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Ann Thorac Surg 1999;68:2049-2052
© 1999 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Hyogo Medical Center for Adults, Akashi City, Hyogo, Japan
Address reprint requests to Dr Tsubota, Department of Thoracic Surgery, Hyogo Medical Center for Adults, Kitaohji-cho 13-70, Akashi City 673, Hyogo, Japan
Abstract
Background. The results of surgical treatment for non-small cell lung cancer with interlobar pleural involvement and direct invasion of the other lobe have seldom been documented.
Methods. Of 1,130 consecutive patients who were operated on for primary bronchogenic carcinoma between 1984 and 1997, we studied 132 patients who had complete resection of T3 non-small cell carcinoma.
Results. The structures involved were as follows: parietal pleura, 49 patients; chest wall, 45; interlobar pleura, 19; main bronchus within 2 cm of the carina, 11; mediastinal pleura, 6; and diaphragm, 1. Patients with N2 disease had a significantly worse survival than those with N0 (p = 0.0054) and N1 disease (p = 0.0165). The survival of patients with involvement of the interlobar pleura was significantly worse than that of patients with T1 (p = 0.0001) or T2 disease (p = 0.0484), and was similar to that of patients with T3 disease (p = 0.9821).
Conclusions. In patients with T3 disease, mediastinal lymph node involvement influenced survival significantly. Patients with involvement of the interlobar pleura should be regarded as having T3 lesions.
Although indication for surgical resection for T3 lung cancer was considered controversial a few decades ago, extended surgical procedures were developed and included lung resection combined with en bloc resection of the adjacent structures. According to the revisions in the international system for staging lung cancer reported in 1997 by Mountain [1], T3 lesions were tumors of any size that directly invaded any of the following: chest wall, diaphragm, mediastinal pleura, parietal pericardium, or tumor in the main bronchus less than 2 cm distal from the carina. We wondered how tumors associated with interlobar pleural involvement and direct invasion of the other lobe should be classified, and what procedure should be chosen for these lesions. The results of surgical treatment for non-small cell lung cancer with such an invasion have seldom been documented.
In the current review, we examined the results of surgical treatment in patients with T3 non-small cell lung cancer, excluding those who had incomplete resection to eliminate adverse prognostic effects [2–6], and analyzed the survival characteristics of patients who had completely resected T3 non-small cell lung cancer. We also investigated whether other-lobe invasion with interlobar pleural involvement should be regarded as T3 disease.
Patients and methods
From June 1984 to December 1997, 1,130 consecutive patients were operated on for primary bronchogenic carcinoma by the same surgical team at our center. Of these patients, 901 patients (80%) with proven non-small cell carcinoma had curative operation, which was defined as complete removal of ipsilateral hilar and mediastinal lymph nodes together with the primary tumor. Routine systematic dissection of all the hilar and mediastinal nodes was done in every case, even if the preoperative evaluation was N0 or N1. Patients in whom there was evidence of residual tumor at the surgical margin, malignant effusion, satellite lesions, N3 disease, or distant metastasis verified by intraoperative findings or postoperative pathologic examination were considered to have had non-curative operations and were therefore not included in this study. Patients whose tumors were subsequently classified as small cell carcinoma or low-grade malignant tumor were not included either. Because of significant differences in survival between patients who had complete resection and those who had incomplete resection, only the former were included in this analysis. Of this group, 132 patients (15%) had operations for T3 cancer associated with invasion of the parietal pleura, chest wall, mediastinal pleura, diaphragm, or interlobar pleura, or localized in the main bronchus at pathologic examination. For reasons of convenience, patients with interlobar pleural involvement and other-lobe invasion were considered as T3 lesions. Patients who had received induction therapy, such as chemoradiotherapy, perioperatively were not included.
Surgical-pathologic staging was performed according to the new International Staging System for Lung Cancer [1]. Resected specimens were examined histopathologically, and histologic typing was done according to the World Health Organization classification [7]. Survival was estimated by the Kaplan-Meier method [8], and differences in survival were determined by log-rank analysis. Zero time was the date of pulmonary resection, and the terminal event was death attributable to cancer, other disease, or unknown cause. A variable analysis of independent prognostic factors was done with Cox proportional hazards regression model when the number of samples was small. Significance was defined as p less than 0.05.
Results
The median age was 64 years and the age range was 34 to 77 years. One hundred seventeen patients were male and 15 were female. The primary tumor was in the right lung in 82 patients (62%) and in the left lung in 50. In 92 patients (70%) the tumor was in the upper lobe. The histologic diagnosis was squamous cell carcinoma in 67 patients (51%), adenocarcinoma in 53 (40%), large cell carcinoma in 9 (7%), and adenosquamous carcinoma in 3 (2%). The relationship between the pathologic TNM classification and the structures involved in T3 tumors is shown in Table 1. The involved structures were as follows: parietal pleura, 49 patients; chest wall including ribs or muscle, 45; other lobe through interlobar pleura, 19; main bronchus within 2 cm of the carina, 12; mediastinal pleura including pericardium or phrenic nerve, 6; and diaphragm, 1. Sixty-two patients had no nodal metastases (N0 disease), 34 had hilar node metastases (N1 disease), and 36 had mediastinal node metastases (N2 disease). The extent of the pulmonary resection for the primary lesion was as follows: lobectomy, 65 patients; segmentectomy, 17; sleeve lobectomy, 15; pneumonectomy, 11; bilobectomy, 9; lobectomy with partial resection, 9; sleeve bilobectomy, 4; and sleeve pneumonectomy, 2. Because we followed the policy that lung-saving procedures such as bronchoplasty must always be kept in mind [8, 9], pneumonectomy was done relatively infrequently. All patients who had involvement of adjacent structures underwent completely en bloc combined resection.
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In patients with T3 non-small cell carcinoma, three factors can mainly affect survival—resectability, extent of T3 lesion, and status of the lymph nodes. Although some studies about T3 disease have been published, there are very few concerning only patients who have had complete resection. Complete resection is a prerequisite to long-term survival in patients with non-small cell lung cancer [10, 11]. Our study included only patients who had en bloc complete removal of the tumor and related tissues, and it also has the advantage of being done at a single institution. Single-center trials have the fewest variations in surgical techniques and perioperative treatment [12]. Histologic assessment was also carried out by a small group of dedicated pathologists, allowing the fewest possible variations in staging.
Some authors have reported that hospital mortality rates were closely related to type of procedure, that is, pneumonectomy was associated with a higher hospital mortality rate than lobectomy [5, 13, 14]. Those findings suggest that resections involving less tissue than pneumonectomy might be appropriate, and sleeve lobectomy should have been considered in more patients with T3 main bronchus disease regardless of pulmonary function. Because of our policy that lung-saving procedures such as bronchoplasty must always be kept in mind [8, 9], this study included more cases of sleeve lobectomy than pneumonectomy.
In previous studies, patients with tumor invasion of the main bronchus within 2 cm of the carina were reported to have good prognostic results when complete removal was accomplished [3, 5]. Our findings agree with that. Among patients with T3 lesions, those with tumor invasion of the main bronchus within 2 cm of the carina were considered the most favorable subset for resection. In our series, the depth of chest wall invasion did not significantly affect survival, provided that the resection, with normal macroscopic and microscopic margins, was complete. This result was similar to that reported by Pitz and associates [15].
There have been few reports regarding prognosis after resection of tumors that invade the interlobar pleura and the other lobe, and revisions in the international system for staging lung cancer [1] have not considered this condition. Although we treated a limited number of patients with interlobar p3 disease which should have been given greater attention, the prognosis of these patients was similar to that of patients with the other T3 disease, supporting the idea that patients who have involvement of the interlobar pleura should be classified as having T3 lesions. Controversy exists over the treatment of a tumor that had invaded the other lobe found at operation. The results of lobectomy plus partial resection were equivalent to those of bilobectomy or pneumonectomy, suggesting that the extended procedure was not a significant survival determinant for patients presenting with interlobar invasion. We therefore think that complete removal of the adjacent lobe would provide no advantages and be an unnecessary operation. Considering postoperative complications and the quality of life, we should select lobectomy with partial resection for patients with invasion beyond interlobar pleura. The classification and treatment for patients with interlobar p3 lesions need to be studied further.
References
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 W. J. Scott, J. Howington, and B. Movsas Treatment of Stage II Non-small Cell Lung Cancer Chest, January 1, 2003; 123 (2009): 188S - 201S. [Abstract] [Full Text] [PDF]
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