Surgical treatment of IIIb-T4 lung cancer invading left atrium and great vessels.

Background: IIIb-T(4) non-small cell lung cancer (NSCLC) is commonly considered a contraindication to surgery, although chemo-radiotherapy also achieves a poor survival rate. We reviewed our experience with T(4) NSCLC patients who underwent surgery to explore the indications and prognostic factors of surgical treatment of lung cancer invading the left atrium and great vessels.

Methods: We investigated a cohort of 105 patients, 79 men and 26 women, who underwent surgery from May 1996 to July 2008. Their pathological staging was T(4)N(0)-(2)M(0). The median age was 59 years, ranging from 36 to 75 years. Patients were grouped based on invading sites: tumors invading the left atrium (LA group), tumors invading the superior vena cava (SVC group), and tumors invading the intrapericardial pulmonary artery (PA group). Patients were further characterized based upon the type of operation, complete resection and incomplete resection groups, and on the lymph node pathological status, N(0), N(1) and N(2) groups. We calculated the overall five-year survival rate.

Results: All patients received resection of primary lesions, with partial resection of the left atrium in the LA group (n = 25), angioplasty of superior vena cava in the SVC group (n = 23) and intrapericardial ligation of the pulmonary artery in the PA group (n = 57). Complete resection was possible in 77 patients (73.3%). The overall survival rate of the 105 patients was 41.0% at 5 years; 36.0% for the LA group, 34.8% for the SVC group and 45.6% for the PA group. Pathological N status significantly influenced the overall 5-year survival rate; 61.5% for N(0), 51.1% for the N(1) and 11.8% for the N(2) groups (N(2) group versus N(0) group, P < 0.0001, N(2) versus N(1) group, P < 0.0001). Surgical resection also influenced survival; 49.4% for the complete resection group and 17.9% for the incomplete resection group (P < 0.0001). Cox regression analysis demonstrated that pathological N status was a significant independent predictor of prognosis.

Conclusions: Pathological N status is a significant independent predictor for survival of patients with IIIb-T(4) lung cancer invading the left atrium and great vessels. The completeness of resection has a significant influence on the overall 5-year survival rate. Surgery for T(4) lung cancer may be effective in patients without mediastinal lymph node involvement.