Elsevier

The Annals of Thoracic Surgery

Volume 92, Issue 3, September 2011, Pages 1024-1030
The Annals of Thoracic Surgery

Original article
General thoracic
Long-Term Outcomes of En Bloc Resection of Non-Small Cell Lung Cancer Invading the Thoracic Inlet and Spine

Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.
https://doi.org/10.1016/j.athoracsur.2011.04.100Get rights and content

Background

The purpose of this study was to determine whether en bloc resection of non-small cell lung cancer (NSCLC) invading the thoracic inlet (TI) and spine can provide good long-term outcomes.

Methods

We studied 54 consecutive patients treated with en bloc resection of NSCLC invading the TI and spine between 1992 and 2009 at our center. There were 36 men and 18 women with a mean age of 51 years (range, 37 to 71 years). Tumor resection involved at least 2 vertebral levels. We divided the patients into 3 groups based on whether vertebral invasion involved the transverse process only, the intervertebral foramina, requiring hemivertebrectomies with spinal fixation, or the vertebral body, requiring total vertebral body resection with spinal fixation.

Results

Induction chemotherapy was given to 27 (50%) patients including 3 who also received induction radiotherapy. Nine (17%) patients were in the transverse process group, 42 (78%) in the intervertebral foramina group, and 3 (6%) in the vertebral body group. Resection involved the subclavian artery in 19 (35%) patients. Complete resection was achieved in 49 (91%) patients. There were no perioperative deaths or residual neurologic impairments. Recurrence occurred in 31 (57%) patients and was local (n = 6), systemic (n = 24), or both (n = 1). Local recurrence was more common in patients with N2-3 disease (p = 0.0008) and subclavian artery involvement (p = 0.031). There was a nonsignificant increase in local recurrence in patients with positive resection margins (40% vs 10%, p = 0.058). The 1-, 5-, and 10-year survival rates were 82%, 31%, and 31%, respectively. The 1-, 5- and 10-year disease-free survival rates were 63%, 28%, and 28%, respectively. Five patients are alive and free of disease 10 years after surgery. By multivariate analysis, factors that independently affected survival were incomplete (R1) resection (p = 0.006; odds ratio 67; 95% confidence interval 1.5 to 11.3) and subclavian artery involvement (p = 0.037; odds ratio 0.46; 95% confidence interval 0.2 to 0.9).

Conclusions

Good long-term survival can be achieved in highly selected patients with NSCLC invading the TI and spine, provided complete en bloc resection is performed.

Section snippets

Patients

Between January 1992 and December 2009, 54 consecutive patients underwent en bloc resection with curative intent for NSCLC invading the TI and spine, at the Department of Thoracic Surgery, Marie Lannelongue Hospital, France. Our Institutional Review Board approved this retrospective study and waived the need for informed consent.

Inclusion criteria were histologically documented NSCLC and invasion of the first rib and spine and (or) IF suggested by the preoperative investigations and confirmed

Results

There were 36 men and 18 women with a mean age of 52 years (range, 37 to 71 years). Serum carcinoembryonic antigen was elevated in 12 patients, normal in 32, and unknown in 10. Induction treatment was given to 27 (50%) patients and consisted of platinum-based chemotherapy alone (n = 24) or with radiation in a mean dose of 35 Gy (range, 30 to 45 Gy) (n = 3).

The tumor was on the right side in 31 (57%) patients and on the left side in 23 (43%). Spinal resection involved 2 levels in 5 (9%) patients

Comment

We previously reported a preliminary study in 17 patients that aimed to describe a new combined surgical approach for en bloc resection of NSCLC invading the TI and spine [1]. The current study is an extension of our experience and includes a larger number of patients with longer follow-ups. It clearly confirms the safety and efficacy of our combined anterior transcervical and posterior midline approach for complete en bloc resection of NSCLC invading both the TI and the spine. Although

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