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

Abstract

Objective: Several reports emphasize the importance of en-bloc resection as the optimal surgical treatment of lung cancer with chest wall invasion. We investigated possible factors which could affect long-term survival following radical resection of these tumors. Methods: Between 1981 and 1998, 100 patients (90 male; ten female), with a median age of 60 years (36±84), underwent radical en-bloc resection of non-small cell lung cancer (NSCLC) with chest wall involvement. Patients with superior sulcus tumors invading the thoracic inlet were excluded from this series. There were 43 squamous and 57 non-squamous tumors. The median number of resected ribs was three (1±5). Lung resection included 73 lobectomies, two bilobectomies, 18 pneumonectomies and seven segmentectomies. Chest wall resection also extended to the sternum in one patient, the transverse process in one, the costotransverse foramen and hemivertebrae in two. All patients had a complete resection. Sixty-three patients received postoperative radiotherapy and 12 received chemotherapy. Histological data, including differentiation and depth of chest wall invasion, were carefully reviewed. The effect of various factors on survival were studied. Results: There were four in-hospital deaths. Lymph node involvement was negative on surgical specimens in 65 patients, and 28 patients had positive N1 nodes; the ®nal histology revealed seven N2 diseases. Chest wall invasion was limited to the parietal pleura in 29 patients and included intercostal muscles, bones and extrathoracic muscles in 67, 24 and seven cases, respectively. The overall 2-year survival rate was 41%. The 5-year survival for patients with N0, N1 and N2 disease was 22, 9 and 0%, respectively. A local recurrence occurred in 13 patients, with four having a new resection and 45 patients developing systemic metastases. The nodal status (N0±1 vs. N2; P 0:026) and the number of resected ribs(,2 vs. .2; P 0:03) were survival predictors in univariate analysis. By multivariate analysis, the two independent factors affecting long-term survival were the histological differentiation (well vs. poorly differentiated; P 0:01) and the depth of chest wall invasion (parietal pleura vs. others; P 0:024). Conclusions: Histological differentiation and depth of chest wall involvement were the main factors affecting long-term survival in this series. The role of induction chemotherapy for tumors with poor prognosis should be investigated. q

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

“…Lymphnodal infiltration and completeness of resection appear to be the main survival predictors in the univariate analysis: nodal status and not the completeness of resection (probably for the small number of R1 patients) maintained its significance in the multivariate analysis. These results have been observed also in the previous literature and are universally accepted [2,3,7]. However, the impact of these two factors on long-term survival is so important that secondary factors like extension of infiltration, surgical strategy and postoperative treatment were often difficult to define especially in a multivariate analysis.…”

“…However, the impact of these two factors on long-term survival is so important that secondary factors like extension of infiltration, surgical strategy and postoperative treatment were often difficult to define especially in a multivariate analysis. In his series of 104 surgically resected patients, Chapelier found that patients with a tumour infiltration confined to the parietal pleura had a significantly better 5-year survival than those with chest wall infiltration [3]. Deeper involvement was advocated as a predictor of worse prognosis also by Mischina et al [9] and in a recent report by Facciolo et al [4], who found that depth of tumour invasion affected prognosis in the sub-group of pN0 patients.…”

“…Invasion of chest wall is not rare, with a percentage of 5-8% of all resected NSCLC; nowadays the prognostic importance of this finding is controverse. Although neoplastic invasion of chest wall cancer has never been considered evidence of unresectability, early reports showed a very low long-term survival [1][2][3]. Recent studies have shown instead exceptional 5-year survivals, never reported before in literatures [4,5].…”

Surgery for nonsmall cell lung cancer

“…Chest wall resection is routinely perfomed ''en-bloc'' with the lung specimen, with perioperative mortality rates of 1-4% [111][112][113]. 5-year survival rates of 40-50% have been reported in patients with stage T3N0M0 disease, but of ,20% in patients with stage IIIa disease [111][112][113].…”

“…Chest wall defects can be reconstructed or not depending upon their size and location. Various materials are routinely used to repair the chest wall: methyl metacrylate, polytetrafluoroethylene (PTFE), metallic rods and plates with excellent long-term results [110][111][112][113]. In patients whose tumour infiltrates into the parietal pleura only, en-bloc chest wall resections provide a much better survival than extrapleural resections [111].…”