Lung Cancer.pdf

134 S.G. Swisher
Pancoast tumors that have been resected have follow-up clinic visits 1
month after surgery, at 6-month intervals for 4 visits, and yearly thereafter.
Treatment of Patients with Stage IIIB Disease
Stage IIIB NSCLC encompasses tumors involving the contralateral mediastinal
nodes (N3 disease) and T4 tumors, which by definition invade the
mediastinum, heart, great vessels, trachea, esophagus, vertebral body, or
carina or have separate tumor nodules in the same lobe or are associated
with a malignant pleural effusion (Mountain, 1997).
Patients with contralateral mediastinal nodal involvement are better
treated with chemoradiation rather than surgery because of the high
propensity of such tumors to metastasize (see chapter 8). However, patients
with T4 tumors with minimal nodal involvement (N0 or N1 disease)
may benefit from surgery because these tumors are often more
local-regionally than systemically aggressive. Survival rates of up to 30%
have been reported for resected T4N0–1 tumors (Tsuchiya et al, 1994;
Mitchell et al, 1999; Rendina et al, 1999). However, T4 tumors associated
with N2 or N3 nodal involvement or malignant pleural effusions are
probably better treated without surgery since their biological behavior is
more systemic.
In this section, we will focus on operative strategies for T4N0–1 tumors.
All other subsets of stage IIIB disease will be discussed in chapter 8.
Both patients with T4N0–1 non-Pancoast tumors and patients with
T4N0–1 Pancoast tumors can benefit from extended surgical resections
(Dartevelle et al, 1993; Macchiarini et al, 1994; Tsuchiya et al, 1994; Gandhi
et al, 1999; Mitchell et al, 1999; Rendina et al, 1999). Given the proximity of
critical structures and the difficulty of achieving negative margins with
surgery alone, most T4N0–1 non-Pancoast tumors are treated initially
with induction chemotherapy in an attempt to downstage the tumor and
improve the chance of obtaining negative microscopic margins at surgery.
At our institution, Pancoast tumors are treated initially with surgery; this
is followed by postoperative chemoradiation to treat any residual microscopic
disease. Patients with T4N0–1 tumors must be physiologically fit to
tolerate the extended surgical resections required, and preoperative pulmonary
function tests are needed.
Selection of Therapy
T4N0–1 non-Pancoast tumors are usually treated with 2 to 3 courses of induction
chemotherapy. The most commonly used regimen is paclitaxel
and carboplatin, but other regimens—including cisplatin and navelbine or
gemcitabine and navelbine—are equally effective at downstaging tumors
and treating potential micrometastatic disease (Macchiarini et al, 1994;
Pisters et al, 2000). At M.D. Anderson, we tend not to give preoperative ra-