Survival after extended resection for mediastinal advanced lung cancer: Lessons learned on 167 consecutive cases

Background: Extended resections (ER) for lung cancer may improve survival in selected patients. However, analysis on large series is still lacking. We reviewed our experience to identify prognostic factors useful for patient selection. Methods: Between 1998 and 2010, 167 patients with involvement of one or more mediastinal organs underwent operations with the intent to perform ER. At thoracotomy, 42 patients (25%) were considered unresectable (explorative thoracotomy [ET]), and 125 (75%) underwent ER. The types of ER were superior vena cava in 43 patients (34.4%), carina in 33 (26.4%), combined with superior vena cava in 18 (14.4%), with the left atrium in 35 (28%), and with the aorta in 14 (11.2%). We excluded Pancoast tumors and vertebral resections. The minimum follow-up was 6 months. Kaplan-Meier method and log-rank test were used for statistical analysis of survival. Results: There were 136 men (81.4%), with mean age of 63 years (range, 36 to 81 years). Of the 167 patients, induction chemotherapy was administered in 119 (71.3%), including 34 ET patients (81%) and 85 ER patients (68%). Complete resection was achieved in 106 patients (84.8%). The overall 5-year survival was 23% (27% in ER and 13% in ET, p = 0.41). Overall 30-day mortality was 4.8% and morbidity was 34.1%. Factors affecting survival were complete resection (p <0.01), pStage 0-I-II disease (p <0.0007), and age younger than 60 years (p <0.01). Conclusions: ER for lung cancer invading mediastinal organs could improve long-term survival (46% at 5-years in pN0). The best surgical candidates are young patients without lymph nodes involvement who undergo radical resection. Multimodality treatment is suggested in case of mediastinal lymph node involvement.