Surgical management of T3 and T4 lung cancer

Locally advanced lung cancer (T(3) or T(4)) has a significantly worse prognosis than lower stage disease. However, this diagnosis is usually made radiologically, and experienced thoracic surgeons are familiar with the low radiologic to pathologic correlation in tumors that abut the great vessels, mediastinum, or chest wall. Commonly these tumors do not directly invade adjacent structures and are, in fact, T(1) or T(2) tumors that are resectable through standard techniques. Where there is no clearly evident invasion of unresectable structures, the patient should be given the benefit of the doubt and considered at a lower (resectable) stage until proven otherwise. The curability of T(3) tumors varies according to the involved site. A T(3)N(0) tumor involving the chest wall provides the most favorable prognosis among the resected T(3) lesions, with a 5-year survival of >50% in lymph node-negative patients if resection is complete. Palliative incomplete resections of T(4) disease, in which tumor has invaded mediastinal structures, have not shown any survival benefit and are associated with very high morbidity and mortality. However, patients with limited invasion of the carina, left atrium, superior vena cava, or pulmonary artery may be able to be completely resected despite their T(4) classification. Surgical resection remains an important part of the therapy for patients with locally advanced lung cancer. Modern techniques of chest wall resection and reconstruction and bronchoplastic procedures allow complete resection of locally advanced tumors with favorable 5-year survival rates and low morbidity and mortality.