27 - Technical Aspects of Lobectomy

Editors: Shields, Thomas W.; LoCicero, Joseph; Ponn, Ronald B.; Rusch, Valerie W.

Title: General Thoracic Surgery, 6th Edition

Copyright 2005 Lippincott Williams & Wilkins

> Table of Contents > Volume I - The Lung, Pleura, Diaphragm, and Chest Wall > Section VII - Pulmonary Resections > Chapter 35 - Extended Resection of Bronchial Carcinoma in the Superior Pulmonary Sulcus

Chapter 35

Extended Resection of Bronchial Carcinoma in the Superior Pulmonary Sulcus

Kamal A. Mansour

In 1924, Henry K. Pancoast, then Chairman of Radiology at the University of Pennsylvania, reported four cases of superior sulcus tumors and stressed the importance of careful radiographic evaluation of apical chest tumors. It is probable that his 1932 paper is the one that established the name of the syndrome: Pancoast's tumor. The tumors occur at a definite location at the thoracic inlet and are characterized clinically by pain around the shoulder and down the arm, Horner's syndrome and atrophy of the muscles of the hands and present radiographic evidence of a small, homogeneous shadow at the extreme apex, always more or less local rib destruction and often vertebral infiltration.

The definition of the superior pulmonary sulcus is obscure. Teixeira (1983) reported that, as defined by Kubik, the pulmonary sulcus is nothing but the costovertebral gutter whose superior limit is the first rib arch and whose inferior limit is the insertion of the diaphragm in the thoracic cage. Anatomically defined, Pancoast's tumor, therefore, is a painful apicocostovertebral syndrome and as such should be differentiated from other bronchial carcinomas arising in the upper lobes and invading the chest wall, vena cava, and recurrent laryngeal or phrenic nerves. Paulson (1973) stressed that Pancoast's tumors are bronchial carcinomas developing in the extreme periphery of the lung and typically involve, by direct extension, structures in the thoracic inlet, including the lower trunk of the brachial plexus, intercostal nerves, sympathetic trunk and stellate ganglion, subclavian vessels, adjacent ribs, and vertebrae producing severe, steady, and unrelenting pain in the eighth cervical (ulnar surface of forearm and little and ring fingers) and first thoracic nerve root distribution (ulnar aspect of arm to the elbow) and often causing Horner's syndrome (Fig. 35-1).

As is true of bronchial carcinoma in any location, the extent of the tumor and stage of nodal invasion are the dominant factors in prognosis. By definition, carcinomas in the superior pulmonary sulcus are at least T₃ lesions. Once mediastinal or vertebral column invasion occurs, these tumors become T₄ lesions. According to Mountain (1997), the most recent revision in the International System for Staging Lung Cancer T₃N₀M₀ disease corresponds to a stage IIB. N₁ or N₂ nodal involvement associated with T₃ lesions advances these carcinomas to stage IIIA. Patients with stage IIB and IIIA disease usually have locally resectable tumors, although the presence of N₂ or N₃ disease markedly reduces survival, according to Ginsberg and associates (1994) and Detterbeck (1997). A T₄ lesion irrespective of nodal involvement places these carcinomas at a stage IIIB, and these historically have usually been unresectable; however, with modern-day neoadjuvant therapy, many of these stage IIIB tumors have become resectable.

DIAGNOSIS AND PREOPERATIVE EVALUATION

Superior pulmonary sulcus tumors account for less than 5% of all lung cancers. Histologically, these carcinomas are squamous cell in 50% of cases, with adenocarcinoma and large cell types accounting for the remainder. Small cell cancer is rare. Nevertheless, tissue diagnosis is necessary to rule out other lesions occurring in the superior pulmonary sulcus, such as acute or chronic infections, usually fungal in origin, that may mimic Pancoast's syndrome. Stanley and Lusk (1985) reported a case of actinomycosis, and Simpson (1986) and Ziomek (1992) and their associates reported cases that were caused by invasive aspergillosis and cryptococcosis, respectively. Gallagher and colleagues (1992) reported a case that was caused by a Staphylococcus aureus infection.

In the early stages, chest radiography may show a crescentic shadow at the apex of the lung resembling an apical pleural cap. Regardless of its appearance in the frontal view, an apical lordotic view shows the tumor as a mass with a convex lower border indenting the lung. Destruction of the upper ribs or dorsal vertebrae, together with a unilateral

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apical lesion, is specific for Pancoast's tumor. Historically, planigraphy and bone scanning were used to delineate the location of the tumor and the extent of involvement of the ribs, paraspinal region, and vertebrae. However, these studies have been superseded by more contemporary imaging techniques, such as computed tomography (CT) and magnetic resonance (MR) imaging.

Fig. 35-1. Pancoast's tumor located in the superior section of the costovertebral gutter, invading the lower trunk of the brachial plexus and posterior aspects of the upper ribs.

CT and MR imaging are used for staging purposes and also to determine the soft tissue extent of the tumor invasion. MR imaging offers the ability to obtain coronal or sagittal planes that give a better delineation of the most superior or inferior extent of the lesion. In addition, Heelen and associates (1989) noted that sagittal and coronal MR imaging allows better appreciation of the relationship of the subclavian vessels and brachial plexus to the lung apex. These images also allow better assessment of invasion of these latter structures by tumor. Both CT and MR imaging can help if the vasculature is involved; however, venous angiography and subclavian arteriography may be resorted to if MR imaging is not diagnostic. CT and MR imaging are also important in evaluating spinal disease because they demonstrate tumor replacement of bone marrow and the extent of epidural soft tissue disease.

CT myelography is invasive but demonstrates both bony detail and cord compression. Enzmann and DeLaPaz (1990) believe it is indicated in patients who are unsuitable for MR imaging (e.g., those with pacemakers, those who do not have access to emergency MR imaging facilities, and those who are considered for surgical decompression and stabilization).

Cytohistologic diagnosis may be obtained in a small percentage of cases by sputum examination, bronchoscopic aspirates, brush biopsy, and transbronchial biopsy. More frequently, tissue diagnosis is obtained by percutaneous fine-needle aspiration (FNA). If the tumor is large, it can undergo fluoroscopic biopsy using either an anterior or posterior approach. Smaller lesions that are in difficult areas, surrounded by bony or vascular structures, or both, usually undergo CT-guided biopsy. Either fluoroscopic or CT-guided biopsy should have a high degree of accuracy with a low risk for pneumothorax. This is because the lung parenchyma is rarely entered.

The transcervical supraclavicular technique described by McGoon (1964) or the supraclavicular thoracotomy described by Dart and colleagues (1977) for removal of a specimen from a superior sulcus tumor may be resorted to on rare occasions.

Scalene node biopsy for palpable nodes and an extended cervical mediastinoscopy or left parasternal mediastinotomy (Chamberlain's procedure) should be performed as a staging procedure, especially if CT shows enlarged (>1 cm) mediastinal lymph nodes. Ginsberg and associates (1994) have suggested that ipsilateral supraclavicular nodal metastases (N₃ disease) may not preclude long-term survival. Preoperative evaluation of these patients should also address systemic disease, and appropriate scans should be obtained to rule out distant metastases to the brain, bones, and abdomen. Positron emission tomography (PET) is helpful in identifying both mediastinal nodal involvement [which, as noted by Detterbeck (2003), is present in 10% to 20% of these patients] and distant metastases.

PREOPERATIVE IRRADIATION AND EXTENDED RESECTION

In the 1950s, tumors in the superior pulmonary sulcus were widely believed to be resistant to radiation and inaccessible to complete therapy resection. The average survival time of untreated patients after diagnosis was 10 to 14 months. Radiation therapy alone or after resection left few survivors after 1 year. Since the 1960s, results have been improving. Irradiation used alone has been reported to relieve pain, prolong survival, and in some instances affect a cure. Surgical resection remains the primary modality in the treatment of superior sulcus tumor. However, improved survival and decreased morbidity have been documented with the use of preoperative irradiation combined with extended resection. Preoperative radiation therapy combined with extended resection, as reported by Shaw and associates (1961), improved survival dramatically. The reports of many investigators, including Hilaris (1974) and Komaki (1990) and their colleagues, support this approach (Table 35-1).

The purpose of preoperative irradiation is to modify the extent of the lesion and sterilize the periphery of the disease at the chest wall level. Using megavoltage equipment, a tumor dose of 4,000 to 4,500 cGy, given in 10 fractions, is delivered over the tumor in the superior sulcus, chest wall, and superior mediastinum beyond the midline. Two to three weeks after the completion of irradiation, an extended enbloc

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resection of the carcinoma and chest wall is done, usually including the upper two or three ribs with the intercostal muscles and nerves, the posterior portions of the appropriate thoracic vertebrae, the lower trunk of the brachial plexus, a portion of the stellate ganglion, and the dorsal sympathetic chain. The involved lung has been resected in the past by means of either lobectomy or segmental resection, depending on the extent of the parenchymal disease; however, at present, a standard lobectomy is considered the pulmonary resection of choice.

Table 35-1. Results of Series Reporting Outcome After Surgery for Lung Cancers of the Superior Sulcus

First Author (year)	No. of Patients	Preoperative Treatment	Patients Having Complete Resection (%)	Two-Year Survival Rate (%)	Five-Year Survival Rate (%)
Paulson (1975)	61	RT	NS	34	26
Miller (1979)	26	RT	NS	NS	32
Attar (1979)	73	RT	48	23 (3-yr)	NS
Stanford (1980)	16	RT	NS	NS	49
Anderson (1986)	28	RT	50	NS	34
Devine (1986)	40	RT	70	NS	10
Shahian (1987)	18	RT	50	64	56
Wright (1987)	21	RT	NS	55	27
Sartori (1992)	42	RT	NS	38	25
Dartevelle (1993)	29	None (postop RT)	NS	50	31
Ginsberg (1994)	124	RT	56	45	26
Maggi (1994)	60	RT	60	NS	17.4
Martinez-Monge (1994)	18	Chemo + RT	76	NS	56 (4-yr)
Muscolino (1997)	15	RT	73	NS	26.6
Rusch (2000)	225	Chemo + RT	64 (T3, N0)	59	46
			39 (T4, N0)	33	13
Martinod (2001)	139	RT	81.3	41	35
Wright (2002)	35
	20	RT	80	49	49
	15	Chemo + RT	93	93	84
RT, Radiation therapy; Chemo, chemotherapy; NS, not stated.

The pathologic effects of irradiation of the tumor are related to the length of survival after extended resection. Those patients without nodal involvement who had no residual viable carcinoma in the chest wall or margins of resection did well and were long-term survivors. Those patients who had viable tumor in the chest wall, positive margins at the site of resection, or the presence of tumor in the perineural lymphatics or the nerve roots at the intervertebral foramen, however, did poorly and died in less than 2 years. Most of the deaths were due to distant metastases, although local recurrence of carcinoma, regardless of postoperative external beam irradiation therapy, was likewise a common course of events.

Clinical and experimental observations suggest that preoperative irradiation in doses not sufficient to cause gross regression of tumor, decreases local recurrence, prevents growth of disseminated tumor cells, and increases survival when compared with irradiation or operation alone.

The theoretical advantages of preoperative over postoperative irradiation depend on the treatment administered before surgical interference and its attendant risks for dissemination, implantation, or inflammation, together with violation of the vascular bed of the tumor, resulting in reduced oxygen tension and consequent diminished irradiation sensitivity. Use of additional postoperative irradiation in patients who have had preoperative irradiation and resection raises the risk for radiation fibrosis and nerve entrapment of the brachial plexus caused by the increased cumulative dose exceeding the tolerance of normal tissues. However, some evidence supports the use of postoperative irradiation in patients in whom the nodes or the margins of resection are found to be positive at the time of operation, as shown by the Lung Cancer Study Group (1986). In this select group of patients, postoperative irradiation appears to decrease the incidence of local recurrence. Ginsberg and associates (1994) were unable to demonstrate an advantage for the use of intraoperative brachytherapy in patients with complete resection. For patients with incomplete resection, the use of brachytherapy, combined with preoperative or postoperative external radiation therapy, resulted in a 9% 5-year survival rate.

PREOPERATIVE CHEMORADIATION AND EXTENDED RESECTION

Although local control can be achieved with resection with or without radiation therapy in a large number of these patients, tumor relapse, more frequently at a distant site, remains a common cause of morbidity and mortality. Therefore, a systemic form of therapy is appealing in the management of these patients.

Multiple trials, such as that reported by Albain and colleagues (1995), in patients with stage IIIa (N₂) tumors, provided

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the rationale for combined-modality therapy. Recently, Rusch and associates (2001) reported the initial results of Southwest Oncology Group Trial 9416 (Intergroup Trial 0160) of induction chemoradiation and surgical resection for non small cell lung carcinomas (NSCLC) of the superior sulcus. Patients with mediastinoscopy-negative T_{3 4},N_{0 1} disease received two cycles of cisplatin (50 mg/m² on days 1, 8, 29, and 36) and etoposide (50 mg/m² on days 1 to 5 and 29 to 33) chemotherapy concurrent with 45 Gy of radiation (180 cGy daily in 25 fractions). All patients received two more cycles of chemotherapy and were followed up by serial radiographs and scans. Two to four weeks after completion of the induction therapy, patients were restaged by repeat imaging studies and underwent thoracotomy if they had stable or responding disease. Patients found to have progressive disease went off study but were continued on follow-up. A lobectomy or pneumonectomy was required for resection, and lesser pulmonary resections were not allowed. Areas of direct tumor extension into the chest wall or spine were resected en bloc with the involved lung. Mediastinal lymph node sampling or dissection was mandated. The trial showed that combined-modality treatment was feasible in a multiinstitutional setting, and a complete resection was accomplished in 92% of the patients. Pathologic complete response was seen in 33% of the patients, and only residual minimal microscopic disease was found in an additional one third of the patients. Resectability and overall survival were improved compared with historical experience, especially for T₄ tumors, which usually had a grim prognosis.

The combination of cisplatin and etoposide is often considered an old-fashioned chemotherapy regimen; however, the low toxicity and high response rates seen with etoposide, cisplatin, and radiation therapy in the aforementioned study emphasize that this approach remains highly effective and well tolerated and therefore is the standard regimen in the multiinstitutional setting. Further trials should probably not seek to alter this particular chemotherapy and radiation therapy combination, but instead add to it to diminish the risk for systemic relapse. Possible approaches include the addition of a chemotherapy agent such as docetaxel, which appears to be effective, as reported by Shepherd and colleagues (2000), even in tumors previously treated with or resistant to cisplatin, or biologic agents such as antiangiogenesis agents or tyrosine kinase inhibitors, which may enhance the response to chemotherapy or decrease the risk for systemic relapse. A new trial based on these results with the addition of docetaxel postoperatively is currently in progress.

CONTRAINDICATIONS FOR SURGICAL RESECTION

Contraindications to surgical intervention include extensive involvement of the brachial plexus, the paraspinal region, particularly the intervertebral foramina, and the bodies or laminae of the vertebrae [Fadel and co-workers (2002) recorded only a 20% 5-year survival rate with en bloc resection of these structures]; mediastinal perinodal involvement; soft tissue involvement at the base of the neck; and distant metastases, in addition to the usual cardiopulmonary limitations. Venous obstruction, although not typical of a carcinoma in the superior pulmonary sulcus, is another contraindication to the operation. In some instances, patients with ipsilateral involved mediastinal nodes (N₂ disease) have undergone resection for palliation of pain, but survival in this situation is poor, and these patients should probably be treated with chemotherapy and irradiation only.

SURGICAL TECHNIQUE

Anterior Transcervical Thoracic Approach (Dartevelle's Procedure)

The approach developed by Dartevelle and colleagues (1993) is discussed separately in Chapter 36.

Classic Posterior Approach (Paulson's Operation)

The patient is placed on his or her side with the arm over the head, exposing the axilla and scapular region. A long parascapular incision is made starting just above the level of the spine of the scapula and carried two fingerbreadths beyond the tip of the scapula, ending in the anterior axillary line (Fig. 35-2). The trapezius and latissimus dorsi muscles

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are divided, exposing the serratus anterior muscle and rhomboideus major muscle. The serratus anterior muscular attachments to the upper ribs, particularly the second, and the rhomboideus major muscle are divided, elevating the scapula and shoulder and exposing the apex of the chest cage. The serratus posterior superior muscle is divided at its insertion on ribs two to five, lateral to their angles, and preserved for later use.

Fig. 35-2. The classic posterolateral thoracotomy incision.

Fig. 35-3. Anterior and superior phases of dissection (division of upper ribs, scalenus anticus and medius muscles) and identification of the subclavian artery and vein by retracting the first rib inferiorly.

The pleural cavity is entered through the space below the planned limit of the rib resection. For example, if the third rib is involved, then the incision should be made along the top of the fourth rib, and if the first two ribs are to be removed, then the pleural space should be entered on top of the third rib. The rib spreader is then placed between the undersurface of the scapula and the third or fourth ribs, depending on the situation. Dissection is divided into anterior, superior, and posterior phases. Anterior dissection is started first (Fig. 35-3). The third and second ribs and intercostal muscles, nerves, and vessels are divided about 2 inches anterior to the growth and involved lung. The subclavian vein is identified, and dissection is carried medially to divide the first rib anteriorly using a first rib cutter or a Gigli saw.

Superior dissection continues by grasping the first rib using a bone-holding forceps and retracting it downward to expose the attachment of the scalenus anticus to the scalene tubercle of the first rib between the subclavian vein in front and the subclavian artery behind. The scalenus anticus muscle is then divided, and dissection is carried posteriorly beyond the brachial plexus. At this time, the scalenus medius muscle is divided at its attachment into the upper surface of the first rib between the tubercle of the rib and the groove for the subclavian artery.

The posterior phase of the dissection starts by dividing the first rib beyond the extent of the tumor (Fig. 35-4A). With the hand inside the chest, the first rib is cut either at its neck or beyond the attachment of its tubercle to the transverse process of the vertebral body. At this point, the lower trunk of the brachial plexus is identified, as the first rib is retracted downward and the lower trunk is divided as necessary after the extent of its involvement by the tumor has

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been determined (see Fig. 35-4B). The posterior phase of the dissection continues inferiorly by dividing the second and third ribs. The sacrospinalis muscle is retracted outward, and the transverse processes are divided flush with the tubercles of the ribs or more posteriorly, depending on the extent of the tumor. Conversely, the posterior phase of the dissection may start from below upward, dividing the third, second, and first ribs in that order. Using a chisel-and-hammer technique, the transverse processes may be divided, and a section of the vertebral body may be resected, depending on the degree of the tumor invasion. The intercostal nerves and vessels are clipped before division, but if uncontrolled bleeding or spinal fluid leak occurs at the intervertebral foramen, a muscle graft using a small section of an intercostal muscle is sewn over the leak. Bone wax may be used; however, it is not advisable to use oxidized regenerated cellulose (Surgicel, Johnson & Johnson, Somerville, NJ, U.S.A.) or absorbable gelatin sponge (Gelfoam, The Upjohn Company, Kalamazoo, MI, U.S.A.) because migration or swelling and cord compression are liable to occur with hazardous consequences, as has been reported by Tashiro and associates (1987) and Short (1990). It is also not advisable to use the electrocautery in close proximity to the spinal cord because neural injury may result. The dorsal sympathetic chain is divided posteriorly, and the internal mammary artery is divided as it crosses the apex of the chest to reach the undersurface of the sternum.

Fig. 35-4. A. Posterior approach to resection of the tumor by division of transverse processes of the vertebrae and elevation of the heads of the ribs. B. Division of the lower trunk of brachial plexus as the first rib is retracted inferiorly.

The extended resection of the carcinoma is then completed by the usual technique of upper lobectomy or pneumonectomy. Lobectomy rather than wedge resection should be considered the standard.

Adequate pleural drainage is established by means of an upper anterior chest tube and a lower posterior tube placed in the ninth interspace so as to lie in the paravertebral gutter. The remaining lung is expanded, and hemostasis is carefully controlled. The chest is closed, usually by suturing the serratus posterior superior muscle to the intrinsic dorsal musculature. No synthetic materials are used because the scapula furnishes the posterior support. However, if portions of more than three ribs have been removed, the use of Prolene or Gore-Tex (W.L. Gore & Associates, Flagstaff, AZ, U.S.A.) mesh sutured to the margins of the defect under tension is helpful in minimizing paradoxic motion.

Tumor with Mediastinal Node Invasion

In patients with N₂ disease, the same approach of preoperative chemoradiation should be considered, as suggested by the good results obtained in the Southwest Oncology Group trial for patients with stage IIIa (N₂) disease that was reported by Albain and co-workers (1995). However, by in large, these patients should probably be managed nonoperatively unless they have a complete response to chemoradiation with the subsequent absence of metastatic disease in the mediastinal nodes.

Tumor Involvement of the Subclavian Artery

Dissection of the growth away from the subclavian artery may be difficult, but it usually can be accomplished through the adventitial plane. If the artery is invaded, resection of the involved segment with end-to-end anastomosis or interposition graft may be considered. For the latter, a No. 6 or 8 ringed polytetrafluoroethylene graft may be used. Branches of the subclavian artery, including the internal mammary, thyrocervical, and occasionally vertebral, may have to be sacrificed. The anterior transcervical thoracic approach described by Dartevelle should be used when dealing with apical tumors located anteriorly at the thoracic inlet (see Chapter 36).

Tumor Involvement of the Vertebral Bodies

Vertebral body invasion by superior sulcus tumor has traditionally been considered a contraindication for surgical resection. Attempts at definitive radiation or chemoradiation have not been successful. Recent advances in spinal instrumentation have allowed more complete resection of vertebral body tumors by the combined efforts of thoracic and neurosurgeons. Gandhi and co-workers (1999) reported their experience with vertebral resection of superior sulcus T4 tumors in 17 patients with vertebral involvement. Total or partial vertebrectomy and neural foramina or transverse process resection were performed. Postoperative complications included pneumonia, arrhythmia, cerebrospinal fluid leak, wound breakdown, and reoperation for bleeding. Sixteen of seventeen patients received preoperative or postoperative radiation therapy. No perioperative mortality occurred. All patients remained ambulatory after spinal reconstruction. Overall actuarial survival at 2 years was 54%. Unfortunately, locoregional tumor recurrence was noted in all patients who had positive surgical margins. However, the 2-year actuarial survival of patients with negative microscopic margins was 80%, compared with 0% for positive margins. The surgical technique emphasized an attempt to achieve a negative surgical margin of all areas including the involved vertebrae as well as en bloc resection of the tumor. The resection was performed through a posterolateral thoracotomy incision in most patients, with an extension over the vertebrae if posterior fixation was required. The involved vertebrae were then resected separately by a neurosurgeon according to the amount of vertebral involvement. In patients with only neural foramina or transverse process involvement, the transverse process was drilled out with a high-speed diamond burr power drill. The nerve root sleeve was then visualized and ligated at the nerve root proximal to the dorsal root ganglion. Involvement of the surrounding osseous elements was ablated with additional high-speed diamond burr resection. If there was significant extension of the tumor into the spinal canal or gross invasion of the proximal transverse process, facet joints, or lamina, a multilevel laminectomy was performed with a posterior midline extension

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of the thoracotomy incision. The vertebrectomy defect was reconstructed with methylmethacrylate using the chest tube technique described by Cooper and colleagues (1993). Anterior fixation was obtained with an anterior cervical locking plate and screw construct. Additional posterior segmental fixation was done in extensive resections and multilevel laminectomies by using hooks, rods, and, in selected cases, Wisconsin spinous process wires several levels above and below the laminectomy site. Posterior fusion was obtained dorsally with an allograft as well as Grafton (Osteotech, Inc., Eatontown, NJ), a fusion promoter. The importance of negative surgical margins and en bloc resection was emphasized. The transverse process and vertebral body resections were done first, starting from the back, mobilizing the vertebrae first and placing the entire vertebral column forward into the thorax. The patient was then turned to a standard posterior or a combined posterior and Dartevelle procedure, thus performing a true en bloc resection.

Bilsky and associates (2002) reported a similar experience and emphasized the value of preoperative MR imaging in evaluating the spine and surgical planning.

SURGICAL MORBIDITY AND MORTALITY

In addition to the expected postoperative development of atelectasis caused by pain and interruption of the chest wall, unique complications consist of persistence of spinal fluid leaks and pleural drainage, both of which eventually subside, as do parenchymal air leaks. In the event of a pneumothorax and spinal fluid leak, air may pass into the spinal canal, resulting in meningitis.

Permanent neurologic deficits involving the ulnar nerve, resulting from resection of the lower trunk of the brachial plexus, are not incapacitating. If the extent of the tumor permits preservation of the eighth cervical nerve, the defect secondary to resection of the first and second thoracic nerve roots is not severe. Horner's syndrome, if not present preoperatively, develops postoperatively secondary to resection of the dorsal sympathetic chain and at least a portion of the stellate ganglion. None of these defects is disabling, and all patients surviving longer than 3 years are relieved of their original pain. No complications of irradiation after the doses recommended are reported.

The operative mortality rate has been no more than 3%. The stage of nodal involvement, the local extent of the carcinoma, and the pathologic effects of irradiation at the chest wall level are the important factors in prognosis. Paulson (1979) and Miller and associates (1979) of our group reported that, with the combined preoperative irradiation and extended resection, a 35% survival rate at 5 years is achieved for all patients and 44% for patients without nodal involvement. With the trimodality approach of chemoradiation therapy followed by extended resection, the overall survival rate appears to reach a plateau of about 55% at 2 years, and for the patients who had a complete resection, the plateau is about 70% at 2 years after surgery.

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