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Resection of Non-small Cell
Lung Cancer*
realized that local recurrence was a major problem in
locally advanced disease, especially with incomplete resec¬
How Much and
have become commonplace, especially for lesions
invading the chest wall (eg, T3 chest wall tumors, superior
sulcus tumors). As with other lung cancers, the overriding
prognostic factor has always been a complete resection
with negative resection margins.1112
Cahan et al13 were the first to introduce the concept of
mediastinal lymph node dissection. This approach was
used especially in patients with hilar or mediastinal lymph
node disease in an attempt to completely resect all obvious
tumor with the goal of improving ultimate survival. With
this approach, advocates have claimed superior 5-year
survival rates, even in patients harboring N2 disease, as
long as a complete resection can be accomplished.1415 As
with other tumors, incomplete resections have failed to
yield many long-term survivors. As a result of work by the
Robert J.
by What Route
Ginsberg, MD, FCCP
Surgical resection remains the preferred treatment,
possible, in patients with non-small cell lung
cancer (NSCLC). A complete resection is required to
improve survival of these patients. Lobec¬
potentially
is
the
minimum resection of choice. En bloc
tomy
resections ofinvolved adjacent organs and structures
are performed routinely with acceptable morbidity
and mortality. Mediastinal lymph node dissection
allows accurate surgical and pathologic staging of
lymph node disease but has yet to be proven effica¬
cious as a curative procedure. The standard ap¬
proach to the hemithorax is via posterolateral thora¬
cotomy. Recent muscle-sparing incisions and videoassisted techniques have been employed safely to
accomplish goals of surgery. This article evaluates
past and current approaches to the resection of
NSCLC, and looks at the impact of route and extent
of resection on survival of NSCLC patients.
when
(CHEST 1997; 112.203S-205S)
/^ ompleteness of resection is the ultimate goal of sur^^ gical resection in the management of lung cancer.
Following its introduction by Graham and Sedal,1 pneu¬
monectomy became the standard approach to resection of
lung cancer, no matter the stage of disease. Once surgeons
developed the techniques of individual ligation of vessels
and bronchi, it became evident that, for early-stage disease
limited to one lobe, lobectomy could usually offer a
complete resection, thus preserving functioning pulmo¬
nary tissue.2 Segmental resections were championed 30
years later by Jensik et al3 as a method of managing
early-stage lung cancer; their results appeared similar to
those seen with lobectomy. For many years, wedge resec¬
tions have been employed in an attempt to preserve
function in compromised individuals and, on
pulmonary
the whole, have been limited to treatment of small
peripheral tumors (T1N0). These resections have always
been considered a compromise and have been reserved
for patients with very limited pulmonary reserve.4"9
Extended resections were originally introduced over 40
years ago. "Radical pneumonectomy" described the pro¬
cedure that included intrapericardial dissection and re¬
moval of mediastinal lymph nodes en bloc with the surgical
specimen.10 This approach was first suggested when it was
*From the Department of Surgery, Memorial Sloan-Kettering
Cancer Center and Cornell University Medical College, New
York.
Reprint requests: Robert J. Ginsberg, MD, FCCP, Memorial
Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY
10021
tions.
En bloc resections of tumors
invading adjacent struc¬
tures
Lung Cancer Study Group (LCSG),16 minimum intraop¬
staging now requires selective biopsy of all ipsilat¬
erative
eral mediastinal nodal stations without a complete lymph
node dissection when N2 disease is not present. Most
recently, extended lymph node (two-field) dissections
have been advocated by a variety of surgeons in Japan,
who suggest this approach will yield better long-term
survival in advanced as well as early-stage disease com¬
pared with historical data.1718
Although anterolateral thoracotomy was the first ap¬
proach used to attempt pulmonary resection via the
hemithorax, posterior and posterolateral approaches
quickly became commonplace in resecting these tumors.
By the 1950s, posterolateral thoracotomy was the incision
of choice. More recently, sternotomy, hemi-clamshell
incisions, and full clamshell incisions (transverse sternot¬
omy) have also been used in special circumstances.19-20
In an attempt to decrease postoperative pain, musclesparing incisions, championed by Kittle,21 have now
emerged as viable options that still allow full access to the
hemithorax by open thoracotomy.2223 Video-assisted tech¬
niques have also been employed to further decrease
postoperative pain, reduce hospital stays, and improve
cosmesis. In the past 5 years, video-assisted surgery has
evolved to the point at which complete resections can be
accomplished using standard hilar dissection techniques.24
Mediastinal lymph node sampling and dissection can also
be performed safely.25
How Much?
Extent of Dissection
There is now sufficient evidence from retrospective
analyses and atorecently reported LCSG prospective ran¬
domized trial support the use of lobectomy as minimum
resection even for the earliest-stage lung cancer in other¬
wise fit patients. When lesser resections are employed, the
risk of local recurrence in patients with T1N0 disease is
threefold as compared with lobectomy in
approximately
most series.2627 For this reason, lobectomy should con¬
tinue to be the resection of choice, except in severely
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203S
compromised individuals. This has been substantiated by
lymphatic drainage demonstrating
evidence of occult lymphatic permeation proximal to the
tumor, even in tumors surgically staged as T1N0, in up to
15% of cases.2830
In patients severely compromised by poor pulmonary
function, the lesser resection of choice, whenever possible,
should be segmentectomy, which allows removal of lym¬
channels and lymph nodes, draining the tumor bed.
phatic
In the recent LCSG report,26 segmentectomy appeared to
be associated with a lesser chance of local recurrence than
wedge resection, although these subsets were too small to
gauge statistical significance.
The use of wedge resection in the management of lung
cancer must be considered a compromise, regardless of
the size or stage of the tumor. Most reports of satisfactory
results with wedge resection have also added postopera¬
tive radiotherapy to the ipsilateral hemithorax and medi¬
astinum.68 Although late follow-up of such patients has
not included pulmonary function analysis, other studies
have demonstrated a late adverse effect of postoperative
radiotherapy on pulmonary function. In reality, postoper¬
ative radiotherapy produces a "slow lobectomy" due to
A new approach in the management of
pulmonary fibrosis.
reduction
COPD.lung
surgery.produces improved pul¬
monary function in severely compromised patients.31
These results call into question the whole concept of how
large a resection such patients can tolerate, and whether
the condition of even severely compromised patients
might be improved by a "lung-reducing" lobectomy.
For tumors invading adjacent structures, an en bloc
resection of the adjacent involved area is not only advis¬
able but necessary. This may include the following struc¬
tures: chest wall, contents of the superior sulcus, superior
vena cava, pericardium, intrapericardial major vessels,
lower trachea and carina, esophageal wall, vertebra, or
diaphragm.2930
All of the above-mentioned structures may be resected
and the anatomy reconstituted with only minimally in¬
creased morbidity and mortality. Wherever possible, these
resections should be performed en bloc, avoiding any
transgression of the tumor at the time of surgeiy. Even in
placed T3-4 tumors, a recent retrospective
peripherally
analysis of superior sulcus tumor resections at Memorial
Sloan-Kettering Cancer Center concluded that a large
wedge resection yielded a lesser chance of ultimate sur¬
vival than a standard lobectomy.32
anatomic studies of
Mediastinal Lymph Node Dissection vs
Node Sampling
Lymph
The minimum acceptable resection in the management
of lung cancer must include adequate lymph node sam¬
pling of hilar and ipsilateral mediastinal lymph nodes for
the final pathologic staging required for accurate assess¬
ment of prognosis and possible need for adjuvant therapy.
To our knowledge, no study has conclusively demon¬
strated any survival advantage for a complete mediastinal
node dissection.33 Our experience has been that
lymph
this procedure adds very little morbidity, increased oper¬
ating time, or effort. Therefore, for the most complete
204S
surgical and final pathologic staging, we believe that
complete ipsilateral mediastinal lymph node dissection (vs
sampling) should be considered a routine part of the
oncologic surgical procedure. This will also ensure the best
chance for complete resection of all tumor present in the
hemithorax.1415 Extended lymph node dissection to in¬
clude contralateral mediastinal and supraclavicular lymph
nodes has been adopted as the treatment of choice by
some surgeons in Japan.1718 As yet (to our knowledge),
there has been no prospective randomized trial to dem¬
onstrate improved survival with this modified procedure.
However, compared with historical data, surgeons em¬
this technique have claimed improved 5-year
ploying
survival for patients ultimately identified to have N3
disease.1718 Only a very large randomized trial will confirm
the efficacy of lymph node dissection, be it limited to the
hemithorax or extended to include all medias¬
ipsilateral
tinal and supraclavicular lymph nodes.
By What Route?
There is no doubt that a generous posterolateral thora¬
cotomy or, when indicated, anterior approaches by ster¬
notomy or clamshell incisions (transverse sternotomy)
best access to intrathoracic contents. The avail¬
yields the
of
ability improved pain-relieving techniques (eg, epidural
analgesia), allowing decreased postoperative morbidity,
has made these incisions less formidable. Muscle-sparing
incisions have also been used to decrease postoperative
pain and improve cosmesis, but these can compromise
exposure and extensibility, thereby limiting their use. To
our knowledge, there has yet to be a conclusive random¬
ized trial to prove the efficacy of muscle-sparing incisions
in
minimizing postoperative pain or improving cosmesis.
The
recent interest in video-assisted
some surgeons to
methods
techniques has
of resection
spurred
employ
or
excision
lobar
resections
without
(eg, wedge
adequate
lymph node dissection or sampling) that are less than
satisfactory, even in early-stage disease, because of the risk
of leaving occult lymphatic disease.3435 However, other
surgeons, more adept at video-assisted techniques, have
accomplished standard lobectomies, pneumonectomies,
and mediastinal lymph node sampling and dissection.24-25
For the most part, video-assisted approaches have been
reserved for very-early-stage tumors requiring uncompli¬
cated resections. Despite the claims of improved cosmesis,
acute and chronic postoperative pain relief, and reduced
randomized trials to date (and to our
hospital stays,
have
knowledge) failed to demonstrate any advantages for
video-assisted surgery other than improved cosmesis.36
CONCLUSIONS
Surgical resection for lung cancer remains the treat¬
ment of choice whenever possible. A complete resection is
required. Lobectomy is the minimum resection of choice,
with lesser resections being reserved for only the most
severely compromised individuals. En bloc resection of
involved adjacent organs and structures can be accom¬
plished with acceptable morbidity and mortality, allowing
complete resections to occur. The addition of mediastinal
lymph node dissection produces the best possible surgical
Multimodality Therapy of Chest Malignancies.Update '96
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and pathologic staging of lymph node disease but has yet
as a curative procedure. The
role of extended (N3) lymphadenectomy has yet to be
defined. Although posterolateral thoracotomy remains the
standard approach to the hemithorax, more recent musclesparing incisions and video-assisted approaches have been
used to accomplish many of the above-mentioned
safely
resections. When necessary, sternotomy, transverse ster¬
notomy, and combinations of these two can be used to
improve access to anterior-situated tumors.
to be proven more efficacious
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