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Sopravvivenza nei tunori polmonari T3 di parete Dott. Marcello Costa Angeli MATERIAL and METHODS
Between January, 1993, and December 2001, 1071patients underwent our observation at S. Gerardo Hospital Thoracic Surgery Division for lung cancer. 41 of them were treated for non-small cell lung cancer invading the chest wall. There were 36 male and 5 female, with a median age of 63 years (range, 38 to 85). Histhologically, the tumors were epidermoid carcinoma in 36,58%, adenocarcinoma in 26,82%, large cell carcinoma in 24,39%, and bronchiolo alveolar carcinoma in 12,19%. At first observance during the diagnostic exam, it was important to define the symptomathologic outline ofdisease. In 18 patients showed thoracic pain (43,9%), fever and cough in 5, haemoptysis in 4. In one patient only was possible to see a wall swelling. In diagnosis and staging all patients considered for surgery had a plain chest radiograph, a computed tomographic (CT)scan of the thorax including the adrenal glands and the liver, CT of the brain and a total body bone scintigraphy. Patients with superior sulcus neoplasm at presentation were excluded by our study. Preoperative clinical (cTNM) staging, as accurately as possible given the limitations of the investigationsavailable, is therefore crucial. After primary preoperating valuation, only 25 patients underwent operation (60,97%). Fourteen of them (34,14% af all patients) were treated with radical surgery by en-bloc resection of the chest wall. Complete hilar and mediastinal lymph node dissection was done in all radical resected patients. A lobectomy was done in 7 patients, an atypical segmentectomy in 4 and a pneumectomy in 2. Only one underwent bilobectomy. Five patients had an adenocarcinoma histotype, 5 an epidermoid and 4 a large cell carcinoma. Tumors were graded according to classification as grade IIIA in all 14 patients underwent radical surgery. Ten patients showed no nodal involvement(T3N0), N2 disease in 2, while unknown nodal involvement was found in 2. On pathologic examination, all patients had tumor-free margins on the chest wall resected en bloc with the pulmonary cancer. Complete en-bloc resection of tumor plus radical lymphoadenectomy was feasible in 17 patients(41,46%). The others 11 patients (26,82% of all) underwent palliative and/or diagnostic surgical treatment(diagnostic videothoracoscopy 2, explorative thoracotomy 3, palliative surgery, without en-bloc resection of the chest wall for loose infiltration of the wall, 3). At first, 16 patients didn't undergo surgical treatment, but directed to investigations with successive indications to chemiotherapy and/or radiotherapy(39,02%). Two of them underwent to careful assessment only. 6 patients had an epidermoid carcinoma histotype, 5 a large cell carcinoma, 3 an adenocarcinoma and a bronchiolo alveolar carcinoma for 2 only. Tumors were graded, always with tha same classification, as grade IIIA in 9 patients(56,25% of no-resected patients), grade IV in 6(37,5%) and grade IIIB in 1(6,25%). About this group, 2 patients showed no nodal involvemente. Differently, N1 and N2 disease was found in 11 and 3, respectively. In 4 it was possible to settle thepresence of metastases in different places( bone, brain, adrenal glands and against lateral lung). The effect of various factors on survival were studied. SURGERY IN 14 PATIENTS.
RESULTS The aim of our study was to help to establish a rational for en-bloc resection in lung cancer invading the chest wall. All patients underwent complete resection of the tumor with microscopically disease-free tissue margins. There were neither intraoperative nor postoperative deaths. Out of a group of 41 patients, fourteen have been the real subjects of our study, because treated with radical surgery. 13 were male and one was female only. Ages ranged from 44 to 77 years with a median of 65 years. Five patients (35,71%)presented, as primary symptom, with chest pain and in less measure with cough(28,57%). Evidence of the neoplasm invading the chest wall was obvious preoperatively on computed tomograaphic scan of the thorax in ten of thirty-four patients(71,42%). These patients, without evidence of distant metastases or other contraindications to operation, were treated with radical surgery. At thoracotomy a complete mediastinal lymph node dissection accompanied the lung cancer resection. However, ten patients required en-bloc resection of lung plus segments of ribs and muscles because of neoplasm extension beyond the parietal pleura. Eleven patients had no nodal involvement(71,42%), only one had N1 disease(7,14%)and two had mediastinal lymph node metastases(N2 disease). Upon completion of the study, the follow up doesn't result complete, because one patient wasn't reachable. Six patients(42,85%)are alive. Without recurrent disease for five of them. Only one has a bone secondarism at ten months from operation. These six patients had T3N0 but for one that had T3N2 disease. For the other seven patients, the cause of death was lung cancer progression in six(42,85%), and, it was unrelated to the tumor in one only(for IMA). Involved sites by metastases were the lung(4 patients), bone(3 patients), and, total body disease in one patient. Brain metastatic and local disease in the omolateral hemithorax occurred in one patient only. Overall median survival in patients treated with radical surgery is 24 months(range 2 to 62 at the follow up moment). In particular, survival in patients with postsurgical stage T3N0 is 54,54%
CONCLUSIONS The main observed recurrence or metastases were at a distant site in the majority of these patients. The observation of bone structure metastases in 3 out of 7 patients with local recurrences defines the capacity for T3-tumor to penetrate the chest wall and to reduce survival in patients with contemporary nodal involvement. Survival of patients with lung cancer invading the chest wall after resection with curative intent is highly dependent on the extent of nodal involvement and the completeness of resection, and much less so on the depth of chest wall invasion.(1) According to survival data obtained by our study, the invasion of the chest wall reveals a poor prognosis if the is positivity of N factor at the postsurgical staging. On the contrary if there is negativity of N factor and the tumor is totally resectable, the prognosis within 5 years is satisfactory. With reference to the recent revision of the International Staging System for pulmonary cancer, patients with T3N0 are classified as having stage IIB disease due to the comparable survival with T1-2N1 subsets.(2) Survival data of group T3N0 don't fit, with those of the stage III, but more similar to those of the second stage confirming the stronger importance that the factor T has on the N factor. Infact, the presence of regional lymph node metastases significantly reduced survival. So doing, in the absence of N positivity, the importance of the depth of chest wall invasion hasn't particular affect on survival data, if we performe a radical surgery. Then, at thoracotomy, a complete resection will be possible in most studied cases with the prognosis determined primarily by the status of the regional lymphonodes.(3) Surgical treatment of stage IIB and IIIA in NSCLC invading chest wall and lung by en-bloc resection is widely adopted and justified by the good results in terms of morbidity and relief of pain. We conclude that this surgical technical is the procedure of choice to obtain complete resection of tumor, and, the same operation can be performed with a strong likelihood of long-term survival if regional lymph nodes are not metastatically involved and there is no evidence of distant metastases.
BIBLIOGRAFIA
(1) Downey R, Martini N, Rusch V, Bains M, Korst R, Ginsberg R. Extent of chest wall invasion and survival in patients with lung cancer.
(2) Mountain CF. Revisions in the international system for staging lung cancer. Chest 1997;111:1710-7
(3) McCaughan B, Martini N, Manjit S, McCormack P. Chest wall invasion in carcinoma of the lung. J Thoracic Cardiovasc Surg 89:836-841, 1985
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