Long-Term Outcomes of En Bloc Resection of Non-Small Cell Lung Cancer Invading the Thoracic Inlet and Spine

Abstract

The purpose of this study was to determine whether en bloc resection of non-small cell lung cancer (NSCLC) invading the thoracic inlet (TI) and spine can provide good long-term outcomes. We studied 54 consecutive patients treated with en bloc resection of NSCLC invading the TI and spine between 1992 and 2009 at our center. There were 36 men and 18 women with a mean age of 51 years (range, 37 to 71 years). Tumor resection involved at least 2 vertebral levels. We divided the patients into 3 groups based on whether vertebral invasion involved the transverse process only, the intervertebral foramina, requiring hemivertebrectomies with spinal fixation, or the vertebral body, requiring total vertebral body resection with spinal fixation. Induction chemotherapy was given to 27 (50%) patients including 3 who also received induction radiotherapy. Nine (17%) patients were in the transverse process group, 42 (78%) in the intervertebral foramina group, and 3 (6%) in the vertebral body group. Resection involved the subclavian artery in 19 (35%) patients. Complete resection was achieved in 49 (91%) patients. There were no perioperative deaths or residual neurologic impairments. Recurrence occurred in 31 (57%) patients and was local (n=6), systemic (n=24), or both (n=1). Local recurrence was more common in patients with N2-3 disease (p=0.0008) and subclavian artery involvement (p=0.031). There was a nonsignificant increase in local recurrence in patients with positive resection margins (40% vs 10%, p=0.058). The 1-, 5-, and 10-year survival rates were 82%, 31%, and 31%, respectively. The 1-, 5- and 10-year disease-free survival rates were 63%, 28%, and 28%, respectively. Five patients are alive and free of disease 10 years after surgery. By multivariate analysis, factors that independently affected survival were incomplete (R1) resection (p=0.006; odds ratio 67; 95% confidence interval 1.5 to 11.3) and subclavian artery involvement (p=0.037; odds ratio 0.46; 95% confidence interval 0.2 to 0.9). Good long-term survival can be achieved in highly selected patients with NSCLC invading the TI and spine, provided complete en bloc resection is performed.