If lung cancer metastases is discovered in the chest wall, what are the typical treatment options?

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GarrettWalshMD (Physician - Surgery - Thoracic (Verified) ) - 06 / 18 / 2013

A lung cancer can involve the chest wall by two mechanisms. The first would be by direct extension of the lung cancer into the neighboring rib, vertebrae or sternum which are the bone elements to the chest wall. Tumors that involve the rib are typically classified as T3 tumors in the TNM staging classification. Lung cancers that directly involve the spine are staged as T4 tumors. A patient who has such a tumor that directly involves the boney structures of the thorax may still be considered a surgical candidate for resection provided they do not have extra thoracic metastases or extensive intrathoracic lymphnode metastases. A patient who has had imaging studies to rule out metastatic disease including a PET scan and MRI of the brain would then be evaluated to rule out nodal metastatic disease in the chest. If no metastasis were identified, then surgery would be performed, provided the patient had sufficient cardiac and pulmonary reserve to tolerate the planned resection. Resections of lung cancers that involve the neighboring boney skeleton usually entail a pulmonary resection which would include a lobectomy or pneumonectomy with the removal of the involved ribs or vertebralbody in continuity with the tumor. This is called an “en-bloc” resection. Care is taken to ensure adequate margins around the tumor and to remove the accompanying lobe or lung together with the chest wall. Margins of a few centimeters above and below, in front and in back of the tumor are generally desirable. To remove ribsrequires tying off of the small blood vessels and nerves that run beneath the rib and then cleanly cutting the rib outside of the tumor site with a bone cutter. When operating on the spine, a thoracic surgeon usually involves one of their colleagues in orthopedic surgery or neurosurgery to help resect the vertebrae and neighboring soft tissues around the spine. Although these tumors being locally advanced, surgical cures are possible if clean margins can be obtained.

The second way that lung cancer can involve a rib or chest wall is through metastatic spread. This requires that the lung cancer be disseminated generally through the blood stream with a metastatic implant that comes back to one or more ribs or the spine. A metastatic focus in a chest wall is staged as a stage IV lung cancer patient. The treatment for such a lesion is usually with palliative radiation therapy if the patient is experiencing discomfort associated with the chest wall metastases. Surgical resection of a chest wall metastases is a very rare indication for surgery and would only be undertaken in the rare event of a patient with a solitary rib metastases with no other extra thoracic or brain sites of metastases.

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