Evaluation of an aortic stent graft for use in surgery on esophageal cancer involving the thoracic aorta

Reconstruction of the heart and the aorta for radical resection of lung cancer

INTRODUCTION

We report a single-center experience of resection and reconstruction of the heart and aorta infiltrated by lung cancer in order to prove that involvement of these structures is no longer a condition precluding surgery.

METHODS

Twenty-seven patients underwent surgery for lung cancer presenting full-thickness infiltration of the heart (n = 6) or the aorta (n = 18) and/or the supra-aortic branches (subclavian n = 3). Cardiac reconstruction was performed in 6 patients (5 atrium, 1 ventricle), with (n = 4) or without (n = 2) cardiopulmonary bypass, using a patch prosthesis (n = 4) or with deep clamping and direct suture (n = 2). Aortic or supra-aortic trunk reconstruction (n = 21) was performed using a heart-beating crossclamping technique in 14 cases (8 patch, 4 conduit, 2 direct suture), or without crossclamping by placing an endovascular prosthesis before resection in 7 (4 patch, 3 omental flap reconstruction). Neoadjuvant chemotherapy was administered in 13 patients, adjuvant therapy in 24.

RESULTS

All resections were complete (R0). Nodal staging of lung cancer was N0 in 14 cases, N1 in 10, N2 in 3. No intraoperative mortality occurred. Major complication rate was 14.8%. Thirty-day and 90-day mortality rate was 3.7%. Median follow-up duration was 22 months. Recurrence rate is 35.4% (9/26: 3 loco-regional, 6 distant). Overall 3- and 5-year survival is 60.9% and 40.6%, respectively.

CONCLUSIONS

Cardiac and aortic resection and reconstruction for full-thickness infiltration by lung cancer can be performed safely with or without cardiopulmonary bypass and may allow long-term survival of adequately selected patients.

Covered Stent of the Left Common Carotid and Subclavian Arteries Assist the Invasive Tumor Resection

Background

Some recent reports have described the usefulness of thoracic aortic stent grafts to facilitate en bloc resection of tumors invading the aortic wall. We report on malignant peripheral nerve sheath tumor resection in the left superior mediastinum of a 16-year-old man with neurofibromatosis type 1. The pathological margin was positive at the time of the first tumor resection, and radiation therapy was added to the same site. After that, a local recurrence occurred. The tumor was in wide contact with the left common carotid and subclavian arteries and was suspected of infiltration. After stent graft placement of these arteries to avoid fatal bleeding and cerebral ischemia by clamping these arteries and bypass procedure, we successfully resected the tumor without any complications.

Conclusion

s. Here, we report the usefulness of the prior covered stent placement to aortic branch vessels for the resection of invasive tumor.

Thoracic endovascular aortic repair for esophageal cancer invading the thoracic aorta: a questionnaire survey study

BACKGROUND

Locally advanced esophageal cancer occasionally invades the aorta, and hemorrhage from the esophagoaortic fistula can cause sudden death. Thoracic endovascular aortic repair (TEVAR) enables hemostasis in such cases, and prophylactic TEVAR can prevent fatal hemorrhagic events during treatment. However, its efficacy in Japan has not been evaluated. This study aimed to clarify the clinical significance of TEVAR in esophageal cancer patients.

METHODS

The Japan Esophageal Society conducted a questionnaire survey targeting authorized or semi-authorized member institutes of the Authorized Institutes for Board Certified Esophageal Surgeons. Patients who underwent TEVAR for esophageal cancer were identified from 19 institutes. Data on patient demographics, treatment performed, and survival rate were obtained using the questionnaire. The Kaplan-Meier method was used for survival analysis and to compare differences in survival rates between those who underwent TEVAR for hemorrhage and those for preoperative prophylaxis.

RESULTS

Of the 41 patients identified, 20 patients underwent TEVAR for hemorrhage or impending hemorrhage from the esophagoaortic fistula, while 21 patients underwent TEVAR as preoperative prophylaxis. The median survival time after TEVAR was 135 days in the hemorrhage or impending hemorrhage group and 378 days in the preoperative prophylaxis group. Eighteen patients underwent esophagectomy after TEVAR. No hemorrhagic event was observed during the perioperative period. The median survival time of the patients who underwent esophagectomy was 373 days. Some patients who achieved R0 resection obtained long-term survival.

CONCLUSION

TEVAR is an efficacious modality to control a life-threatening hemorrhage from esophagoaortic fistula and helps to prolong the survival of patients with locally advanced esophageal cancer invading the aorta.

Off-label use of thoracic aortic endovascular stent grafts to simplify difficult resections and procedures in general thoracic surgery

OBJECTIVES

Tumour infiltration, or gross infectious involvement of the thoracic aortic wall, poses a significant intraoperative risk for fatal bleeding and therefore could compromise adequate resection or efficient surgical management of pleural infection in a considerable amount of cases. We present 3 successful cases of off-label thoracic aortic endografting to safeguard thoracic aortic wall integrity.

METHODS

After all patients received thoracic stent grafts through femoral access into the descending aorta, the first patient underwent a resection of a locally advanced squamous cell carcinoma of the left inferior lobe cT4cN0-1cM0 after neoadjuvant chemoradiation, which had infiltrated the descending aortic wall. The second case was video-assisted thoracoscopic bilateral pleural decortication for empyema with aortic ulcers of the distal thoracic aorta in a patient with pancreatic intrathoracic fistula in a necrotizing pancreatitis. The third patient was operated for a locally advanced squamous cell carcinoma of the left inferior lobe initial stage cT4 cN1-2 cM0 after neoadjuvant chemoradiation, which had broad contact to the descending aorta at the level of thoracic vertebrae 7 and 8 on a circumference of circa 180°. Regional ethics committee approval according the Swiss Federal Human Research Act was obtained according to regulations.

RESULTS

Preventive stent graft placement resulted in complication-free resection and significantly minimized the risk of fatal intraoperative bleeding. Patients were thus not exposed to complications associated with aortic cross-clamping, possible prosthetic replacement and extracorporeal circulation techniques.

CONCLUSIONS

In carefully selected patient populations, the resection of locally advanced tumours or infectious processes involving the aortic wall can be facilitated by thoracic endovascular aortic repair prior to resection.

Case Report: En Bloc Resection of Pancoast Tumor with Adjuvant Aortic Endograft and Chemoradiation

"Pancoast" tumors frequently require a multidisciplinary approach to therapy and are still associated with high morbidity and mortality. Due to their sensitive anatomic location, complex resections and chemoradiation regimens are typically required for treatment. Those with signs of aortic invasion pose an even greater challenge, given the added risks of cardiopulmonary bypass for aortic resection and interposition. Placement of an aortic endograft can facilitate resection if the tumor is in close proximity to or is invading the aorta. Prophylactic endografting to prevent radiation-associated aortic rupture has also been described. This case describes a 60-year-old female who presented with a stage IIIa left upper lobe undifferentiated non-small-cell carcinoma encasing the subclavian artery with thoracic aorta and bony invasion. Following carotid-subclavian bypass with Dacron, en bloc resection of the affected lung, ribs, and vertebral bodies was performed. The aorta was prophylactically reinforced with a Gore TAG thoracic endograft prior to adjuvant chemoradiation. The patient remains disease-free at more than 5 years follow-up after completing her treatment course. Endovascular stenting with subsequent chemoradiation may prove to be a viable alternative to palliation or open operative management and prevention of aortic injury during tumor resection and/or adjuvant therapy in select patients with aortic involvement.

Safe resection of the aortic wall infiltrated by lung cancer after placement of an endoluminal prosthesis

BACKGROUND

Few investigators have reported the results of combined resection of lung cancer infiltrating the thoracic aorta; only anecdotal accounts of off-label use of thoracic aortic endografts to facilitate resection of such tumors have been published. In this paper, we describe our experience using this innovative approach in terms of technical details and outcomes.

METHODS

We retrospectively reviewed data on 9 patients (6 men and 3 women, median age 61 years) with preoperatively suspected thoracic aorta neoplastic invasion, who were operated on after positioning of an endograft and underwent en bloc tumor resection including the aortic wall.

RESULTS

All but one cancer were non-small cell lung carcinomas; 4 patients received neoadjuvant chemotherapy, and 7 received adjuvant therapy. Aortic endografting was performed 2 to 17 days before resection of the tumor in 7 patients and as part of a one-stage procedure in 2 patients. The proximal end of the stent graft was deployed in the aortic arch (n = 1) or the descending aorta (n = 8). Lung resections were left pneumonectomies in 4 patients and left lower lobectomies in 5. Five patients underwent additional buttressing of the aortic defect using a synthetic patch (n = 2) or the omentum (n = 3). No cardiopulmonary bypass was required. At the last follow-up, 3 patients had evidence of tumor recurrence (one local and two distant). No endograft-related complications were detected.

CONCLUSIONS

Thoracic aortic endografting allowed safe en bloc resection of tumors invading the aortic wall, avoiding the need for extracorporeal circulatory support. Such an extended indication for thoracic aortic endografts seems promising and should be considered for selected oncologic cases.

A history of surgery for locally-advanced (T4) cancer of the thoracic esophagus in Japan and a personal perspective

The history of esophageal surgery in Japan can be divided into three periods, an era of safety from 1930 to 1980, an era of radicality from 1980 to 2000, and the era of quality of life (QOL) from 2000 to the present. The treatment for T4 cancers of the thoracic esophagus has also changed over time from preoperative radiotherapy, combined resection of the neighboring organs with esophagectomy, and to definitive chemoradiotherapy (dCRT) with salvage surgery. At present, almost all patients with an unresectable T4 esophageal cancer receives dCRT. However, there are many patients with a residual or recurrent tumor after dCRT. Salvage surgery for such patients often results in incomplete resection of the tumor because the tumor involves the trachea and/or aorta. New techniques to enable the resection of such neighboring organs even during salvage surgery are needed. In the future, the mainstay of treatment for esophageal cancer will be CRT with the foreseeable progress in new drugs and new techniques of radiotherapy. Surgery will be indicated for a local failure after CRT, while combined resection of the neighboring organs will be necessary to treat a local failure after CRT for T4 cancers. New surgical techniques have to be developed through some application of new devices and equipment.

President's address of the 65th annual scientific meeting of the Japanese Association for Thoracic Surgery: challenges for advanced esophageal cancer

Advanced esophageal tumors have been a challenge for surgery since the very beginning, and these challenges continue still today. In the early period of three-field lymphadenectomy (late 1980s), there was no special attention paid to tracheal necrosis after such an extended operation. In 1988, we reported functional mediastinal dissection preserving the right bronchial artery to prevent such complications. In 1993, we reported that the survival after three-field lymphadenectomy was better than that after en-bloc esophagectomy, and then the lymph node compartment classification based on the metastatic rate and the survival rate. This concept was introduced into the 9th edition of the Guidelines for Clinical and Pathologic Studies on Carcinoma of the Esophagus published in 1999. In early 1980s, combined resection of the neighboring organs was initiated for a locally advanced esophageal cancer. Almost all patients who underwent such an operation, however, died of metastasis in the short-term after surgery without any additional treatment. In 1987, we reported several types of tracheal repair using the latissimus dorsi muscle flap, as a less-invasive surgery that enabled adjuvant or additive therapy, after resection of the trachea involved by cancer. Then in 2004, we demonstrated that the canine aorta could be resected even immediately after aortic stenting. This suggests that an esophageal cancer involving the aorta can be resected using a new technique. To meet the challenges posed by advanced esophageal cancer, the help of other specialized fields besides esophageal surgery is needed: "The specialist must know everything of something, something of everything."