Lung Cancer.pdf

128 S.G. Swisher
upper paratracheal regions (nodal stations 2R, 4R, 2L, and 4L) and subcarina
(nodal station 7) (Figure 7–1 and Table 7–2) are biopsied. If the lymph
nodes are positive, the procedure is terminated and the patient is evaluated
for chemotherapy followed by surgery or radiation therapy for localregional
control.
If the mediastinal lymph nodes are negative, chest wall resection and
pulmonary resection can be performed in the same operative setting. A
double-lumen endotracheal tube is placed to allow selective ventilation of
the operative field. Bronchoscopy is used to confirm that the endotracheal
tube is within the left main bronchus. The patient is then placed in the lateral
decubitus position unless the tumor involves the anterior chest wall,
in which case a supine position and an anterior approach through an inframammary
or parasternal incision may be better. If a lateral decubitus position
is chosen, a posterolateral incision is made with a muscle-sparing approach
or with the standard approach (latissimus dorsi division) through
the fifth intercostal space. This intercostal space should be adjusted so that
the chest is entered without incision of the tumor.
Once the chest is entered, exploration is performed to rule out metastatic
disease in other locations (e.g., pleural studding or pulmonary metastases).
The surgeon also assesses whether the patient can tolerate the chest
wall and pulmonary resection that will be required to remove the tumor.
Partial resection of the tumor with residual positive margins is not beneficial
for the patient, and it must be decided early whether the operation is
technically and physiologically feasible.
If a decision is made to proceed with the operation, the chest wall is resected
at least 1 to 2 ribs above and below the tumor. The chest wall is divided
anteriorly initially with rib shears with ligation of the intercostal
vessels. Superior and inferior margins can then be divided with cautery,
with rib shears used to divide the posterior rib attachments. In some cases,
posterior extension requires disarticulation of the rib from the transverse
process using an osteotome. Paravertebral tissue should be resected if it
lies close to the tumor. In rare cases, unexpected vertebral involvement is
noted. In these cases, we work in conjunction with our neurosurgeons,
who are available as needed, to ensure a negative margin with either partial
or total vertebrectomy (see the description of surgery for Pancoast
T4N0–1 tumors under the heading Operative Strategy in the section Treatment
of Patients with Stage IIIB Disease).
Once the chest wall resection is complete, the pulmonary resection is
performed. A lobectomy is usually required, although in some cases a
pneumonectomy will be required because of the extent of the tumor. Segmentectomies
or wedge resections are performed only if findings on the
patient’s pulmonary function tests indicate that the patient cannot tolerate
an anatomic resection. Once the pulmonary resection is complete, the
specimen is removed en bloc from the operative field. A complete mediastinal
lymph node dissection is then performed, with removal of the nodes