 5-21 days) in group 1 and 13.3 days (range 7-36 days) in group 2 (p = .015). The MM-MM graft is inexpensive and easy to apply, provides better cosmetic options, and offers minimal morbidity. We therefore recommend that the MM-MM sandwich graft be used rather than the PTFE graft for large defects of the anterolateral chest wall and sternum where successful prevention of paradoxical respiration is required.

Lung cancer with chest wall involvement: Predictive factors of long-term survival after surgical resection

Multimodal management of lung cancer extending to chest wall and type of surgical procedure to be performed are still debated. The aim of this retrospective analysis was to analyze the predictive factors of long-term survival after surgery, focusing on depth of infiltration, type of surgical intervention and possible role of preoperative therapies, comparing survival of these patients with that of a group of patients affected by a Pancoast tumour and surgical treated in the same period.

MATERIALS AND METHODS

We reviewed records of 83 consecutive patients with NSCLC in stage T3 (owing to direct extension to chest wall), who underwent surgical resection in our Thoracic Surgery Unit between January 1994 and December 2003. Patients were classified in two groups: pancoast tumours (PT) or chest wall extending tumours (CW): survival and prognostic factors of each category were analyzed.

RESULTS

In the CW group we had 68 patients: 45 were in stage IIB (pT3N0), 23 in stage IIIA (pT3-N1-2). Histology revealed adenocarcinoma in 23 cases, squamous cell carcinoma in 34, large cells anaplastic carcinoma in 8, adenosquamous carcinoma in 3. An involvement of chest wall tissues beyond the endothoracic fascia was found in 21 patients, while in the remaining 47 the invasion of chest wall tissues was confined to the parietal pleura. An extrapleural dissection was performed in 48 patients while combined pulmonary and chest wall en bloc resection was required in 20 patients. Resection was incomplete in three cases. In the PT group we had 15 patients: 11 were in stage IIB and 4 in stage IIIA. Histological type was adenocarcinoma in 10 cases, squamous cell carcinoma in 4 and adenosquamous carcinoma in 1. A univariate analysis performed in the CW group showed that survival was significantly affected by nodal status, stage, extension of chest wall invasion, type of lung resection and residual disease. In a multivariate analysis we found that nodal status, completeness of resection and extension of chest wall involvement maintained a significant prognostic value. There was no difference between the survival curve of CW and PT group: considering the two subset of CW patients, on the basis of depth of infiltration, survival of PT patients was significantly better than that of CW patients with involvement of muscular tissues and ribs (p=0.02).

CONCLUSION

Nodal status, radical resection and depth of chest wall infiltration are the main predictive factors affecting long-term survival, while surgical procedure does not impact on it if margins of resection are free from disease. The better survival observed in PT patients let us to hypothesize that an induction chemo-radiation therapy, as routinely administered to PT patients, could have a potential benefit in survival of patients with CW tumour extending beyond parietal pleura.

En bloc resection for lung cancer with chest wall invasion

BACKGROUND

The aim of this study was to retrospectively assess the results of en bloc chest wall plus lung resection for patients with non-small cell lung cancer (NSCLC) invading the chest wall.

METHODS

From January 1986 to December 2000, of 1,820 patients having surgery for NSCLC, 42 (2.3%) patients with neoplasms involving the chest wall underwent en bloc chest wall and lung resection. Patient demographics, preoperative symptoms, operative procedures, tumor cell type and size, removed nodal status, and pathologic stage were summarized. The 5-year survival rates of the groups were compared.

RESULTS

Postoperative staging revealed 28 were T3N0M0, 4 were T3N1M0, and 10 were T3N2M0. The in-hospital mortality rate was 11.9% (5/42). The mean age was 79.0 +/- 2.8 years in the patients who died of complications, which was significantly older than the mean age of 67.9 +/- 8.1 years in the patients who survived the surgery (p = 0.005). The overall 5-year survival was 28.4%. The 5-year survival was significantly longer in the patients with negative (N0) nodal metastasis than in those with N1 and/or N2 nodal metastasis (39.6% versus 7.1%, p = 0.01). Eleven patients had tumor involvement of the parietal pleura. Thirty-one patients had tumor involvement of the soft tissue and/or bone. There was no significant difference of 5-year survival rate between the patients with involvement of the parietal pleura only and the patients with involvement of the parietal pleura and the soft tissue and/or bone (10.9% versus 33.5%, p = 0.94).

CONCLUSION

En bloc resection for bronchogenic carcinoma invading the chest wall provides a favorable prognosis in cases without nodal metastasis. Significant postoperative mortality is associated with old age (> 80 years). The 5-year survival rate is not significantly different between the patients with involvement of the parietal pleura only and the patients with involvement of the parietal pleura and the soft tissue and/or bone.

Lung Cancer Invading the Chest Wall: A Plea for En-Bloc Resection but the Need for New Treatment Strategies

BACKGROUND

Factors influencing survival of patients with a nonsmall-cell lung cancer (NSCLC) invading the parietal pleura or the chest wall are still controversial. The aim of this study was to assess prognostic factors in completely resected pT3 chest wall NSCLC patients.

METHODS

We retrospectively reviewed a three-center experience between 1984 and 2002 with 309 patients.

RESULTS

There were 269 male and 40 female patients. Pulmonary resections consisted of 13 wedge resections or segmentectomies, 211 lobectomies, 6 bilobectomies, and 79 pneumonectomies. One hundred patients underwent extrapleural mobilization, and 209, en-bloc resection. Tumors were staged as stages IIB (n = 212) and IIIA (n = 97). Overall 5-year survival rates were 40% and 12% for stage IIB and IIIA, respectively (p < 10(4)). Multivariate analysis shows male sex and bigger tumor size as independent indicators of poor prognosis in stage IIB patients. In stage IIB patients with a chest wall invasion limited to the parietal pleura, en-bloc resections provided higher 5-year survival rates when compared with extrapleural resections (60.3% versus 39.1%; p = 0.03). In stage IIIA patients, multivariate analysis disclosed two independent prognostic factors: the number of resected ribs and adjuvant parietal and mediastinal radiotherapy.

CONCLUSIONS

The presence of lymph node metastases has a disastrous impact on survival in this subset of patients. En-bloc resection is strongly suggested to be the standard of surgical care, and adjuvant radiotherapy does not seem to be necessary in N0 patients when a complete R0 resection has been achieved. For huge tumors (larger than 6 cm), this report suggests that the role of perioperative chemotherapy needs further evaluation.

[Oncoplastic surgery for thoracic wall tumours]

INTRODUCTION

Surgical treatment of tumours of the chest wall (primary or metastatic) requires special skills by the thoracic and the plastic surgeons, from the functional as well as the aesthetic perspective (oncoplastic surgery), when the treatment requires surgical reconstruction.

MATERIAL AND METHODS

We present a series of 14 patients who needed extensive resection of the thoracic wall (external and/or 3 or more ribs) with disease-free margins and reconstruction with prostheses (7 with polytetrafluoroethylene [PTFE(R)] and 7 with the Sandwich Marlex-Methyl Metacrylate) technique with additional covering with muscle-skin flaps (6 pectoral, 5 recto-anterior, 3 dorsal) pedicled during the same surgical intervention.

RESULTS

The aetiology of the extirpated tumours, following pathology assessment, were: 4 chondrosarcoma, 3 metastatic sternum, 2 breast cancer relapse, 1 desmoid tumour, 1 neurofibrosarcoma, 1 rhabdomiosarcoma, 1 malignant schwannoma and 1 radiation induced sarcoma. One patient died from complications and another 4 from disease progression before the conclusion of the study follow-up (3-22 months).

CONCLUSIONS

Extensive resection of tumours of the chest wall with reconstruction using prostheses and muscle-skin flaps is a safe method that can be performed in the same surgical intervention period when combining the skills of the thoracic surgeon with that of the plastic surgeon.

Chest wall resection for invasive lung carcinoma, soft tissue sarcoma, and other types of malignancy. Pathologic aspects in a series of 107 patients

With improvements in surgical techniques for resection and reconstruction of the chest wall, pathologists are confronted with complicated surgical specimens. There are no currently available guidelines specifically dedicated to the handling of these specimens. Extended resections of lung carcinoma chest wall invasions may change the clinical value of some TNM subsets. We reviewed a series of 107 consecutive malignant tumors involving the chest wall and resected in our institution during a 3-year period. The 107 patients included 39 females and 68 males aged 6 to 80 years (mean, 53 years). Ninety-eight cases (92%) were en bloc resection. There were 55 invasions by lung carcinomas including 19 Pancoast tumors. With the current TNM classification, five lung carcinomas, treated with vertebral body resection because of vertebral foramina invasion, were T3. Four lung carcinomas were N3 or M1 only because of supraclavicular or chest wall lymph node invasion. Other tumors included 20 primary soft-tissue tumors, 13 primary skeletal tumors, 12 metastases, four local invasions by breast tumors, and three miscellaneous lesions. Resected structures included one to six ribs (mean, 2.6; n = 89), thoracic inlet (n = 24), three or four vertebral bodies (n = 13), sternum (n = 17), clavicles (n = 15), shoulder blade (n = 4), upper limb (n = 2), skin (n = 29), lung (n = 64), diaphragm (n = 2), and mediastinum (n = 2). Ten cases were incomplete resections including five because of vertebral body or vertebral foramina tumor invasion. The study of surgical specimens resulting from resection of malignant tumors of the chest wall is complicated because of the variety of both tumor histologic types and involved anatomic structures. Specimen radiograms have a great informative value. Assessment of surgical margins, especially vertebral foramina, is imperative. In lung carcinomas invading the chest wall, we suggest that vertebral foramina invasion could be classified T4 and that the prognostic value of chest wall lymph nodes isolated invasions should be assessed for a possible N1 classification.

Non-small cell lung cancer with chest wall invasion: evolution of surgical treatment and prognosis in the last 3 decades

STUDY OBJECTIVES

The treatment of patients with non-small cell lung cancer (NSCLC) that is invading the chest wall is still debated. We aim to illustrate the improvements in treatment results that have occurred over last decade.

DESIGN

Retrospective analysis of our experience and an overview of the literature.

SETTING

Department of Surgery, San Giuseppe Hospital, University of Milan.

PATIENTS

From January 1970 to December 1999, of 2,738 patients with NSCLC, we operated on 146 patients (5.4%) with chest wall invasion by NSCLC. Superior sulcus tumors and tumors invading the diaphragm or mediastinum were excluded. We reclassified all cases according to the current TNM classification.

RESULTS

We registered one postoperative death (0.69%) and five major complications (3.4%). From 1970 to 1979, of 32 patients, 10 underwent an exploratory thoracotomy (ET) and 22 underwent a radical resection (stage IIB disease, 17 patients; stage IIIA disease, 5 patients). The 5-year survival rate was 22.7% (25% for stage IIB disease). From 1980 to 1989, of 67 patients, 11 underwent an ET and 56 underwent a radical resection (stage IIB disease, 34 patients; stage IIIA disease, 12 patients; stage IIIB disease, 5 patients; and stage IV disease, 5 patients). The survival rate following radical resection was 14.1%, ranging between 23.5% for patients with stage IIB disease and 0% (3 years, 14%) for those with stage IIIA disease. From 1990 to 1999, of 47 patients, 2 underwent an ET, 2 underwent an exploratory thoracoscopy, and 43 underwent a radical resection (stage IIB disease, 23 patients; stage IIIA disease, 20 patients). The survival rate was 42.7% (stage IIB disease, 78.5%; stage IIIA disease, 7.2%).

CONCLUSIONS

Considering the low morbidity, mortality, and significant improvement in survival during the last decade, we advocate the performance of radical en bloc resection for the treatment of chest wall invasive NSCLC.

Chest wall resections and reconstruction: a 25-year experience

BACKGROUND

Chest wall defects continue to present a complicated treatment scenario for thoracic and reconstructive surgeons. The purpose of this study is to report our 25-year experience with chest wall resections and reconstructions.

METHODS

A retrospective review of 200 patients who had chest wall resections from 1975 to 2000 was performed.

RESULTS

Patient demographics included tobacco abuse, hypertension, diabetes mellitus, alcohol abuse, coronary artery disease, chronic obstructive pulmonary disease, and human immunodeficiency virus. Surgical indications included lung cancer, breast cancer, chest wall tumors, and severe pectus deformities. Twenty-nine patients had radiation necrosis and 31 patients had lung or chest wall infections. The mean number of ribs resected was 4 +/- 2 ribs. Fifty-six patients underwent sternal resections. In addition 14 patients underwent forequarter amputations. Immediate closure was performed in 195 patients whereas delayed closure was performed in 5 patients. Primary repair without the use of reconstructive techniques was possible in 43 patients. Synthetic chest wall reconstruction was performed using Prolene mesh, Marlex mesh, methyl methacrylate sandwich, Vicryl mesh, and polytetrafluoroethylene. Flaps utilized for soft tissue coverage were free flap (17 patients) and pedicled flap (96 patients). Mean postoperative length of stay was 14 +/- 14 days. Mean intensive care unit stay was 5 +/- 9 days. In-hospital and 30-day survival was 93%.

CONCLUSIONS

Chest wall resection with reconstruction utilizing synthetic mesh or local muscle flaps can be performed as a safe, effective one-stage surgical procedure for a variety of major chest wall defects.

Therapy for stage I and stage II non-small cell lung cancer

Despite complete resection of what seems to be all evident tumor, one third to three quarters of patients with stages I and II NSCLC ultimately succumb to this neoplasm. Patients who are cured of an original NSCLC or small cell cancer remain at risk for a new primary lung cancer. Although the importance of lifelong surveillance is clear, the extent and timing of optimal follow-up remain undefined. Although clinicians refer to the development after treatment of clinically discernible sites of tumor as "recurrence," it is probably more accurate to consider these foci as "persistence"--that is, the locoregional site was not sterilized by surgery, and the distant implants were present from the outset but undetected. Although data are sparse, induction and improved adjuvant therapy for early NSCLC may be helpful. Much further experience is needed. Further study and application of biologic indicators in addition to TNM staging likely will help identify patients at high risk for surgical failure who may benefit by combination treatment.

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.