title: Lung cancer with chest wall invasion: retrospective analysis comparing en-bloc resection and 'resection in bird cage'.
abstract: BACKGROUND
  Invasion of the chest wall per se is not a contraindication for tumor resection in non-small cell lung cancer (NSCLC), provided there is no mediastinal lymph node or vital structure involvement. Although widely known to Brazilian surgeons, the 'resection in bird cage' technique has never been widely studied in terms of patient survival. Thus, the objective of this study was to evaluate the postoperative consequences and overall survival of extra-musculoperiosteal resection compared with en-bloc resection in NSCLC patients with invasion of the endothoracic fascia.
  
  
  METHODS
  Between January 1990 and December 2009, 33 NSCLC patients with invasion of the thoracic wall who underwent pulmonary resection were retrospectively analyzed. Of the 33 patients evaluated, 20 patients underwent en-bloc resection and 13 underwent 'resection in bird cage.' For each patient, a retrospective case note review was made.
  
  
  RESULTS
  The median age at surgery, gender, indication, rate of comorbidities, tumor size and the degree of uptake in the costal margin were similar for both groups. The rate of postoperative complications and the duration of hospitalization did not differ between the groups. Regarding the outcome variables, the disease-free interval, rate of local recurrence, metastasis-free time after surgery, overall mortality rate, mortality rate related to metastatic disease, duration following surgery in which deaths occurred, and overall survival were also similar between groups. The cumulative survival curves between the 'resection in bird cage' and en-bloc resection and between stages Ia + Ib and IIb + IIIa + IV were not significantly different (p = 0.68 and p = 0.64, respectively). The cumulative metastasis-free survival curves were not significantly different between the two types of surgery (p = 0.38).
  
  
  CONCLUSIONS
  In NSCLC patients with invasion of the endothoracic fascia, 'resection in bird cage' is a less aggressive procedure that yields similar results in terms of morbidity and mortality compared with en-bloc resection. Thus, 'resection in bird cage' meets the oncologic principles of resection and does not adversely affect the patients in terms of cure.
authors.forename: Heron Teixeira Andrade
authors.initials: HT
authors.lastname: Santos
authors.affiliation: Postgraduate Programme in Medical Sciences, State University of Rio de Janeiro, Boulevard 28 de Setembro, 77, Vila Isabel, 20551-030 Rio de Janeiro, Brazil. agnaldolopes.uerj@gmail.com.
authors.forename: Agnaldo José
authors.initials: AJ
authors.lastname: Lopes
authors.forename: Cláudio
authors.initials: C
authors.lastname: Higa
authors.forename: Rodolfo Acatauassú
authors.initials: RA
authors.lastname: Nunes
authors.forename: Eduardo Haruo
authors.initials: EH
authors.lastname: Saito
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D013510:Pulmonary Surgical Procedures / Q000379:methods*; D012189:Retrospective Studies; D035441:Thoracic Wall / Q000473:pathology / Q000601:surgery*