Long-Term Outcome after En Bloc Resection of Non–Small-Cell Lung Cancer Invading the Pulmonary Sulcus and Spine

Superior Sulcus Tumors Invading the Spine: Multimodal Treatment Outcomes From the Preimmunotherapy Era

Introduction

Curative-intent treatment of superior sulcus tumors (SSTs) of the lung invading the spine presents considerable challenges. We retrospectively studied outcomes in a single center, uniformly staged patient cohort treated with induction concurrent chemoradiotherapy followed by surgical resection (trimodality therapy).

Methods

An institutional surgical database from the period between 2002 and 2021 was accessed to identify SSTs in which the resection included removal of at least part of the vertebral body. All patients were staged using fluorodeoxyglucose positron emission tomography (/computed tomography), computed tomography scan of the chest/upper abdomen, and brain imaging. Surgical morbidity was assessed using the Clavien-Dindo classification. Overall and disease-free survival were calculated using the Kaplan-Meier method.

Results

A total of 18 patients were included: 8 complete and 10 partial vertebrectomies were performed, with six of the eight complete vertebrectomies involving two vertebral levels, resulting in Complete surgical resection (R0) in 94%. Nine patients had a 1-day procedure, and nine were staged over 2 days. The median follow-up was 30 months (interquartile range 11-57). The 90-day postoperative morbidity was 44% (grade III/IV), with no 90-day surgery-related mortality. There were 83% who had a major pathologic response, associated with improved survival (p = 0.044). The 5-year overall and disease-free survival were 55% and 40%, respectively. Disease progression occurred in 10 patients, comprising locoregional recurrences in two and distant metastases in eight patients.

Conclusions

Multimodality treatment in selected patients with a superior sulcus tumor invading the spine is safe and results in good survival. Such patients should be referred to expert centers. Future research should focus on improving distant control (e.g. [neo]adjuvant immunotherapy).

Trimodality Treatment of Superior Sulcus Non-Small Cell Lung Cancer: An Institutional Series of 47 Consecutive Patients

OBJECTIVES

Treatment of superior sulcus tumors (SST) using concurrent chemoradiation followed by surgery is a current standard. However, due to the rarity of this entity, clinical experience in its treatment remains scarce. Here, we present the results of a large consecutive series of patients treated with concurrent chemoradiation followed by surgery at a single academic institution.

MATERIALS AND METHODS

The study group included 48 patients with pathologically confirmed SST. The treatment schedule consisted of preoperative 6-MV photon-beam radiotherapy (45-66 Gy delivered in 25-33 fractions over 5-6.5 weeks) and concurrent two cycles of platinum-based chemotherapy. Five weeks after completion of chemoradiation, pulmonary and chest wall resection was performed.

RESULTS

From 2006 to 2018, 47 of 48 consecutive patients meeting protocol criteria underwent two cycles of cisplatin-based chemotherapy and concurrent radiotherapy (45-66 Gy) followed by pulmonary resection. One patient did not undergo surgery due to brain metastases that occurred during induction therapy. The median follow-up was 64.7 months. Chemoradiation was well tolerated, with no toxicity-related deaths. Twenty-one patients (44%) developed grade 3-4 side effects, of which the most common was neutropenia (17 patients; 35.4%). Seventeen patients (36.2%) had postoperative complications, and 90-day mortality was 2.1%. Three- and five-year overall survival (OS) were 43.6% and 33.5%, respectively, and three- and five-year recurrence-free survival were 42.1% and 32.4%, respectively. Thirteen (27.7%) and 22 (46.8%) patients had a complete and major pathological response, respectively. Five-year OS in patients with complete tumor regression was 52.7% (95% CI 29.4-94.5). Predictive factors of long-term survival included age below 70 years, complete resection, pathological stage, and response to induction treatment.

CONCLUSIONS

Chemoradiation followed by surgery is a relatively safe method with satisfactory outcomes.

The oncologic efficacy of extended resections for lung cancer

Extended lung resections for T3-T4 non-small-cell lung cancer remain challenging. Multimodal management is mandatory in multidisciplinary tumor boards, and here the determination of resectability is key. Long-term oncologic efficacy depends mostly on complete resection (R0) and the extent of N2 disease. The development of novel innovative treatments (targeted therapy and immune checkpoint inhibitors) sets interesting perspectives to reinforce current therapeutic options in the induction and adjuvant setting.

Extended Pulmonary Resection for T4 Non-Small Cell Lung Cancer

T4 non-small cell lung cancer is a locally advanced disease with poor prognosis. The operation can be challenging even for an experienced surgeon. N2 disease has been shown repeatedly as a risk factor for poor outcome, and these patients should not be candidates for surgical treatment. Surgery for locally advanced T4 tumors without mediastinal lymph node involvement (T4N0 and T4N1) has been demonstrated to result in good outcomes in carefully selected patients. Patients with T4N0-1M0 should be rejected for surgery only after consulting an expert surgical center. As with other stages, the decision for resectability and surgery should be made by a multidisciplinary team.

The oncologic efficacy of extended thoracic resections

Locally invasive lung cancers pose unique challenges for management. Surgical resection of these tumors can pose high morbidity due to the invasion into surrounding structures, including the spine, chest wall, and great vessels. With advances in immunotherapy and chemoradiation, the role for radical resection of these malignancies and associated oncologic outcomes is evolving. This article reviews the current literature of extended thoracic resections with a focus on technical approach, functional outcomes, and oncologic efficacy.

Extended salvage surgery after high-dose chemoradiation therapy for tumors in the cervico-thoracic junction with invasion of the chest wall and the spine: a case series

The treatment of malignant tumors localized in the upper thoracic cavity and involving the spine at the cervico-thoracic junction (CTJ) is challenging. We report on three patients with malignant tumors invading the thoracic inlet and the spine at the CTJ. All three patients underwent radical tumor resection and 360° spine fusion following the posterior pedicle screw instrumentation and anterior vertebrectomy combined with implantation of an expandable titanium cage. Postoperatively, a mild paresis with hypesthesia of the ipsilateral arm occurred in one patient because of brachial plexus involvement. Two patients were still alive at last follow-up after 83 and 143 months, the third patient succumbed to tumor progression 13 months after extended salvage surgery. We display the possibilities of extended 'salvage' therapy in well-selected patients that were deemed hopeless regarding neurological function, biomechanical stability and tumor control after multiple courses of combined radio-chemotherapy.

Prognostic evaluation of the proposed residual tumor classification in a Chinese non-small cell lung cancer population

BACKGROUND

This study aimed to validate the R classification including uncertain resection (R-un) proposed by the International Association for the Study of Lung Cancer (IASLC) in a Chinese non-small cell lung cancer (NSCLC) population.

METHODS

The study retrospectively investigated a 2009-2013 single-institutional NSCLC resection cohort in China. After reclassification, recurrence-free survival (RFS) and overall survival (OS) were calculated using survival analyses and compared with those using the 2005 version IASLC R classification.

RESULTS

Under the proposed stratification, 3819 (72.1%) individuals were classified as R0, 1371 (25.9%) as R-un, 71 (1.3%) as R1, and 32 (0.6%) as R2. The 5-year OS probabilities for the R0, R-un, and R1/R2 groups were 71%, 46%, and 34%, respectively. The prognostic stratification remained significant in the fully adjusted Cox models (p < 0.001). Compared with the original classification, Harrell's concordance index of reclassification improved significantly, from 0.508 to 0.679 for RFS and from 0.510 to 0.692 for OS (RFS: p = 0.007; OS: p = 0.001). The survival analysis showed that R-un patients with highest mediastinal lymph node station metastasis had significantly worse survival than R0 patients with mediastinal nodal metastasis (RFS: 44 vs. 36 months, hazard ratio [HR]: 1.29, p < 0.001; OS: 59 vs. 50 months, HR: 1.34, p < 0.001). Cox proportional hazards regression analysis showed that highest mediastinal lymph node station metastasis was an independent risk factor for RFS (HR: 1.22) and OS (HR: 1.25).

CONCLUSIONS

The proposed R classification showed valid prognostic stratification, including highest mediastinal nodal station metastasis.

Combined video-assisted thoracoscopy surgery and posterior midline incision for en bloc resection of non-small-cell lung cancer invading the spine

OBJECTIVES

This article aims to evaluate the feasibility and safety of a hybrid video-assisted thoracic surgery (VATS) approach to achieve en bloc lobectomy and spinal resection for non-small-cell lung cancer (NSCLC).

METHODS

Between October 2015 and November 2020, 10 patients underwent VATS anatomical lobectomy and en bloc chest wall and spinal resection through a limited posterior midline incision as a single operation for T4 (vertebral involvement) lung cancer. Nine patients had Pancoast syndrome without vascular involvement and 1 patient had NSCLC of the right lower lobe with invasion of T9 and T10.

RESULTS

There were 5 men and 5 women. The mean age was 61 years (range: 47-74 years). Induction treatment was administered to 9 patients (90%). The average operative time was 315.5 min (range: 250-375 min). The average blood loss was 665 ml (range: 100-2500 ml). Spinal resection was hemivertebrectomy in 6 patients and wedge corpectomy in 4 patients. Complete resection (R0) was achieved in all patients. The average hospitalization stay was 14 days (range: 6-50 days). There was no in-hospital mortality. The mean follow-up was 32.3 months (range: 6-66 months). Six patients (60%) are alive without recurrence.

CONCLUSIONS

VATS is feasible and safe to achieve en bloc resection of NSCLC inviding the spine without compromising oncological efficacy. Further experience and longer follow-up are needed to determine if this approach provides any advantages over thoracotomy.

Reactivation of dormant tumor cells by modified lipids derived from stress-activated neutrophils

Tumor recurrence years after seemingly successful treatment of primary tumors is one of the major causes of mortality in patients with cancer. Reactivation of dormant tumor cells is largely responsible for this phenomenon. Using dormancy models of lung and ovarian cancer, we found a specific mechanism, mediated by stress and neutrophils, that may govern this process. Stress hormones cause rapid release of proinflammatory S100A8/A9 proteins by neutrophils. S100A8/A9 induce activation of myeloperoxidase, resulting in accumulation of oxidized lipids in these cells. Upon release from neutrophils, these lipids up-regulate the fibroblast growth factor pathway in tumor cells, causing tumor cell exit from the dormancy and formation of new tumor lesions. Higher serum concentrations of S100A8/A9 were associated with shorter time to recurrence in patients with lung cancer after complete tumor resection. Targeting of S100A8/A9 or β2-adrenergic receptors abrogated stress-induced reactivation of dormant tumor cells. These observations demonstrate a mechanism linking stress and specific neutrophil activation with early recurrence in cancer.

The Favorable Prognostic Factors for Superior Sulcus Tumor: A Systematic Review and Meta-Analysis

Background: Superior sulcus tumor is a rare non-small cell lung cancer with poor prognosis. Exploring the potential prognostic factors of patients with superior sulcus tumor and adopting individualized treatment for patients with different prognostic factors are of great significance for the prolongation of patients' lives. To figure out the prognostic factors of upper sulcus tumors, a meta-analysis was conducted.

Method: We searched all the articles published until January 2020 in PubMed, Embase, and Web of Science databases, and the search strategy included the following terms, combining superior sulcus tumor and prognosis. Hazard ratio (HR) with associated confidential interval (CI) was evaluated for the purpose of investigating prognostic factors for superior sulcus tumor. STATA 16.0 was used for analysis of extracted data and assessment of publication bias.

Result: Fifteen eligible studies, which had 1,009 patients with superior sulcus tumor, were included in this meta-analysis. The studies were published between 1994 and 2018, and the patient recruitment periods ranged from 1974 to 2016. The median follow-up time ranged from 18 to 95 months. The meta-analysis indicated that lower T stage (HR, 1.63; 95% CI, 1.35–1.97), lower N stage (HR, 3.08; 95% CI: 2.37–3.99), negative surgical margin (HR, 0.25; 95% CI, 0.17–0.38), and pathologic complete response (HR, 0.55; 95% CI, 0.39–0.77) were favorable prognostic factors.

Conclusion: We found that T stage, N stage, surgical margin, and pathologic complete response are prognostic factors for superior sulcus tumor. To reach a better long-term survival, patients with these negative prognostic factors may need a more aggressive treatment, while more studies should be conducted to further validate these results and explore a more effective treatment.

Trimodality therapy for superior sulcus tumour: experience of a single institution over 19 years

OBJECTIVES

Induction chemoradiotherapy followed by surgery is the standard treatment for superior sulcus tumours (SSTs). However, the protocols, chemotherapy agents and cycles used as well as the mode and intensity of radiotherapy vary between institutions. Thus, the objective of the study was to investigate the effects of trimodality therapy on the outcomes of patients with SSTs.

METHODS

Sixty patients with SSTs were enrolled between January 1999 and December 2017. Induction therapy consisted primarily of 2 cycles of mitomycin-vindesine-cisplatin or cisplatin-vinorelbine delivered concurrently to the tumour with 40-45 Gy of radiation. Surgery was performed 2-6 weeks after completion of induction therapy.

RESULTS

Fifty-four (90%) patients underwent radical surgical resection. Complete pathological resection was achieved in 44 patients (81%). There was no 30-day mortality. After a median follow-up of 57.0 months, 19 (35%) patients experienced recurrence, and 8 (15%) patients showed brain metastasis. A pathological complete response (PCR) was observed in 12 (22%) patients. The 5-year survival rate for the entire population (n = 54) was 69% (95% confidence interval 55-81%). The survival rate was better for patients who underwent complete resection than for those who underwent incomplete resection (73% vs 51%, P = 0.46). A better survival rate was evident in patients with PCR than in those without PCR (92% vs 62%, P = 0.12).

CONCLUSIONS

Trimodality therapy for SSTs was efficacious and associated with favourable outcomes, with acceptable morbidity and mortality. PCR in patients with resected SSTs reveals promising long-term survival prospects with the trimodality therapy.

Extended resections for the treatment of patients with T4 stage IIIA non-small cell lung cancer (NSCLC) (T4N0-1M0) with or without cardiopulmonary bypass: a 15-year two-center experience

Background

Stage IIIA non-small cell lung cancer (NSCLC) is a heterogeneous group of patients, often requiring variable and individualized approaches. The dilemma to operate or not frequently arises, since more than 75% of the cases of NSCLC are diagnosed in advanced stages (IIIA). The main objective of this study was to assess whether the benefits outweigh surgical risks for the T₄N_0-1M₀ subgroup.

Methods

Data from 857 patients with locally advanced T4 NSCLC were retrospectively collected from two different institutions, between 2002 and 2017. Clinical data that were retrieved and analyzed, included demographics, comorbidities, surgical details, neoadjuvant or/and adjuvant therapy and postoperative complications.

Results

Twelve patients were in the cardiopulmonary bypass (CPB) group and thirty in the non-CPB. The most common types of lung cancer were squamous cell carcinoma (50.0%) and adenocarcinoma (35.7%). The most frequent invasion of the tumor was seen in main pulmonary artery and the superior vena cava. Significantly more patients of the CPB group underwent pneumonectomy as their primary lung resection (P=0.006). In all patients R0 resection was achieved according to histological reports. The overall 5-year survival was 60%, while the median overall survival was 22.5 months. Analysis revealed that patient age (P=0.027), preoperative chronic obstructive pulmonary disease (COPD) (P=0.001), tumor size (4.0 vs. 6.0 cm) (P=0.001), postoperative respiratory dysfunction (P=0.001) and postoperative atelectasis (P=0.036) are possible independent variables that are significantly correlated with patient outcome.

Conclusions

We suggest that in patients with stage IIIA/T4 NSCLC, complete resection of the T4 tumor, although challenging, can be performed in highly selected patients. Such an approach seems to result in improved long-term survival. More specific studies on this area of NSCLC probably will further enlighten this field, and may result in even better outcomes, as advanced systemic perioperative approaches such as modern chemotherapy, immunotherapy and improvements in radiation therapy have been incorporated in daily practice.

En Bloc Resection of Thoracic Tumors Invading the Spine: A Single-Center Experience

BACKGROUND

Vertebral involvement by a thoracic tumor has long been considered as a limit to surgical treatment, and despite advances, such an invasive operation remains controversial. The aim of this study was to characterize a single-center cohort and to evaluate the outcome, focusing on survival and complications.

METHODS

We retrospectively reviewed the data of all patients operated on for tumors involving the thoracic spine in an 8-year period. En bloc resection was generally performed by a double team involving thoracic and orthopedic surgeons. Distant follow-up was recorded for oncologic and functional analysis.

RESULTS

There were 31 patients operated on. An induction therapy was administered in 20 patients. Spinal resection (mostly including ≥2 vertebral levels) was combined with lobectomy in 48.3% of the patients, and osteosynthesis was required in 22 patients. We observed no in-hospital death and a major complications rate of 32.3%, including 5 patients with early neurologic complications. There were 61.3% primary lung carcinomas, 12.9% extrapulmonary primaries, 9.7% metastases, and 16.1% benign tumors. Mean follow-up was 32.1 months. The 5-year overall survival rate was 81.3% in the entire cohort and 75.0% in patients with a malignant tumor. Occurrence of an early postoperative major complication was the only factor significantly associated with shorter overall survival (p = 0.03). The 5-year disease-free survival rate was 37.0% in malignancies. Delayed complications occurred in 35.5% of patients, including persistent neurologic deficit in 12.9%, instrumentation migration in 19.4%, and local infection in 12.9%.

CONCLUSIONS

En bloc resection of spinal thoracic tumors offers long-term survival and few recurrences in highly selected patients but is associated with significant delayed mechanical or infectious complications.

Treatment of clinical T4 stage superior sulcus non-small cell lung cancer: a propensity-matched analysis of the surveillance, epidemiology, and end results database

Purpose/Objective(s): Treatments for superior sulcus non-small cell lung cancer (SS-NSCLC) have evolved, but adequate treatments of T4 disease have not been found. The aim of our study was to evaluate the prognostic factors and optimal treatment strategy for patients with T4 SS-NSCLC. Materials/Methods: We utilized the Surveillance, Epidemiology, and End Results (SEER) database (1973–2015) to identify patients diagnosed with T4 stage SS-NSCLC (according to the 7th edition American Joint Committee on Cancer (AJCC) staging system) from 2004 to 2015; those with M1 disease were excluded. Propensity score matching (PSM) with Kaplan–Meier and Cox proportional hazards’ models was performed to estimate prognosis. Results: A total of 384 patients were included. The majority was male (59.4%) at stage IIIB (56.6%), with N2 accounting for 45.3%. A total of 47 patients underwent cancer-directed surgery, while radiotherapy alone was received by 60.2% of patients. Median overall survival (OS) and lung cancer-specific survival (LCSS) were 12 and 17 months, respectively, and the 5-year OS and LCSS rates were 15.8 and 25.4%, respectively. In the matched population, the median survival outcomes were better following surgery (OS: 25 compared with 9.0 months, P<0.001; LCSS: not available (NA) compared with 11.0 months, P<0.001). Multivariate Cox analysis showed that ages ≥ 66 years (hazard ratio (HR) = 1.639, P=0.001), unmarried status (HR = 1.356, P=0.034), and tumor size ≥ 6.0 cm (HR = 1.694, P<0.001) were associated with inferior OS. Cancer-directed surgery (HR = 0.537, P=0.009) and radiotherapy (HR = 0.644, P=0.006) were independent prognostic factors for patients with T4 SS-NSCLC. Conversely, in the subgroup analysis, favorable impacts of radiotherapy were observed for nonsurgical patients (OS: HR = 0.58, P<0.001; LCSS: HR = 0.55, P<0.001). Conclusion: Our study showed that T4 stage SS-NSCLC patients had a poor prognosis. Surgical resection remains the best option for those with resectable disease. For nonsurgical T4 SS-NSCLC patients, radiotherapy should be actively considered.

Initial extended resection or neoadjuvant therapy for T4 non-small cell lung cancer-What is the evidence?

Locally advanced non-small cell lung cancer (NSCLC) tumors that invade surrounding structures within the chest (T4) are a heterogeneous group, and, as such, there are no straightforward guidelines for their management. Advances in imaging, invasive mediastinal staging, and neoadjuvant therapies have expanded the role of surgery with curative intent for this patient group and have also diminished the rate of explorative thoracotomies. Unlike for T4 superior sulcus tumors, the use of neoadjuvant therapy for central T4 tumors is not clearly defined. The most important determinants of a successful outcome after surgery are achieving an R0 resection and avoiding incidental pathologic N2 disease. Use of neoadjuvant therapy in this setting may yield better outcomes after surgery, as both of these variables can be altered if the tumor responds to neoadjuvant therapy. Moreover, response to induction therapy has been shown to have prognostic value.

Utilizing Stereotactic Spine Navigation for Posterior Partial Vertebrectomy in an En Bloc Resection of a Superior Pulmonary Sulcus Tumor Invading the Thoracic Vertebrae: A Technical Note

Prior to the development of en bloc techniques, vertebral invasion by non-small cell lung cancer (NSCLC) had been considered a relative contraindication to surgical intervention. However, reports in the literature have demonstrated increased progression-free survival with the use of neoadjuvant chemotherapy followed by anterior en bloc resection of the residual tumor. Stereotactic spine navigation has been shown to improve accuracy during complex vertebral osteotomies, improving patient outcomes. We report a 53-year-old woman with an NSCLC in the left upper lobe, a periosteum attachment of the second and third thoracic vertebrae (T2 and T3, respectively), and an infiltration of the corresponding nerve roots. We describe a surgical approach for the resection of NSCLC with vertebral infiltration utilizing stereotactic spine navigation and intraoperative computed tomography (CT) (O-Arm, Medtronic, Minneapolis, Minnesota, US) for a posterior approach laminectomy, osteotomy, and partial vertebrectomy, followed by trans-thoracic en bloc resection of a superior pulmonary sulcus tumor with nerve root infiltration. Posterior approach vertebral osteotomy and en bloc resection for superior sulcus NSCLC infiltrating the vertebrae utilizing stereotactic spine navigation and intraoperative CT (O-Arm) is a viable alternative to the traditional anterior approach.

En Bloc Resection with the Assistance of Video-Assisted Thoracoscopy for Left Lower Lung Cancer Invading Thoracic Vertebrae and Rib: A Case Report

Lung cancer invading the spine was previously considered unresectable and fatal and, consequently, there are few reports focusing on tumors located in the lower lung lobe and invading the spine. With the development of spinal instrumentation and surgical techniques, and wider acceptance of spondylectomy by surgeons, radical surgical resection has become feasible. Here, we present a case of a male patient with a left lower lung cancer invading thoracic vertebrae who underwent complete resection with sagittal en bloc hemivertebrectomy with video-assisted thoracoscopy. A 60-year-old man complained of left chest pain for 3 months. Chest computed tomography and thoracic vertebrae magnetic resonance image revealed that a tumor in the left lower lung lobe had invaded the seventh and eighth thoracic vertebrae and the eighth rib. As no lymph node or distant metastasis was detected by positron emission tomography-computed tomography, the patient was diagnosed with left lower lung cancer directly invading the seventh and eighth thoracic vertebrae and the eighth rib (T4N0M0, stage IIIA) instead of metastasizing to the thoracic vertebrae. An en bloc resection of the lung tumor and the involved vertebrae was performed by a thoracic surgeon and orthopaedic surgeon with video-assisted thoracoscopy. Six months after the operation, there was no evidence of local recurrence, and the patient had recovered well. En Bloc resection with video-assisted thoracoscopy for lung cancer invading thoracic vertebrae is a safe and feasible surgical method. This method can significantly improve the safety and convenience of this type of surgery.

Management of Lung Cancer Invading the Superior Sulcus

Superior sulcus tumors have posed a formidable therapeutic challenge since their original description by Pancoast and Tobias in the early twentieth century. Initial therapeutic efforts with radiotherapy were associated with high rates of relapse and mortality. Bimodality therapy with complete surgical resection in the 1960s paved the way for trimodality therapy as the current standard of care in the treatment of superior sulcus tumors. The evolution of treatment approaches over time has provided outcomes that come increasingly closer to rivaling those of similarly staged nonapical lung cancer.

Single Posterior Approach for En-Bloc Resection and Stabilization for Locally Advanced Pancoast Tumors Involving the Spine: Single Centre Experience

STUDY DESIGN

Monocentric prospective study.

PURPOSE

To assess the safety and effectiveness of the posterior approach for resection of advanced Pancoast tumors.

OVERVIEW OF LITERATURE

In patients with advanced Pancoast tumors invading the spine, most surgical teams consider the combined approach to be necessary for "en-bloc" resection to control visceral, vascular, and neurological structures. We report our preliminary experience with a single-stage posterior approach.

METHODS

We included all patients who underwent posterior en-bloc resection of advanced Pancoast tumors invading the spine in our institution between January 2014 and May 2015. All patients had locally advanced tumors without N2 nodes or distant metastases. All patients, except 1, benefited from induction treatment consisting of a combination of concomitant chemotherapy (cisplatin-VP16) and radiation.

RESULTS

Five patients were included in this study. There were 2 men and 3 women with a mean age of 55 years (range, 46-61 years). The tumor involved 2 adjacent levels in 1 patient, 3 levels in 1 patient, and 4 levels in 3 patients. There were no intraoperative complications. The mean operative time was 9 hours (range, 8-12 hours), and the mean estimated blood loss was 3.2 L (range, 1.5-7 L). No patient had a worsened neurological condition at discharge. Four complications occurred in 4 patients. Three complications required reoperation and none was lethal. The mean follow-up was 15.5 months (range, 9-24 months). Four patients harbored microscopically negative margins (R0 resection) and remained disease free. One patient harbored a microscopically positive margin (R1 resection) and exhibited local recurrence at 8 months following radiation treatment.

CONCLUSIONS

The posterior approach was a valuable option that avoided the need for a second-stage operation. Induction chemoradiation is highly suitable for limiting the risk of local recurrence.

Superior sulcus tumors (Pancoast tumors)

Superior Sulcus Tumors, frequently termed as Pancoast tumors, are a wide range of tumors invading the apical chest wall. Due to its localization in the apex of the lung, with the potential invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, the superior sulcus tumors cause characteristic symptoms, like arm or shoulder pain or Horner's syndrome. The management of superior sulcus tumors has dramatically evolved over the past 50 years. Originally deemed universally fatal, in 1956, Shaw and Paulson introduced a new treatment paradigm with combined radiotherapy and surgery ensuring 5-year survival of approximately 30%. During the 1990s, following the need to improve systemic as well as local control, a trimodality approach including induction concurrent chemoradiotherapy followed by surgical resection was introduced, reaching 5-year survival rates up to 44% and becoming the standard of care. Many efforts have been persecuted, also, to obtain higher complete resection rates using appropriate surgical approaches and involving multidisciplinary team including spine surgeon or vascular surgeon. Other potential treatment options are under consideration like prophylactic cranial irradiation or the addition of other chemotherapy agents or biologic agents to the trimodality approach.

Chest wall reconstruction after en bloc Pancoast tumour resection with the use of MatrixRib and SILC fixation systems: technical note

STUDY DESIGN

Technical note.

OBJECTIVE

In cases in which partial resection of the rib cage is accomplished with vertebrectomy, reconstruction of the chest wall may be challenging. That is because of lack of the anchor point which normally would be a proximal end of a rib or transverse process. We report a straightforward technique for chest wall reconstruction with the novel use of two systems of fixation commonly applied in spinal practice.

METHODS

The operation of a squamous cell carcinoma (Pancoast tumour) of the right lung infiltrating T2, T3 and T4 vertebrae was performed though T4 lateral thoracotomy. Posterior instrumentation with transpedicular screws T1-3-5 on the left and T1-5 on the right side was followed with the right upper lobectomy and hemivertebrectomy. The laminae and facet joints of T2-T4 vertebrae were removed on the side of the tumour. An osteotomy was performed medial to the pedicle at the lateral aspect of the dural sac on the side of the tumour. Proximal parts of four adjacent ribs were removed allowing radical en bloc resection with tumour-free margins. The distal end of each of four rib plates used (MatrixRib Precontoured Plate system) was attached to the proximal end of the rib. The proximal end of the plate was then attached to the rod of posterior fixation construct with the use of a flexible polyethylene terephthalate (PeT) band of the SILC™ fixation system. The other end of the PeT band was then passed through the top-loading clamp subsequently attached to the rod of the posterior fixation.

RESULTS

The patient did not require additional procedures for chest wall reconstruction. On the 7-month follow-up, in chest CT he was found with satisfactory expansion of the remaining lung tissue with proper spinal alignment and anatomical shape of the rib cage.

CONCLUSIONS

The reported technique can be applied for chest wall reconstruction in cases of total or subtotal vertebrectomy accomplished with the resection extending towards rib cage. It appears to be straightforward, safe and effective allowing good cosmetic and functional outcome.

Long-term outcome after resection of non-small cell lung cancer invading the thoracic inlet

BACKGROUND

The aim of this study was to update our previous experience and describe long-term results after resection of non-small-cell lung cancer (NSCLC) invading the thoracic inlet.

METHODS

Patients from a single center undergoing resection of NSCLC invading the thoracic inlet were reviewed with data retrieved retrospectively from their charts.

RESULTS

Sixty-five consecutive patients with a median age of 61 (32-76) years underwent resection of NSCLC invading the thoracic inlet from 1991 to 2011. Tumor location was divided into 5 anatomic zones from anterior to posterior. Fifty-two (80%) patients had induction therapy, mostly with 2 cycles of cisplatin-etoposide and 45 Gy of concurrent irradiation. All patients underwent at least first rib resection. Lobectomy was performed in 60 patients (92%). Twenty-four patients (37%) had vertebral resection. Arterial resections were performed in 7 patients (11%). Postoperative morbidity and mortality were 46% and 6%, respectively. Pathologic response to induction was complete (pCR) (n = 19) or nearly complete (pNR) (n = 12) in 31 patients (48%). Adjuvant treatment was administered in 14 (25%) patients. After a median follow-up of 20 (0-193) months, 34 patients are alive without recurrence. The overall 5-year survival reached 69%. Univariate analysis identified site of tumor within the thoracic inlet (p = 0.050), response to induction (p = 0.004), and presence of adjuvant treatment (p = 0.028) as survival predictors.

CONCLUSIONS

Survival after resection of NSCLC invading the thoracic inlet in highly selected patients reached 69% at 5 years. Tumor location within the thoracic inlet, pathologic response to induction therapy, and adjuvant treatments were significant survival predictors.