Long-Term Survival with Surgical Management for Superior Sulcus Tumors with Vertebral Resection
William D. Bolton1, David C. Rice1, Adam Goodyear1, Arlene M. Correa1, Jeremy Erasmus1, Ziya Gokaslan2, Wayne Hofstetter1, Ritsuko Komaki1, Reza Mehran1, Katherine Pisters1, Jack A. Roth1, Stephen G. Swisher1, Ara A. Vaporciyan1, Garrett L. Walsh1, Jason Weaver1, Laurence Rhines1; 1Thoracic and Cardiovascular Surgery, University of Texas M.D. Anderson Cancer Center, Houston, TX; 2The Johns Hopkins University, Baltimore, MD
Comment on this Abstract
Objective: Superior sulcus tumors with involvement of the spine are classified as stage IIIB and are usually considered unresectable. We have previously documented 2-year survival of 54% in patients (pts) treated with a multimodality approach including combined pulmonary and vertebral resection. This work builds on our previous experience and examines the long term outcomes with this aggressive regimen.
Methods: This IRB approved retrospective review was performed on pts with NSCLC and superior sulcus tumors with involvement of the vertebral column (n=39) treated at MDACC from 1990 to 2006. Their clinical and pathologic data were analyzed for short and long-term outcome.
Results: Median age was 56 years and there were 29 men. Pts were divided into 3 groups based on the degree of vertebral body resection. Group I included 8 pts (21%) with neuroforamen or transverse process involvement (no vertebrectomy), Group II had 16 pts (41%) with partial vertebrectomy, and Group III had 15 pts (38%) with total vertebrectomy. Of pts who had vertebrectomy (n=31), 13 (42%) had one, 14 (45%) had two and 4 (13%) had three vertebrae resected. 14 pts had preoperative radiation (12 with chemotherapy). There were no complete pathologic responses, 2 pts (14%) had microscopic residual disease and 12 (86%) had gross disease at the time of surgery. There were 2 (5%) postoperative deaths (both from respiratory failure) and 11 (28%) pts had major complications. Median hospital stay was 11 days (range 4 - 48 days). Margins were positive in 17 pts (44%) and did not correlate with extent of resection or preoperative treatment. N-stage was N1 in 5 pts (13%), N2 in 6 (15%) and N3 (scalene) in 3 (8%). Recurrence occurred in 23 pts (59%) and was local in 11 (28%), distant in 11 (28%) and both in 1 (3%). Median time to local recurrence was 7 months in pts with positive margins and has not been reached for pts with negative margins (p=0.007). Median, 2-yr and 5-yr overall survival were 18 months, 47% and 27% respectively. Positive margins and nodal metastases were associated with shorter survival (see Table). On multivariate analysis the only independent predictor of shorter survival was nodal metastases (p=0.001, HR 6.5; CI 2.2 - 19.2).
Conclusion: An aggressive multimodality approach involving surgical resection can be performed with an acceptable morbidity on selected pts with superior sulcus tumors and vertebral invasion. Encouraging long-term survival can be achieved in pts with negative margins and no lymph node involvement.
| | Survival |
| n | Median(Mo) | 2-year(%) | 5-year(%) |
| Group I | 8 | 36 | 63 | 38 |
| Group II | 16 | 24 | 47 | 14 |
| Group III | 15 | 11 | 29 | 22 |
| Node negative | 25 | 68* | 71* | 41* |
| Node positive | 14 | 9 | 0 | 0 |
| Negative margin | 22 | 39* | 62* | 39* |
| Positive margin | 17 | 13 | 29 | 12 |
| * p<0.03 |
Survival data for group, nodal and margin status
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