Extended resections for lung cancer. How far is too far?

Pulmonary resection is the preferred treatment for patients with lung cancer. Half of all patients, however, have signs of unresectability at the time of diagnosis. Contraindication to pulmonary resection is based on cell type, the extent of the disease, and the patient's overall general medical condition. Invasion of the chest wall by bronchogenic carcinoma is not rare. The diagnostic importance of this findings, however, has been controversial. Early reports had regarded thoracic wall invasion as a uniformly ominous sign, while recent reports have been more optimistic, especially when lymph nodes were not metastatically involved. Chest wall resection should be preceeded by mediastinoscopy. If lymph nodes are negative, excision is generally performed en bloc with pulmonary resection. After the thorax is entered and the cancer is found to be invading the chest wall, wide resection of the chest wall with attached lung is performed. Generally, the line of resection should encompass the area of invasion by several centimeters. The lung with attached chest wall is then allowed to fall back into the pleural cavity, where the appropriate pulmonary resection is performed. If the chest wall defect is less than 5 cm in diameter, no reconstruction of the defect is required. If, however the defect is larger and structural, stability is required. The defect should be reconstructed with a prosthetic material, such as the various meshes, metals, or soft tissue patches, and reinforced with a muscle flap. If the wound is contaminated from an intrathoracic source, prosthetic material should be avoided and reconstruction with a muscle flap alone is preferred. Muscles commonly used include serratus anterior, pectoralis major, latissimus dorsi, and occasionaly, rectus abdominus. Because the omentum lacks structural stabilitly, it should be considered a back-up alternative procedure. Operative mortality is usually related to the extent of pulmonary resection rather than the extent of chest wall resection. Five-year survival approaches 50% for patients with T3N0M0 lesions. For patients with either N1 or N2 neoplasms, 5-year survial is less than 10%. Postoperative radiation therapy appears to have no effect on surival.