Surgical treatment of T3 and T4 non-small cell lung cancer

Abstract

The primary goal of lung cancer therapy is complete eradication of the disease. Surgery remains the most curative modality for non-small cell lung cancer. The goal of surgical treatment is to perform a complete resection. Resectability is closely related to the stage of the disease. The thesis focuses on patients with T3 and T4 non-small cell lung cancer. T3 tumours comprise a heterogeneous group, including tumours with invasion of the chest wall, mediastinal structures, or diaphragm, Pancoast tumours, tumours with involvement of the main bronchus within 2 cm of the carina, and tumours associated with atelectasis or obstructive pneumonitis of the entire lung. The data presented in this thesis confirm that surgery is the treatment of choice for patients with a T3 tumour. The most important prognostic factor is to perform a complete resection, as an incomplete resection predicts poor survival. Regarding several subgroups of T3 tumours, survival was better for tumours located in the main bronchus, but the difference was not statistically significant. Another important factor regarding survival of resected T3 tumours is the presence of mediastinal lymph node metastases. Similar results have been published for Pancoast tumours, which can be staged as a T3 or T4 tumour, depending on invasion of adjacent structures. Recent results of combination of chemoradiotherapy and surgical resection suggest that this combined modality treatment offers the best survival results for these tumours. Characterisation of the primary tumour as T4 involves the presence of any of the following: invasion of the mediastinum, heart or great vessels, trachea, oesophagus, vertebral body, or the carina, the presence of a malignant pleural or pericardial effusion or satellite tumour nodule(s) within the same lobe as the primary tumour. The role of surgery for T4 tumours remains unclear due to high hospital mortality rates and few data about long-term survival. The largest experience and the best results for long-term survival are described in patients with T4 tumours invading the carina and trachea. Recently, multimodality treatment has become the recommended therapy for patients with locally advanced T4 tumours. It remains an important issue to demonstrate histopathological downstaging, as patients with persistent N2/N3 disease do not benefit from surgical resection. However, repeat mediastinoscopy does not seem a useful tool for restaging of the mediastinum after induction therapy, as adhesions and fibrosis cause incomplete procedures and false-negative results.