Lung Cancer.pdf

226 J.B. Putnam, Jr.
rates were 47% for patients with stage IIB disease, 14% for patients with
stage IIIA disease, and 16% for patients with stage IIIB disease. Patients
with R2 resections (incomplete resection) who received 55 to 64 Gy as
postoperative radiation therapy had a 5-year survival rate of 82%, compared
to 56% in patients who received 50 to 54 Gy.
Tumors involving the superior sulcus are frequently treated inadequately
and inconsistently with 30 Gy of external-beam radiation to the
primary tumor prior to resection. No prospective trial has proven the benefit
of this approach over surgery alone, and the use of radiation therapy
before surgery has several theoretical disadvantages. First, if primary radiation
therapy is inadequate, accelerated repopulation may occur. Second,
if negative margins are not achieved, the chance for optimal local
control is lost. Third, resection of tumors abutting or invading the brachial
plexus after radiation therapy can be challenging. Finally, definitive
postresection radiation therapy can be performed in a more consistent and
complete manner than can preoperative radiation therapy.
The treatment of patients with superior sulcus tumors should involve a
multidisciplinary approach, with patients evaluated by a medical oncologist,
a radiation oncologist, and a thoracic surgeon. This approach optimizes
the definition of the extent and stage of the tumor and optimizes
decisions regarding whether preoperative or postoperative therapy or alternatives
to surgery (e.g., definitive chemotherapy and radiation therapy)
should be considered.
At M.D. Anderson, patients with superior sulcus tumors are treated
initially with surgery. After pathological evaluation and final staging,
postoperative radiation therapy is used for any microscopic residual disease.
The dose of radiation therapy may exceed 60 Gy. The benefits of radiation
therapy given in this manner are improved local control of the
tumor and the use of each therapeutic modality (surgery and radiation
therapy) in an optimal fashion.
In 1999, investigators at M.D. Anderson published results of a study
showing that superior sulcus tumors with vertebral invasion can be treated
successfully with surgery (Gandhi et al, 1999). Most of the 17 patients in the
study received postoperative external-beam radiation therapy. No perioperative
deaths occurred, and the 2-year actuarial survival rate was 54%. Patients
with a superior sulcus tumor that invades the vertebral column (stage
IIIB disease) can undergo resection with a combined approach including
posterior-lateral thoracotomy, lobectomy with en bloc chest wall resection,
laminectomy, vertebrectomy, anterior spinal column reconstruction with
methylmethacrylate, and spinal instrumentation (York et al, 1999). An additional
study examined the outcomes of preoperative chemotherapy and radiation
therapy followed by resection for clinical T3 and T4 superior sulcus
tumors (Rusch et al, 2000). Five-year survival rates were 46% for stage IIB
disease, 0% for stage IIIA disease, and 13% for stage IIIB disease. Treatment