The role of surgical management in T4 non-small cell lung cancer (NSCLC) remains controversial. Treatment is usually palliative, yet a certain proportion of patients may benefit from curative treatment. We report on radical en bloc resection of a right upper lobe (RUL) NSCLC invading the 3rd and 4th thoracic vertebrae.
A 51-year-old white male smoker developed right shoulder and upper back pain. Initial conservative management failed to resolve the pain. Plain films revealed degenerative joint disease. The pain persisted. Computed tomography (CT) and magnetic resonance imaging showed a 5 x 5.1 cm RUL mass invading the right T3-T4 neural foramen and a portion of the T2 vertebral body. CT-guided biopsy revealed squamous cell carcinoma, and mediastinoscopy was negative for N2 disease. Clinical stage was T4N0M0 (Stage IIIB) NSCLC. After neoadjuvant therapy (Taxol/Cisplatin and 5000 cGy), a Neotec scan revealed no evidence of distant disease. Pulmonary function tests were normal. Repeat imaging studies showed no evidence of cord compression and partial tumor response. The patient was taken to the operating room where he underwent radical en bloc resection of the tumor, which included a right upper lobectomy, chest wall and three level vertebrectomy. Spinal integrity was achieved by anterior cage reconstruction followed by posterior rod stabilization. A complete resection was achieved histologically. Three years later, he is well, without radiologic or clinical evidence of recurrence.
Surgery remains the ‘gold standard’ for early-stage lung cancer. Stage IIIB NSCLC is considered an inoperable disease; however, Stage IIIB represents a heterogeneous group of patients, including the subgroup of T4N0M0 patients. These patients may benefit from an aggressive surgical approach, oftentimes after neoadjuvant therapy. Several authors have described acceptable outcomes after surgical treatment. DeMeester, et al (1) reported 12 patients with T4N0M0 NSCLC with tumor adherent to the vertebral column who underwent preoperative radiotherapy and radical surgical excision with a 5-year Kaplan-Meier survival of 42%. Grunenwald et al (2) demonstrated a 14% predicted 5-year survival in 19 patients undergoing en bloc partial and total vertebrectomy for lung cancer invading the spine. Other authors (34567) have reported 5-year survival rates ranging from 10-28% in a heterogeneous group of T4 lung cancer patients. Operative morbidity and mortality have been acceptable in this high-risk group of patients. Factors contributing to long-term survival appear to include response to neoadjuvant therapy, ability to achieve complete histologic resection, and absence of N2 or N3 nodal disease.
The role of surgery for Stage IIIB NSCLC remains controversial. Various authors have advocated surgical therapy for certain subsets of Stage IIIB NSCLC. We present a case of T4N0M0 NSCLC invading several levels of the thoracic vertebrae. Aggressive en bloc surgical resection and reconstruction after neoadjuvant therapy resulted in a negative margin resection and long-term survival.
E.D. Cox, None.