Lung Cancer.pdf

Surgical Treatment of Locally Advanced Non–Small Cell Lung Cancer 127
failure because the anatomic constraints of the thoracic inlet (subclavian
artery and vein, vertebral body, and brachial plexus) preclude a wide surgical
margin. At M.D. Anderson, patients with T3N1 Pancoast tumors are
treated in a phase II protocol evaluating the role of surgery and postoperative
chemoradiation in this subgroup. After surgical resection, radiation
therapy is delivered over 5 to 6 weeks. Patients receive 2 fractions per day,
to a total dose of 60 Gy in patients with negative margins or 64.8 Gy in patients
with positive margins, plus concurrent chemotherapy (cisplatin 50
mg/m 2 on days 1 and 8 and etoposide given by mouth 30 to 60 minutes
prior to each administration of radiation therapy on days 1 through 5 and
8 through 12, with this chemotherapy cycle repeated starting on day 29).
Prophylactic cranial irradiation (25 Gy in 10 fractions of 2.5 Gy) is given
upon completion of chest irradiation because of the high risk of brain recurrences.
Three additional cycles of chemotherapy are delivered after
prophylactic cranial irradiation. Other institutions have successfully
treated T3N1 Pancoast tumors with preoperative rather than postoperative
chemoradiation (Rusch et al, 2001).
Although surgical resection of T3N1 Pancoast tumors is technically
challenging, these tumors often have a local-regional recurrence pattern
and can be cured in many instances with surgery. Given the rarity of T3N1
Pancoast tumors and the anatomic difficulties associated with resecting
them, treatment is best performed at a referral center experienced with the
multidisciplinary treatment of these difficult and rare tumors. The best opportunity
for cure occurs when these tumors are approached from the
time of diagnosis in a concerted, coordinated manner.
Operative Strategy
Non-Pancoast Tumors. The most common type of T3N1 tumor is a
tumor that invades the chest wall. Although chest wall invasion is not a
contraindication to surgery, it necessitates a more extensive operation
and makes assessment of the mediastinal nodes critical since mediastinal
nodal involvement (N2 disease) is associated with markedly reduced
long-term survival (Figure 7–1 and Table 7–2). Cervical mediastinoscopy
should therefore be performed prior to chest wall resection
in any patient with enlarged mediastinal or hilar lymph nodes on CT.
Cervical mediastinoscopy can be performed immediately before the
chest wall resection, with nodal status assessed using frozen section
techniques.
For cervical mediastinoscopy, the patient is intubated with a singlelumen
endotracheal tube, and bronchoscopy is performed to evaluate the
presence of endobronchial disease. The patient is then placed in the supine
position with the neck extended and a roll under the shoulder blades. A
suprasternal incision is made, and the pretracheal plane is entered and
then explored bluntly into the mediastinum. A cervical mediastinoscope
is placed into the mediastinum, and lymph nodes from the lower and