Selection Criteria for Patients Participating in the Current SST Study

1) World Health Organization pathologic stage < 2.

2) The criteria for SST were fulfilled, ie, tumors arising in the pulmonary apex with invasion of the first, second, or third rib and pain in dermatomes C8, Th1, or Th2.

3) Cytologically or histologically proven non-small cell lung carcinoma stage T3N0-1M0 (IIB-ША) or T4N0-1M0 (IIIB). Mixed forms with small cell lung cancer were excluded.

For T4, extensive destruction of the vertebral body was considered as nonresectable (as seen on MRI).

4) No evidence of metastatic disease as assessed by physical examination, CT scan of the thorax and upper abdomen (liver and adrenals), bone scan, investigation of liver and adrenals by ultrasound, no longer than 4 wk before start of the treatment with Generic Viagra online.

5) Cervical mediastinoscopy was required for mediastinal lymph node staging within 4 wk of definitive start of treatment.

6) Informed consent was obtained.

7) No CNS involvement.

8) Horner syndrome is no contraindication for surgery.

The preoperative external beam radiotherapy consisted of 46 Gy in 23 fractions: 2 Gy per fraction, 5 fractions per week. The treatment was CT planned, and usually two anterior-posterior/ posterior-anterior fields were used. The target volume included the primary tumor, with at least 2-cm margin, the ipsilateral supraclavicular fossa, the whole vertebral bodies at the level of the primary tumor and the ipsilateral mediastinal lymph nodes. The cranial field border was usually placed above C6 and the caudal border at the level of the tracheal carina. In case of N1 nodes, the hilar region was also included. After radiotherapy, a new CT scan of the chest was made including the adrenals. If no progression was found, surgery was performed 4 to 6 weeks after the radiotherapy.

All patients were operated in the same institution by two experienced surgeons working in close collaboration with one of the radiotherapists. The SST was resected by means of a high extended posterolateral approach. In three patients with an anterior-mediastinal localization, a hemi-clamshell incision was carried out. The goal was a radical resection (R0) of at least the upper lobe en bloc with the chest wall. Only in the anterior chest wall resection, an artificial layer was used for reconstruction. For the posterior localization, the scapula was considered to be sufficient as a firm chest wall coverage. Postoperative mortality was defined as death within 4 weeks after surgery.

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