title: IIIB-T4 non-small cell lung cancer: indications and results of surgical treatment.
abstract: OBJECTIVE
  T4 non-small cell lung cancer (NSCLC) is commonly considered a contraindication to surgery, indeed chemo-radiotherapy achieves a poor survival rate. We have reviewed our experience with T4 NSCLC patients who underwent surgery with the aim of debating the indications and results of surgical treatment in this highly selected group of patients.
  
  
  METHODS
  We investigated a cohort of 60 patients, 49 men and 11 women, who underwent surgery for NSCLC from January 1998 to December 2002 and whose pathological staging was T4N0-2M0. The median age was 65 years (range 46-82). The tumors were classified T4 for the following reasons: intralobar satellite metastasis in 24 cases, direct mediastinum invasion in 18 cases, malignant pleural effusion in 7 cases, involvement of the superior vena cava in 4 cases, marginal invasion of the vertebral body in 3 cases, involvement of the carena in 3 cases and invasion of the left atrium in 1 case. Thirteen patients had undergone neo-adjuvant chemotherapy while 39 underwent adjuvant therapies.
  
  
  RESULTS
  Thirty-two patients resulted with N0 disease, 5 with N1 and 23 with N2 disease. Forty patients relapsed (27 systemic and 13 local relapses). The mean survival was 20 months. Of the examined parameters only metastatic nodal involvement was significantly associated with a worse prognosis (P=0.007).
  
  
  CONCLUSIONS
  Surgery for T4 NSCLC may be effective in those patients without mediastinal (N2) lymph node involvement. The prognosis was neither affected by the subtype of T4 tumor nor by the use of adjuvant therapies and/or neoadjuvant chemotherapy but only by the N status. In the preoperative work-up, every possible effort should be made to achieve a careful evaluation of lymph-nodal status (primarily by mediastinoscopy and video operative staging).
authors.affiliation: Division of Thoracic Surgery, Cardiac and Thoracic Department, University of Pisa, Pisa, Italy. m.lucchi@med.unipi.it
authors.forename: M
authors.initials: M
authors.lastname: Lucchi
authors.forename: A
authors.initials: A
authors.lastname: Viti
authors.forename: F
authors.initials: F
authors.lastname: Melfi
authors.forename: M
authors.initials: M
authors.lastname: Ambrogi
authors.forename: F
authors.initials: F
authors.lastname: Givigliano
authors.forename: P
authors.initials: P
authors.lastname: Dini
authors.forename: A
authors.initials: A
authors.lastname: Mussi
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D017024:Chemotherapy, Adjuvant; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D008198:Lymph Nodes / Q000473:pathology; D008207:Lymphatic Metastasis / Q000175:diagnosis; D008297:Male; D008481:Mediastinoscopy; D008875:Middle Aged; D020360:Neoadjuvant Therapy; D009361:Neoplasm Invasiveness; D009367:Neoplasm Staging / Q000379:methods; D018579:Patient Selection; D011013:Pneumonectomy; D018714:Radiotherapy, Adjuvant; D018570:Risk Assessment; D012307:Risk Factors; D020775:Thoracic Surgery, Video-Assisted; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome