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Induction chemoradiation therapy followed by surgical resection for non-small cell lung cancer (NSCLC) invading the thoracic inlet

^a Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, University Health Network, 200 Elizabeth Street, 9th floor, Toronto, Ontario, Canada M5G 2C4
^b Department of Medical Oncology, Princess Margaret Hospital, University of Toronto, University Health Network, Toronto, Ontario, Canada M5G 2C4
^c Department of Radiation Oncology, Princess Margaret Hospital, University of Toronto, University Health Network, Toronto, Ontario, Canada M5G 2C4

Received 14 September 2007; received in revised form 20 February 2008; accepted 4 March 2008.

^_* Corresponding author. Tel.: +1 416 340 5549; fax: +1 416 340 3478. (Email: marc.deperrot{at}uhn.on.ca).

Objective: The role of induction therapy for non-small cell lung cancer (NSCLC) invading the thoracic inlet is unclear. We reviewed our experience with induction chemoradiation followed by surgical resection for NSCLC invading the thoracic inlet. Methods: We performed a retrospective review of 44 consecutive patients with NSCLC invading the thoracic inlet, treated with induction chemoradiation (two cycles of cisplatin and etoposide concurrently with 45 Gy of radiation) followed by surgical resection between 1996 and 2007. Results: All patients underwent chest wall resection (1–5 ribs, mean 3) with resection of the first rib through an anterior (n = 15), a posterior (n = 18), or a combined approach (n = 11). Lobectomy was performed in 40 cases (90%), pneumonectomy in two (5%), and wedge resection in two (5%). Resection of subclavian vessels or portions of vertebrae was performed in five (11%) and 15 (34%) patients, respectively. Hospital mortality was 5% (n = 2). R0-resection was achieved in 39 patients (89%). On pathologic examination, 13 patients (30%) showed complete response (pCR) to induction therapy, and 15 (34%) showed minimal microscopic residual disease (90–99% tumor necrosis). The median follow-up was 2 years (range, 2 month–10 years) with an overall cumulative 5-year survival of 59%. Sixteen patients (36%) developed recurrence, which was local in five cases and distant in 11 patients. The 5-year survival in patients with pCR was 90%; 69% in those with minimal residual disease, and 12% in patients with no relevant response (p = 0.0005). Conclusions: Resection of NSCLC invading the thoracic inlet can be performed safely after induction chemoradiation therapy. The response rate after induction therapy is a strong predictor of survival.

Key Words: Superior sulcus tumor • Pancoast • Neoadjuvant therapy • Vertebral resection • Subclavian artery

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