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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

Surgery for T4 Tumors: The Importance of Local vs. Distant Failure Risk
Wed, 02/06/2008 - 23:11
Author
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

People who have been following my comments know that I am often questioning the wisdom of surgery in patients who don't fit the usual criteria for resection, which is most commonly pursued in stage I and II NSCLC and is often considered an option for some patients with stage IIIA NSCLC. To provide a very quick review of NSCLC staging, it's a combination of three factors:

1) Tumor (T) stage -- from 1 to 4, going from smallest and easiest to remove to hardest or largest to remove

2) Node (N) stage -- from 0 to 3, going from none to further distances from the main tumor

3) Metastasis (M) stage -- just a 0 or 1, to reflect whether there has been distant spread outside of the tumor's lobe of origin

Here is the more detailed staging system, for T stage on one figure, and then for N and M stage in the other.

T stage NSCLC

(Click on image to enlarge)

N and M stage NSCLC

At the bottom of the second figure are the "Stage Groupings" that define our current (although increasingly refined over time) staging system. You can see that stage, which correlates with prognosis overall, is a product of a combination of how advanced the tumor itself is and measures of likelihood of distant spread, which is nodal stage (correlates with increasing risk of micrometastatic disease and distant spread) and M stage (M1 defining metastatic spread).

A key point is that there are related but distinct risks from a lung cancer. While we are generally most worried about distant spread of SCLC, which is why surgery has no established place in SCLC management, NSCLC can have very differing degrees of local or distant risk. We need to weigh these, potentially also along with the third variable of risk in the brain, as we develop treatment plans:

Threats of Recurrence NSCLC

The point is that some patients have higher risk of local recurrence and lower risk of distant recurrence, while other patients have a much higher risk of distant recurrence than local disease. For instance, stage IIIA NSCLC includes T3 N1 disease, as well as T1 or T2 or T3 tumor stage with N2 nodal stage. But the person with T3 N1 disease has a considerably lower risk of distant recurrence than someone with N2 disease. And the patient with stage II NSCLC because of T3 N0 disease has a lower risk of distant disease than other stage II patients with N1 nodes involved. Higher T stage predicts greater risk of local/regional recurrence, while higher N stage predicts higher risk of micrometastases and distant recurrence.

This relates to a question I had from a member today who read a news report about increasing success in performing surgery and achieving favorable long-term results in patients with T4 tumors, as described by Dr. Dartevelle at the meeting of the Society of Thoracic Surgeons. Dr. Dartevelle is a French thoracic surgeon who has been doing pioneering work in redefining what is feasible surgically, a name that I've mentioned before in my introduction to Pancoast tumors (post here) because he pioneered some of the surgical work that has improved our care for these patients (as in, the "Dartevelle approach" for that surgery). While the definitions of T3 vs. T4 had historically emerged to distinguish what was locally advanced but possible to remove surgically (chest wall, mediastinal pleura, diaphragm) from what was not felt to be removable (heart, major blood vessels, esophagus, spine, etc.), surgical advances are now changing the definitions of what is possible to resect successfully.

In fact, although I am wary about unhelpful surgeries being done in patients who can't benefit from them, I have helped care for a few patients who illustrate the value of "pushing the envelope" surgically. One case, from several years ago, was a 56 year old woman who came all the way from Hawaii with a left-sided Pancoast tumor that was invading into her 2nd and 3rd ribs and also her 2nd and third thoracic vertebrae:

Pancoast Pre-Rx CT

Now, this woman had NSCLC proven on biopsy, but her mediastinoscopy was negative. So like many patients with a Pancoast tumor, she had a tumor that would generally be considered unresectable, but we felt that her cancer was much more of a threat locally than distantly.

She was treated with pre-operative chemo (cisplatin/etoposide) and radiation (to a "pre-surgical" dose of 45 Gray), to which she had a good response but the appearance of likely residual disease. She then underwent a remarkably complex, long surgery that was done by an excellent thoracic surgeon in tandem with an orthopedic surgeon who had studied in France with the same group that has been pioneering these techniques. This is NOT something that should be undertaken by people who don't have the experience for it, but the surgeons worked together to remove the tumor, the left upper lobe, and the 2nd and 3rd thoracic vertebrae and ribs on the left. This was followed by an extensive reconstruction. Here's what her x-ray looked like after her surgery:

Pancoast Post resection

Three years later, she has no evidence of recurrence, she has no evidence of recurrence and is living her life. She just has some explaining to do when going through airport security.

What I wanted to highlight was that a very aggressive approach that includes surgery for what would technically be considered T4, unresectable NSCLC was a storng consideration here because her stage was determined much more by local issues than risk of distant disease. In addition, we had a team that included world class thoracic and orthopedic surgeons, including one who had trained with the exceptional group in France that is still moving the field forward (this isn't being done by the surgeon who did an appendectomy this morning and a gall bladder yesterday). They are overcoming some of the technical limitations, but it really makes sense to apply this when the risk of distant disease is limited, not for patients with a history of a malignant pleural effusion or a couple of bone metastases, who have a much, much higher likelihood of developing distant recurrence later.

But there are a few amazing success stories out there thanks to the impressive progress from some very dedicated thoracic surgeons.

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