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SURGERY FOR LOCALLY ADVANCED NON–SMALL CELL LUNG CANCER

A 60-year-old male has a 6-cm right apical lung mass that invades the chest wall. He has chronic obstructive pulmonary disease (COPD) and smokes 1 pack of cigarettes per day.

The mass is biopsied by computed tomographic (CT)–guided core needle and is positive for adenocarcinoma of the lung. The pathology shows non–small cell lung cancer (NSCLC) of the lung.

Positron emission tomography (PET) shows one ipsilateral PET-positive, non-bulky medastinal lymph node that is pathologically positive on mediastinoscopy. Magnetic resonance images (MRI) of the brain and neck are negative for metastases or extension into the plexus.

Learning Objectives

  1. What is the role of surgery in stage III NSCLC?

  2. What surgical techniques are available to resect lung cancer invading adjacent organs?

  3. How are Pancoast tumors of the lung treated?

Locally advanced NSCLC includes tumors that invade the surrounding structures, including the chest wall, vertebrae, great vessels, diaphragm, and structures of the superior sulcus. Treatment typically involves multimodal therapy, with surgical resection providing the best chance at improving 5-year survival. In this chapter, the surgical management of locally advanced NSCLC is discussed.

PANCOAST TUMORS

Pancoast tumors were originally described by Henry Pancoast, the first president of the American Board of Radiology.1 Also known as superior sulcus tumors, these tumors invade the apical chest wall and surrounding structures, including the brachial plexus, sympathetic chain, subclavian artery and vein, vertebrae, spinal cord, clavicle, and ribs.2 Approximately 90% of all Pancoast tumors are NSCLCs2 and are classified according to the tumor, node, metastasis (TNM) staging system as T3 or T4 lesions depending on the extent of invasion. The National Comprehensive Cancer Network (NCCN) guidelines can be used to determine treatment strategies. Treatment options are multimodal and include a combination of chemotherapy, radiation therapy, and surgical excision.3 However, because less than 5% of all NSCLCs are Pancoast tumors, no prospective head-to-head randomized controlled trials comparing treatment strategies have been conducted.2

PREOPERATIVE CHEMORADIATION

The NCCN guidelines recommend neoadjuvant concurrent chemoradiation for T3N0-1 and possibly resectable T4N0-1 Pancoast tumors. Standard regimens include platinum-based chemotherapy along with 45- to 54-Gray (Gy) radiation given in 1.8- to 2-Gy fractions.3 Induction chemoradiotherapy is associated with an improved 5-year survival rate, complete pathologic response, and R0 resection rate compared to the historical treatment regimen of preoperative radiotherapy followed by surgery. Furthermore, trimodal therapy has been shown to downstage tumors.2

OVERVIEW OF SURGERY

Surgical resection is the mainstay of treatment of Pancoast tumors, with the goal of R0 resection, including the upper lobe with one rib with attached intercostal muscles below the inferior margin of the tumor and all invaded structures en bloc.4 Absolute contraindications to surgical resection include extrathoracic metastases, N2 disease, and invasion of the trachea, esophagus, spinal canal, or brachial plexus ...

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