| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2001;71:1094-1099
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic and Vascular Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France
b Unit of Thoracic Surgery, Hôtel-Dieu Hospital, Paris, France
Address reprint requests to Dr Magdeleinat, Service de Chirurgie Thoracique, Hôtel-Dieu, 1, Place du Parvis Notre Dame, 75181 Paris Cedex 04, France
e-mail: pmagde{at}club-internet.fr
Presented at the Poster Session of the Thirty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.
 |
Abstract |
|---|
 Top Abstract IntroductionPatients and methodsResultsCommentReferences |
|---|
Methods. We reviewed retrospectively clinical records of all patients operated on for lung cancer invading chest wall structures between 1984 and 1998.
Results. Two hundred one patients were operated on in this 14-year period. One hundred thirty-seven lobectomies, 55 pneumonectomies, and 9 wedge resections were performed. Extrapleural resection (when invasion was limited to the parietal pleura) and chest wall resection (in the case of invasion of deeper structures) were combined with pulmonary resection in 79 (39%) and 122 (61%) cases, respectively. Pathologic TNM stages were T3N0 in 116 (57.5%) cases, T3N1 in 52 (26%), T3N2 in 27 (13.5%), and T4N0-N1 in 6 (3%). A complete resection was achieved in 167 (83%) cases. Fourteen postoperative deaths (7%) occurred. One hundred thirty-nine patients (74%) underwent postoperative radiotherapy. Actuarial 5-year survival was 24% and 13% after complete and incomplete resection, respectively (p < 0.05). Actuarial 5-year survival after complete resection was 25% in T3N0 patients, 20% in T3N1, and 21% in T3N2. In completely resected patients, univariate and multivariate analyses identified three independent prognostic factors: nodal involvement, depth of parietal invasion, and age. Radiation therapy did not improve survival if a complete resection was possible.
Conclusions. Completeness of resection, nodal involvement, depth of invasion, and age affect survival of patients with lung cancer invading the chest wall. N2 disease should not be considered a contraindication to surgery.
|
Introduction |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentReferences |
|---|
In the present study, we retrospectively reviewed the clinical features and the outcome of 201 patients with non-small cell lung cancer invading chest wall structures treated by surgical resection in the department in a 14-year period in order to evaluate factors influencing survival and to determine the optimal treatment strategy.
|
Patients and methods |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentReferences |
|---|
In the present work, an extrapleural resection was defined as removal of lung parenchyma in continuity with a portion of the overlying parietal pleura after extrapleural mobilization of the tumor at the point of its attachment to the chest wall. Chest wall resection was defined as removal of parietal pleura with chest wall soft tissues and bony structures, in conjunction with lung parenchyma. Chest wall resection was performed en bloc with the lung parenchyma when extrapleural tumor extension was certain and when no doubt about resectability existed; otherwise, a discontinuous resection was carried out.
In all the patients, preoperative evaluation included their history, physical examination, routine blood tests, electrocardiography, spirometry, and perfusion lung scan. All the patients were subject to a uniform staging protocol including chest roentgenogram, fiberoptic bronchoscopy, and thoracic and upper abdominal computed tomography (CT) scan. Cerebral CT scan was carried out if neurological symptoms were present, whereas isotopic bone scan was performed in the presence of extrathoracic bone pain and/or abnormalities in serum calcium or alkaline phosphatase.
Before 1990, patients with suspicion of limited N2 disease were judged immediately operable provided that no bulky disease existed. After this date, in the presence of enlarged (> 1.5 cm) mediastinal nodes, mediastinoscopy was performed. If N2 disease was confirmed, neoadjuvant chemotherapy was administered. Patients subsequently underwent surgery if objective response or no disease progression were observed and provided that the whole disease was judged resectable on preoperative imaging studies.
In the great majority of cases, a posterolateral thoracotomy was performed. When invasion of chest wall structures deeper than parietal pleura was recognized preoperatively, full-thickness chest wall resection was carried out. Otherwise, if the parietal pleura could be easily removed and if there was no tumor on its deep surface, we performed an extrapleural resection, including a large area of parietal pleura several centimeters away from the lesion. On the other hand, in the presence of fixation of parietal pleura to deeper structures or in case of any doubt about the possibility that the tumor extended beyond parietal pleura, full-thickness chest wall resection was carried out. Intraoperative frozen sections were required when doubts concerning the margins existed.
Lymph node sampling was routinely carried out; in any case, all macroscopically involved nodes were entirely removed. Postoperative radiotherapy or chemotherapy was performed under the care of referring physicians, so no uniform protocol was employed.
Operative mortality was calculated by taking into account all the deaths occurring within 30 days from the operation or during the hospitalization. Percentage comparisons were made by the continuity-corrected 
2 test. Survival rates, including postoperative and non-cancer-related deaths, were calculated by the actuarial method and compared by the log-rank test [18]. Age, weight loss, respiratory impairment, tumor size, carcinoembryonic antigen (CEA) levels, histologic type, depth of chest wall invasion, lymph node metastases, type and extent of parietal resection, completeness of resection, and adjuvant radiotherapy were evaluated by univariate and multivariate analysis (Cox proportional hazard model, BMDP statistical software, IDM, Sevres, France [19]). Results were considered significant if the p value was less than 0.05.
|
Results |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentReferences |
|---|
Symptoms
One or more of the following symptoms were present: chest pain (n = 121, 60% of cases), recurrent lower respiratory tract infection (n = 51, 25.%), more than 5% body weight loss (n = 36, 18%), and hemoptysis (n = 25, 12%). Thirty-seven patients (18%) were asymptomatic.
Preoperative studies
Fiberoptic bronchoscopy showed endobronchial lesions in 62 patients (31%). At CT scan, mean tumor diameter was 6.5 cm (range 2 to 18 cm); invasion beyond parietal pleura was clearly evident in 40 patients (20%). A preoperative histological diagnosis was available in 81 patients (40%): in 61 by fiberoptic bronchoscopy and 20 by percutaneous needle biopsy.
Mean FEV1 was 77% of predicted value (range 39 to 126%). Twenty-nine patients had severe respiratory impairment (FEV1 < 60%).
Treatment
One hundred thirty-seven (68%) lobectomies, 55 (27%) pneumonectomies, and 9 (4%) wedge resections were performed. Chest wall resection or parietal pleurectomy (extrapleural resection) were associated in 122 (61%) and 79 cases (39%), respectively.
The number of resected ribs ranged from one to five (mean 2.8). After chest wall resection, the residual defect required reconstruction in 61 (50%) cases. Prosthetic material (generally marlex mesh) was employed in 36 cases; in the remaining 25, a myoplastic procedure was carried out.
Postoperative radiotherapy was carried out in 139 (74%) patients; in 16 of them, systemic chemotherapy was also administered. Postoperative radiotherapy was administered in 83% of patients who had received an incomplete resection (n = 25) and in 73% of patients in whom a complete resection had been achieved (n = 114). Among T3N2 patients operated on after 1990, a neoadjuvant chemotherapy had been carried out in 3 patients with preoperatively recognized N2 disease.
Pathologic examination
There were 94 squamous cell carcinomas, 75 adenocarcinomas, 25 large cell carcinomas, and 7 mixed cellularity carcinomas. Pathologic stages were T3N0 in 116 (58%) cases, T3N1 in 52 (26%) patients, and T3N2 in 27 (13%) cases. In 6 patients (3%), a T4 stage was recognized (vertebral body involvement: 4 cases, satellite tumoral nodule: 2 cases). In 89 patients, tumoral invasion was limited to parietal pleura; in 112 cases, it extended beyond. Ten patients with tumoral invasion limited to parietal pleura underwent chest wall resection, because a deeper invasion was suspected by the surgeon.
A complete resection was achieved in 167 cases (83%). Pathologic stages in these cases were T3N0 in 102 patients, T3N1 in 42, T3N2 in 21, and T4N0 in 2. Resection was not complete in 34 cases. Causes of incomplete resection are listed in Table 1. Of note, in only 1 patient treated by extrapleural resection, the intraoperative estimation of depth of invasion was underestimated and resection was microscopically incomplete.
|
Operative mortality was 7% (n = 14); respiratory failure was the leading cause of death (n = 12). The two other deaths were due to stroke and massive pulmonary embolism, respectively. Perioperative mortality was higher in patients aged over 65 years (15% vs 2%, p < 0.05) and in patients treated by chest wall resection than in those receiving extrapleural dissection; however, this difference did not reach statistical significance (9% vs 4%, p < 0.2). Among patients with FEV1 less than 60%, mortality rate was 10% as compared with 6% observed in those with FEV1 more than 60% (p < 0.6).
At completion of the study, 50 patients were alive and disease free; 6 were alive but with tumor relapse with a mean follow-up of 50 months (3 to 176 months). There were 129 late deaths: 105 tumor-related and 24 due to intercurrent causes. Two patients were lost at follow-up.
After complete resection, local recurrence occurred in 16 out of 157 evaluable patients (10%); in 12 of them, it was associated with metastatic spread. Local recurrence rates were similar after full-thickness chest wall resection (9.9%) or after extrapleural dissection (10.1%). Among patients who had received an incomplete resection (n = 34), 4 were alive at completion of the study, with a follow-up of 16, 45, 55, and 116 months, respectively. All of them had received postoperative radiotherapy for microscopic (n = 2) or macroscopic (n = 2) positive resection margins at the lateral edges of parietal resection. In the remaining 30 patients, death occurred on an average of 15 months postoperatively.
Actuarial 5-year and 10-year survivals for the whole population were 21% and 13%, respectively. Five-year survival was 24% and 13% after complete and incomplete resection, respectively (p < 0.05, Fig 1).
|
|
|
|
The impact on survival of adjuvant radiotherapy was evaluated in completely resected N0 and N1 patients. Radiotherapy did not improve the 5-year survival (23% and 34% with and without adjuvant radiotherapy, respectively; p < 0.9) either after extrapleural resection or after full-thickness chest wall resection.
Multivariate analysis showed the independent prognostic value of nodal involvement (p = 0.006), depth of invasion (p = 0.01), and age (p = 0.04). Actuarial survival for completely resected patients with N0 disease, invasion limited to parietal pleura, and age less than 65 years was 40%.
|
Comment |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentReferences |
|---|
Factors influencing survival and optimal treatment strategy of these tumors remain controversial. In this retrospective study, we found that prognosis mainly depends on completeness of resection, nodal involvement, depth of tumoral invasion, and patient’s age.
In agreement with most authors [9, 12, 13, 17], we consider the completeness of resection as the primary goal of the treatment. It was achieved in 83% of cases. Thirty-four patients (17%) had an incomplete resection: this figure is similar to those reported by others [12, 14, 15, 17] and reflects the difficulties both in preoperative and in peroperative management of these patients. The main cause of incomplete resection (in as much as 23 patients) was the presence of residual disease at edges of resection, due to the lateral extension of the tumor along the mediastinal pleura or the prevertebral fascia in posteriorly localized tumors. This extension had been underevaluated at preoperative CT scan, thus suggesting the strong limits of imaging techniques in this kind of patients; as suggested by others [20], a thoracoscopic evaluation would be useful in selected cases. On the other hand, it is noteworthy that frozen sections are not possible on the whole lateral edges of resection, thus explaining, in some patients, the finding of incomplete resection at definitive pathologic examination though frozen sections had shown the negativeness of margins. Furthermore, it must be remembered that frozen sections are not possible on bone, and in some instances, pathologic examination found that involvement extended more laterally in ribs than in intercostal spaces.
Though it is recognized that nodal involvement is a factor negatively affecting survival [8, 12, 13, 17], some controversies exist concerning selection of surgical candidates. According to some authors, mediastinoscopy and/or anterior mediastinotomy should be performed systematically in patients with lung cancer involving the chest wall before resection; they consider mediastinal lymph node metastases as a sign of invariably poor prognosis and discourage surgical resection if N2 disease is recognized [10, 11]. In agreement with others’ experience [3, 7, 8, 17], we found that the presence of nodal involvement should not be considered a contraindication to surgery. The 5-year survival rate reported in the present study in patients with N2 disease (21%) is encouraging and compares favorably with results reported by others in this subset of patients: 8% by Ricci and associates [8], 14% by Pitz and associates [12], and 15% by Downey and associates [17]. Such discrepancies are probably due to differences in studied populations, possible pre- and postoperative treatments as well as surgical technique itself (radical node dissection or simple picking) [21]. The above-mentioned 5-year survival rate in patients with N2 disease included in this study does not differentiate two subgroups of patients with regard to previous induction treatments, due to the small number in each subgroup. With the introduction of neoadjuvant chemotherapy as a part of treatment of locally advanced non-small cell lung cancer, we now recommend a mediastinoscopy or an anterior mediastinotomy in the presence of enlarged (> 1.5 cm) mediastinal nodes. If N2 disease is confirmed, neoadjuvant chemotherapy is administered. Subsequent surgery with full lymph node dissection is undertaken if objective response or no disease progression is observed and provided that the whole disease is judged resectable.
We did not find differences in terms of survival between patients with N1 or N2 disease. This result is consistent with the findings of others [7, 14], and would suggest that, in case of nodal involvement, the T factor is probably more important than the N factor in conditioning the survival. In the absence of node metastases (N0), the overall 5-year survival rate observed in the present study was 25% (40% if tumoral invasion was limited to parietal pleura). Our values are similar to those reported by some authors [8, 10], but quite lower as compared with others’ experience [3, 6, 12, 13, 17]. We think that the same factors exposed above to explain the differences in survival of N2 patients are probably responsible for the large variability in terms of survival reported in patients with N0 disease. It is noteworthy that, differently from other series [6, 7, 12, 14, 17], in our study, survival figures were calculated also taking into account operative deaths. Furthermore, our population is characterized by a higher rate of tumoral invasion extending beyond parietal pleura (56%) as compared with other series [12, 13, 17]. Yet, 35% of our patients were more than 65 years old, and we reported evidence that age greater than 65 years is a negative prognostic factor. On the other hand, in this retrospective study, among patients staged T3N0, there is probably an unknown number of understaged cases, as lymph node sampling and not full nodal dissection was the most frequently employed modality of nodal staging.
The significance of depth of chest wall invasion represents another object of controversies in terms of choice of surgical technique as well as of prognostic significance [3, 6–13]. McCaughan and associates reported better 5-year survival when the invasion did not extend beyond the parietal pleura and considered pleurectomy fully satisfactory when an extrapleural dissection was easily achieved [3]. Similar results and conclusions were also drawn by Downey and associates [17]. On the other hand, in patients with invasion limited to parietal pleura, Albertucci and associates [13] found improved survival after full-thickness chest wall resection than after extrapleural resection. In the present study, we found that invasion limited to parietal pleura should be regarded as a favorable prognostic factors. Similarly to other authors [3, 12, 17], we recommend extrapleural resection in patients with invasion limited to parietal pleura, provided that the pleura may be easily dissected from the underlying osteomuscular structures. As already observed by others [12, 17], patients with invasion limited to parietal pleura and treated by full-thickness chest wall resection (for intraoperative overestimation of tumoral invasion depth) had similar survivals as compared with patients treated by extrapleural resection. Furthermore, in completely resected patients, local recurrence rates were similar after extrapleural resection or full-thickness chest wall resection (10.1% and 9.9%, respectively). Finally, it should be taken into account that in our as well as in others’ [14] experience, full-thickness chest wall resection was associated with a higher mortality rate as compared with extrapleural resection (9% vs 3.8%).
When invasion extends beyond parietal pleura, chest wall resection is obviously mandatory. The majority of authors advocate systematic en bloc pulmonary and chest wall resection [7, 8, 10–12], suggesting that intrapleural tumor spill would affect negatively the 5-year survival [12]. On the other hand, according to others, a discontinuous resection does not worsen the prognosis [6, 15]. In our experience, en bloc resection was performed whenever feasible; discontinuous resection was performed in two instances: (1) when doubt about resectability existed, especially in extended hilar disease, posteriorly localized tumors, or N2 disease; and (2) after an extrapleural resection performed according to the above-described indications, if any doubt about radicality existed. Statistical analysis showed no differences in terms of 5-year survival between patients treated by en bloc resection and those in which a discontinuous resection had been necessary.
In our experience, in agreement with others’ data [6, 10–12], no benefit in terms of survival was observed in patients treated by postoperative radiotherapy after a complete resection. However, our institution is a tertiary referral center and the patients included in this study were under the care of a great number of physicians with different opinions in terms of adjuvant treatments. So indications for postoperative radiotherapy as well as dose and timing were greatly variable, not allowing to draw any conclusion on this subject. On the other hand, in case of incomplete resection, postoperative radiotherapy could be useful; 4 of our incompletely resected patients treated by postoperative radiotherapy are still alive with no evidence of recurrence at 16, 45, 55, and 116 months of follow-up. Similar results were reported in the series of Downey and associates [17].
Non-small cell lung cancer invading the chest wall remains a very severe condition. Surgery remains the cornerstone of the treatment. Prospective trials are necessary to confirm that full-thickness chest wall resection in the case of invasion limited to parietal pleura or postoperative radiotherapy in the case of complete resection provide no survival benefit.
|
References |
|---|
|
TopAbstractIntroductionPatients and methodsResultsCommentReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  N. Sakakura, S. Mori, F. Ishiguro, T. Fukui, S. Hatooka, M. Shinoda, K. Yokoi, and T. Mitsudomi Subcategorization of resectable non-small cell lung cancer involving neighboring structures. Ann. Thorac. Surg., October 1, 2008; 86(4): 1076 - 1083. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Doddoli, B. D'Journo, F. Le Pimpec-Barthes, A. Dujon, C. Foucault, P. Thomas, and M. Riquet Lung Cancer Invading the Chest Wall: A Plea for En-Bloc Resection but the Need for New Treatment Strategies Ann. Thorac. Surg., December 1, 2005; 80(6): 2032 - 2040. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. A. DiPerna and D. E. Wood Surgical Management of T3 and T4 Lung Cancer Clin. Cancer Res., July 1, 2005; 11(13): 5038s - 5044s. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. Matsuoka, W. Nishio, M. Okada, T. Sakamoto, M. Yoshimura, and N. Tsubota Resection of chest wall invasion in patients with non-small cell lung cancer Eur. J. Cardiothorac. Surg., December 1, 2004; 26(6): 1200 - 1204. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. Alifano, G. Benedetti, and R. Trisolini Can Low-Molecular-Weight Heparin Improve the Outcome of Patients With Operable Non-Small Cell Lung Cancer?: An Urgent Call for Research Chest, August 1, 2004; 126(2): 601 - 607. [Full Text] [PDF]
|
|
|
|
|
|
M. Alifano, M. D'Aiuto, P. Magdeleinat, E. Poupardin, A. Chafik, S. Strano, and J. F. Regnard Surgical Treatment of Superior Sulcus Tumors: Results and Prognostic Factors Chest, September 1, 2003; 124(3): 996 - 1003. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. J. Scott, J. Howington, and B. Movsas Treatment of Stage II Non-small Cell Lung Cancer Chest, January 1, 2003; 123(1_suppl): 188S - 201S. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Akay, A. K. Cangir, H. Kutlay, S. Kavukcu, I. Okten, and S. Yavuzer Surgical treatment of peripheral lung cancer adherent to the parietal pleura Eur. J. Cardiothorac. Surg., October 1, 2002; 22(4): 615 - 620. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. A. Mansour, V. H. Thourani, A. Losken, J. G. Reeves, J. I. Miller Jr, G. W. Carlson, and G. E. Jones Chest wall resections and reconstruction: a 25-year experience Ann. Thorac. Surg., June 1, 2002; 73(6): 1720 - 1726. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. M. Burkhart, M. S. Allen, F. C. Nichols III, C. Deschamps, D. L. Miller, V. F. Trastek, and P. C. Pairolero Results of en bloc resection for bronchogenic carcinoma with chest wall invasion J. Thorac. Cardiovasc. Surg., April 1, 2002; 123(4): 670 - 675. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Deslauriers Current surgical treatment of nonsmall cell lung cancer 2001 Eur. Respir. J., February 1, 2002; 19(35_suppl): 61S - 70s. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. Riquet, L. Lang-Lazdunski, F. Le Pimpec-Barthes, A. Dujon, R. Souilamas, C. Danel, and D. Manac'h Characteristics and prognosis of resected T3 non-small cell lung cancer Ann. Thorac. Surg., January 1, 2002; 73(1): 253 - 258. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
