Pneumonectomy with en bloc chest wall resection: is it worthwhile? Report on 34 patients from two institutions

OBJECTIVES: Pneumonectomy with en bloc chest wall resection is often denied because of the procedure-related high risk. We evaluated the short- and long-term outcome of this procedure. METHODS: From January 1995 to October 2011, 34 patients (30 males and 4 females; mean age: 61.8 years) underwent pneumonectomy with en bloc chest wall resection for 33 non-small-cell lung cancer and 1 metastatic osteosarcoma in two institutions. Data were retrospectively reviewed. RESULTS: Operative (30-day) mortality was 2.9% (1 of 34), and morbidity was 38.2% (13 of 34). There were 14 (41.1%) right-side procedures and 20 (58.8%) left-side procedures. Three (8.8%) patients developed bronchopleural fistulas. The mean number of resected ribs per patient was 2.7 +/- 1.1. In 13 (38.2%) patients, a prosthetic reconstruction of the chest wall was needed. In 3 (8.8%) cases, the bronchial step was buttressed. Preoperative pain was statistically significantly related to the depth of chest wall invasion (P = 0.026). The N status was N0 in 18 (52.9%) cases, N1 in 9 (26.4%), N2 in 6 (17.6%) and Nx in 1 (metastatic osteosarcoma). Patients were followed-up for a total of 979 months. The median survival was 40 months. The overall 5-year survival was 46.8% (+/- 95% confidence interval [CI]: 0.2-0.6): 45.2 (+/- 95% CI: 0.03-0.8) for right-side and 48.4% (+/- 95% CI: 0.2-0.7) for left-side procedures, respectively. According to the N status, the 5-year survival was 59.7 (+/- 95% CI: 0.3-0.8) in N0, 55.5 (+/- 95% CI: 0.06-1) in N1 and 16.6% (+/- 95% CI: 0-0.4) in N2. The subgroup N0 plus N1 (27 patients) showed a 58.08% (+/- 95% CI: 0.3-0.8) 5-year survival compared with 16.6% (+/- 95% CI: 0-0.4) in N2 (chi(2): 3.7; P = 0.053). CONCLUSIONS: Pneumonectomy with en bloc chest wall reconstruction can be safely offered to selected patients. The addition of en bloc chest wall resection to pneumonectomy does not affect operative mortality and morbidity compared with standard pneumonectomy. The pivotal additional effect of the chest wall resection should not be considered a contraindication for such procedures. Survival showed a clinically relevant difference by comparing N0 plus N1 with N2 (58.1 vs 16.6%), not confirmed by the statistical analysis (P = 0.053).