Chest wall resection in patients with non-small cell lung cancer

We read with interest Matsuoka and colleagues’ article [1] on chest wall resection for non-small cell lung cancer (NSCLC) and their analysis of prognostic factors. We agree with their conclusions that completeness of resection and mediastinal nodal status are the most important prognostic factors in patients with chest wall invasion. Whether to do an extrapleural excision or en bloc resection including the chest wall and ribs has been controversial [2]. Our policy with surgical resection of these tumors is to perform extrapleural resections (without chest wall excision) in patients whose tumors have superficial adhesions to the parietal pleura. We perform en bloc excisions in patients with obvious chest wall infiltration or dense adherence to the parietal pleura or when extrapleural excision has been unsatisfactory. This has been known to improve completeness of resection in patients with pleural or chest wall infiltration [2]. The recent article is however unclear on a few points which we feel are important. We wonder whether the patients who had pathological N2 or N3 disease underwent neoadjuvant or postoperative chemotherapy as this is something which could have improved outcomes in these patients. Randomized trials [3–5] have shown significantly improved survival with chemotherapy. We are also very interested in the outcome of patients who underwent ‘incomplete’ resection. How many of these patients had gross residual disease and how many had only microscopic positive margins or positive pleural lavage cytology? Was there a difference in survival between the two? Were patients with residual disease, macroscopic or microscopic treated with postoperative radiotherapy? What were the patterns of recurrence in patients with incompletely resected disease? Though these predominantly involve a subgroup of patients excluded by the authors in this study, elaboration of these points would add definite value to the paper.

References