Stoelben Erich, Ludwig Corinna
Hospital of Cologne, Lungenklinik, Ostmerheimer Str. 200, 51109 Köln, Germany.
Eur J Cardiothorac Surg. 2009 Mar;35(3):450-6. doi: 10.1016/j.ejcts.2008.11.032. Epub 2009 Feb 1.
Lung cancer invasion of the chest wall is not a common challenge and represents only about 5% of all patients resected for lung cancer. In T3N0M0 tumours, long-term survival reaches 40-50%, provided certain conditions are fulfilled. The number of explorative thoracotomies and the rate of non-radical resections might be high due to the local extension of an aggressive tumour. Mortality after resection is as high as for pneumonectomy. For historical and anatomical reasons, we have to divide the patients into two groups: infiltration of, and above, the second rib (Pancoast) and tumours located caudally to the second rib. We have to define the two entities. There is a problem concerning correct diagnosis: many tumours reach the chest wall. If the lung is not adherent to the parietal pleura, a standard lobectomy can be performed. However, in the case of adhesions, the differentiation between tumour invasion and inflammation may be difficult. We do not want to perform over-treatment since lung resection en bloc with the chest wall has a higher morbidity and mortality than lobectomy. But we have to avoid opening the tumour intraoperatively or perform a non-radical resection. Therefore, we need a preoperative diagnostic tool answering the question of extrapulmonary infiltration. In this context, we will discuss whether extrapleural lung resection is acceptable in the case of pleural invasion without chest wall involvement. The prognosis of patients with tumours invading the chest wall and mediastinal lymph node metastasis is worse. But patients with ipsilateral supraclavicular lymph node metastasis are not excluded. Thus, careful clinical investigations are necessary. To achieve complete resection, the surgeon should use anatomical knowledge to choose the best form of access to make radical resection more feasible. The problem of pain after thoracotomy is accentuated after chest wall resection, especially after paravertebral resection. The use of modern pain treatment is very important.
肺癌侵犯胸壁并非常见难题，仅占所有接受肺癌切除术患者的约5%。在T3N0M0肿瘤中，若满足特定条件，长期生存率可达40 - 50%。由于侵袭性肿瘤的局部扩展，探索性开胸手术的数量和非根治性切除率可能较高。切除术后的死亡率与肺切除术一样高。出于历史和解剖学原因，我们必须将患者分为两组：第二肋骨及以上（潘科斯特肿瘤）的浸润和位于第二肋骨下方的肿瘤。我们必须明确这两种情况。在正确诊断方面存在一个问题：许多肿瘤会侵犯胸壁。如果肺与壁层胸膜不粘连，可以进行标准的肺叶切除术。然而，在存在粘连的情况下，区分肿瘤侵犯和炎症可能很困难。我们不想进行过度治疗，因为肺与胸壁整块切除的发病率和死亡率高于肺叶切除术。但我们必须避免术中打开肿瘤或进行非根治性切除。因此，我们需要一种术前诊断工具来回答肺外浸润的问题。在这种情况下，我们将讨论在胸膜侵犯但无胸壁受累的情况下，胸膜外肺切除术是否可接受。肿瘤侵犯胸壁并伴有纵隔淋巴结转移的患者预后较差。但同侧锁骨上淋巴结转移的患者不排除在外。因此，需要进行仔细的临床检查。为了实现完全切除，外科医生应运用解剖学知识选择最佳的入路方式，以使根治性切除更可行。开胸术后的疼痛问题在胸壁切除后，尤其是椎旁切除后会更加突出。使用现代疼痛治疗方法非常重要。
