Extended resections
Advanced Thoracic Surgery, Akademisyen Kitabevi, ss.715-726, 2021
- Yayın Türü: Kitapta Bölüm / Araştırma Kitabı
- Basım Tarihi: 2021
- Yayınevi: Akademisyen Kitabevi
- Sayfa Sayıları: ss.715-726
- Sağlık Bilimleri Üniversitesi Adresli: Evet
Özet
Lung cancer is one of the leading causes of death in both genders. Surgery has been accepted as a treatment for early-stage (Stage 1-2) nonsmall cell lung cancer; however, approximately 70% of patients are diagnosed with locally advanced or metastatic stages. According to the 8th edition of the TNM Classification of Malignant Tumors, superior sulcus tumors with involvement of the phrenic nerve and parietal pericardium are classified as T3 tumors, while tumors with invasion of the diaphragm, mediastinum, major blood vessels, trachea, carina, recurrent laryngeal nerve, esophagus, and vertebral body are classified as T4 tumors. Both T3 and T4 tumors have a highly heterogeneous nature. However, the effectiveness of surgery in these tumors is controversial. The term \"extended lung resection\" was first proposed by Chamberlain in 1959 to describe the complete resection of the lung parenchyma along with an adjacent organ or structure invaded by the tumor in locally advanced lung cancer. The most important prognostic factors in the surgical treatment of locally advanced lung cancer are lymph node involvement, R0 resection, and the necessity of pneumonectomy. Additionally, it has been shown that multimodal treatment of selected patients with locally advanced lung cancer offers a clear advantage in terms of survival and is the best treatment option. Therefore, a comprehensive evaluation should be performed when selecting patients for surgery, including a general assessment, investigation of lymph node involvement, determination of suitability for complete resection, and the necessity of additional treatment modalities. Chest wall invasion in lung cancer occurs in T3 tumors according to the 8th edition of the TNM Classification of Malignant Tumors. In tumors with chest wall invasion, lymph node involvement is a poor prognostic factor, as in other tumors. Superior sulcus tumors are also classified as T3 tumors. Chest wall invasion in lung cancer is defined as the extension of the tumor beyond the elastic layer of the visceral pleura, along with invasion of the intercostal muscles and ribs. While chest wall invasion was previously considered a criterion for inoperability, it has been widely applied since Coleman demonstrated in 1947 that it improves survival and has acceptable morbidity and mortality rates. Chest wall invasion typically presents with chest pain and can sometimes be asymptomatic. The presence of pain at the site of the lesion, especially, is a leading indicator of chest wall invasion. The radiological diagnosis of chest wall invasion may not be reliable when there is no clear sign of invasion on computed tomography (CT) or magnetic resonance imaging (MRI). The preoperative evaluation of patients should include the standard evaluation applied to patients undergoing lung cancer resection. In the diagnosis of chest wall invasion, there can be several indicators such as more than 3 cm of contact between the tumor and the chest wall, obtuse angles between the tumor and the pleura, pleural thickening with shrinkage, and bone destruction. The main principle in the surgical resection of chest wall invasion is the complete resection of the invaded area and, if necessary, reconstruction. In a planned resection of chest wall invasion, the amount of resection should be determined preoperatively, and reconstruction materials should be prepared according to the characteristics of the defect. Additionally, coordination with plastic surgeons is important for patients requiring flap surgery in cases where resection of other soft tissues, besides the ribs and intercostal muscle tissue, is necessary. In patients with chest wall invasion, a posterolateral thoracotomy approach is usually sufficient. In tumors involving both visceral and parietal pleura, extrapleural resection may be sufficient as frozen section confirms a clear surgical margin; however, if the tumor has infiltrated the parietal pleura and invaded the soft tissues and bones of the chest wall, complete resection of the chest wall is necessary.