Superior Vena Cava Replacement for Thymic Malignancies

Extracorporeal membrane oxygenation (ECMO) assisted huge mediastinal tumor resection combined with superior vena cava replacement: A case report and literature review

As to huge solid mediastinal tumor which direct compression or invasion of the superior/inferior vena cava (SVC/IVC), surgical resection remains the main lifesaving treatment. However, it would present formidable anesthetic challenges due to the extremely high risks of cardiorespiratory compromise, drastic hemodynamic fluctuations and death at all perioperative stages. Here, we report a case of huge anterior mediastinal tumor resection combined with SVC replacement under the assistance of venoarterial extracorporeal membrane oxygenation (VA ECMO), and stable hemodynamics were maintained as well as high internal jugular vein pressure being avoided during the operation procedure. He was weaned off ECMO successfully just after surgery and eventually discharged. No signs of postoperatively neurological complications occurred. Therefore, the use of ECMO assistance in huge mediastinal tumor resection combined with SVC replacement is feasible and safe, which may provide the possibility of surgical treatment for such patients and improve outcomes.

Major vascular reconstructions in thoracic oncological surgery

The replacement of the superior vena cava and thoracic outlet vessels for thoracic malignancies often becomes necessary for radical oncological surgery. The pulmonary artery can be directly infiltrated by the tumor or affected by metastatic hilar lymph nodes. In some cases, it must be resected and reconstructed to achieve oncological radicality and/or avoid pneumonectomy. This study reflects a single-surgeon, retrospective experience spanning 6 years (2017-2023). We reviewed data from patients undergoing early anticoagulant therapy after superior vena cava or thoracic outlet vessels bypass and from patients undergoing early antiaggregation therapy following pulmonary artery reconstruction or resection. This series comprises 41 patients treated by a single surgeon. Fourteen patients underwent superior vena cava and thoracic outlet vessel procedures. Among these, eight patients received superior vena cava replacement (six for thymic malignancies and two for lung cancer), and six patients underwent jugular and subclavian artery/vein resection or replacement (all six had sarcomas). There was one death due to respiratory failure, not associated with bleeding or bypass closure. Additionally, there was one graft closure in a patient with severe coagulopathy and three instances of hemothorax (two patients had undiagnosed complex coagulopathies not evident in pre-operative routine blood tests). Following bleeding incidents, anticoagulation was initiated the next day in one case and based on hematological indications in the two coagulopathic patients. In the pulmonary artery series, 27 patients were involved: 20 underwent direct suture after tangential resection, and 7 received pericardial patch reconstruction. Only one case experienced bleeding necessitating redo-surgery. All these patients received early and chronic antiaggregation therapy after pulmonary artery reconstruction. We conclude that major thoracic oncological vascular surgery is safe and feasible with appropriate technical skills. However, achieving optimal results requires integration with correct early anticoagulant therapy or antiaggregation to maintain the patency of bypasses/grafts and prevent life-threatening risks associated with closure of the "new vessels."

Unraveling Intravascular Lobular Capillary Hemangioma: A Comprehensive Scoping Review

This scoping review focuses on intravascular lobular capillary hemangioma (ILCH), a rare and distinct subset of lobular capillary hemangioma (LCH). This study provides a comprehensive overview of ILCH, delving into its clinical characteristics, origins, pathogenesis, diagnostic methods, treatment options, and outcomes. Despite its rarity, ILCH presents unique diagnostic and management challenges due to its intravascular origin. The review emphasizes the importance of accurate differentiation from other vascular lesions and underscores the need for histopathological confirmation. This article discusses the presentation of ILCH in the reported literature. The pathogenesis remains uncertain, with factors such as trauma, inflammation, hormonal changes, and medications being considered potential contributors. Histopathological features, imaging techniques, and diagnostic tools are discussed, highlighting the distinct histological architecture of ILCHs and the importance of immunohistochemical staining for accurate diagnosis. Surgical excision is the primary approach for managing ILCH due to its potential complications, including superior vena cava (SVC) occlusion and thrombosis. This review concludes by outlining potential directions for future research, including investigating genetic and molecular mechanisms underlying ILCH development, developing targeted therapies, building patient registries for collaborative efforts, and exploring minimally invasive surgical techniques. The importance of long-term patient outcome studies and international collaborations is emphasized to enhance our understanding of this rare vascular anomaly.

Thymoma and Thymic Carcinoma: Surgical Resection and Multidisciplinary Treatment

Thymoma and thymic carcinoma are the most common tumors of the anterior mediastinum and a relatively rare type of thoracic cancer. The prerequisite for surgery is clinical staging and operative evaluation, both of which are based on medical imaging. The best strategy for treating a thymic epithelial tumor is surgical resection of the organ and surrounding tissue. Thymectomy modalities vary, including open surgery and minimally invasive surgery, and surgeons have used various innovations to better meet the needs of the procedure; therefore, it is critical to select the appropriate procedure based on the patient's characteristics. Evaluation of resectability is the first step of surgical resection for thymic tumors without distant metastasis. The decision regarding unresectability should be made carefully. During subsequent chemotherapy or chemoradiotherapy, reevaluation of whether an area is resectable or not remains essential. Despite numerous technological advances in the surgical treatment of thymic tumors, several contentious issues remain, including the selection of surgical approaches for difficult cases, the selection of video-assisted thoracoscopic approaches, the evaluation of resectability, minimally invasive surgery for locally advanced thymic tumors, lymphadenectomy in thymic tumors, neoadjuvant therapy for thymic tumors, debulking surgery, and salvage surgery. In solving these problems, the surgeon's judgment, surgical experience, and surgical skills are especially important.

Mid-Term Patency of Spiral Saphenous Vein Graft for Malignant Superior Vena Cava Syndrome

Reports documenting the mid-term patency of spiral saphenous vein grafts for superior vena cava syndrome in patients with advanced thoracic malignancy are, so far, scarce. The present report describes a 69-year-old man who suffered superior vena cava syndrome due to malignant invasion by advanced lung cancer. Since the huge mass in the anterior mediastinum was unresectable, a bypass from the left innominate vein to the right atrium using an autologous spiral saphenous vein graft was surgically created. Postoperatively, the patient received chemoradiotherapy and maintenance anticoagulant therapy, resulting in survival for 4 years without graft occlusion or recurrence of superior vena cava syndrome.

Thymomas With Intravascular and Intracardiac Growth

Thymomas are derived from the epithelial component of the thymus and constitute the most common tumor of the anterior mediastinum. These neoplasms are considered malignant for their potential for invasion and metastases. Several histopathologic subclassification schemes have been proposed over the years, however, correlation of histotypes with prognosis remains controversial. In contrast, studies invariably have shown that staging and resection status correlate with oncologic behavior and disease outcomes. In this regard, several staging systems have been presented, though transcapsular invasion and degree of involvement of adjacent anatomic structures are common denominators of all schemes. Involvement of the great vessels and heart most commonly results from direct invasion, which may lead to unusual clinical presentations such as superior vena cava syndrome. Moreover, intravascular and intracardiac growth with or without direct mural invasion rarely occurs. We provide an overview of thymomas with intravascular and intracardiac involvement.

Outcomes of extended surgical resections for locally advanced thymic malignancies: a narrative review

BACKGROUND AND OBJECTIVE

Thymic malignancies represent the most common anterior mediastinal neoplasms, as well as rare and challenging tumors. Surgery is the cornerstone in the treatment of thymic malignancies, although a multidisciplinary approach is mandatory, for both, locally advanced or metastatic disease. In our narrative review, we explored the recent literature to investigate clinical and radiological assessment, multimodality approach and outcomes of locally advanced thymic tumors. More than one-third of patients affected by an anterior mediastinal mass are asymptomatic at diagnosis. In case of locally advanced thymoma, symptoms are related to compression or invasion of adjacent structures, such as the superior vena cava (SVC), innominate veins and pericardium. Paraneoplastic syndromes, such as myasthenia gravis (MG), are related to release of antibodies, hormones and cytokines.

METHODS

Diagnostic methods must be chosen accurately to avoid unnecessary surgical resections, to define the best strategy of care, and to plan the surgical strategy. Therefore, each case must be evaluated in a multidisciplinary context, where surgery plays an essential role.

KEY CONTENT AND FINDINGS

In this narrative review, we describe indications and surgical techniques for the treatment of locally advanced thymoma; focusing on oncological outcomes after different approaches.

CONCLUSIONS

In conclusion, aggressive surgery is always indicated, when possible, and when a complete resection can be planned, yet, the multidisciplinary approach is mandatory, in case of both locally or metastatic advanced disease.

Meso-Rex bypass for the management of extrahepatic portal vein obstruction in adults (with video)

BACKGROUND

Extrahepatic portal vein obstruction (EHPVO) results in severe portal hypertension (PHT) leading to severely compromised quality of life. Often, pharmacological and endoscopic management is unable to solve this problem. Restoring hepatic portal flow using meso-Rex bypass (MRB) may solve it. This procedure, uncommon in adult patients, is considered the treatment of choice for EHPVO in children.

METHODS

From 1997 to 2018, 8 male and 6 female adults, with a median age of 51 years (range 22-66) underwent MRB procedure for EHPVO at the University Hospitals Saint-Luc in Brussels, Belgium. Symptoms of PHT were life altering in all but one patient and consisted of repetitive gastro-intestinal bleedings, sepsis due to portal biliopathy, and/or severe abdominal discomfort. The surgical technique consisted in interposition of a free venous graft or of a prosthetic graft between the superior mesenteric vein and the Rex recess of the left portal vein.

RESULTS

Median operative time was 500 min (range 300-730). Median follow-up duration was 22 months (range 2-169). One patient died due to hemorrhagic shock following percutaneous transluminal intervention for early graft thrombosis. Major morbidity, defined as Clavien-Dindo score ≥ III, was 35.7% (5/14). Shunt patency at last follow-up was 64.3% (9/14): 85.7% (6/7) of pure venous grafts and only 42.9% (3/7) of prosthetic graft. Symptom relief was achieved in 85.7% (12/14) who became asymptomatic after MRB.

CONCLUSIONS

Adult EHPVO represents a difficult clinical condition that leads to severely compromised quality of life and possible life-threatening complications. In such patients, MRB represents the only and last resort to restore physiological portal vein flow. Although successful in a majority of patients, this procedure is associated with major morbidity and mortality and should be done in tertiary centers experienced with vascular liver surgery to get the best results.

Superior vena cava graft infection in thoracic surgery: a retrospective study of the French EPITHOR database

 

OBJECTIVES

To report our experience on the management of superior vena cava graft infection.

METHODS

Between 2001 and 2018, patients with superior vena cava synthetic graft or patch reconstruction after resection of intrathoracic tumours or benign disease were selected retrospectively from the French EPITHOR database and participating thoracic centres. Our study population includes patients with superior vena cava graft infection, defined according to the MAGIC consensus. Superior vena cava synthetic grafts in an empyema or mediastinitis were considered as infected.

RESULTS

Of 111 eligible patients, superior vena cava graft infection occurred in 12 (11.9%) patients with a polytetrafluoroethylene graft secondary to contiguous contamination. Management consisted of either conservative treatment with chest tube drainage and antibiotics (n = 3) or a surgical graft-sparing strategy (n = 9). Recurrence of infection appears in 6 patients. Graft removal was performed in 2 patients among the 5 reoperated patients. The operative mortality rate was 25%.

CONCLUSIONS

Superior vena cava graft infection may develop as a surgical site infection secondary to early mediastinitis or empyema. Graft removal is not always mandatory but should be considered in late or recurrent graft infection or in infections caused by aggressive microorganisms (virulent or multidrug resistant bacteria or fungi).

Superior Vena Cava Resection and Reconstruction with Resection of Primary Lung Cancer and Mediastinal Tumor

The superior vena cava is a short ∼7-cm valveless vessel that brings blood from the upper half of the body to the heart but has connections to the infracardiac venous structures as well. It can become obstructed, mostly by advanced lung cancer but benign conditions account for one-fourth of cases. When possible, reconstruction can be by biological material or via ring reinforced grafts. When perfomed, replacement should be with small caliber grafts to allow for rapid flow of blood, which, with the addition of anticoagulants, reduces the risk of thrombosis. Even with advanced malignancy, treatment may confer reasonable survival.

Vascular Involvement in Thymic Epithelial Tumors: Surgical and Oncological Outcomes

BACKGROUND

The involvement of mediastinal great vessels is common in advanced stage thymic tumors, which makes their surgical resection challenging. Moreover, the impact of vascular involvement on the oncological prognosis is still unclear. The aim of this study is to investigate the surgical and oncological outcomes and the impact of vascular involvement in a population of patients operated for advanced stage thymic tumors.

METHODS

A retrospective analysis on four hundred and sixty-five patients undergoing resection for advanced stage (Masaoka III-IV) thymic tumors in a single high-volume center was performed. One hundred forty-four patients met the inclusion criteria and were eligible for the study. Patients were divided in two groups according to the presence or absence of vascular involvement.

RESULTS

the two groups did not differ for the baseline characteristics and showed comparable surgical outcomes. Vascular involvement was not associated with worse overall survival but with an increased recurrence rate (p = 0.03). Multivariable analysis demonstrated a higher risk of recurrence in patients without R0 resection (HR 0.11, 0.02-0.54, p = 0.006) and with thymic carcinoma (HR 2.27, 1.22-4.24, p = 0.01).

CONCLUSIONS

resection of thymic tumors with vascular involvement can be performed with optimal surgical results in a high volume center. From the oncological point of view, the involvement of the great vessels seems to be associated with a higher recurrence rate without affecting long-term survival.

Superior Vena Cava Reconstruction in Masaoka Stage III and IVa Thymic Epithelial Tumors

BACKGROUND

We present here a case series of patients who underwent resection for Masaoka Stage III and IVa Thymic Epithelial Tumors (TETs) with invasion into the superior vena cava.

METHODS

29 patients with Stage III and IVa TETs were treated surgically in three institutions. Operative resections involved replacing the superior vena cava from one of the innominate veins (n=18) or via reconstruction by truncal replacement (n=2) or patchplasty (n=9).

RESULTS

Fifteen patients underwent neoadjuvant treatment. Thirty and 90-day mortality rate were 3.4% and 10.3%, respectively. For Stage III patients, the median overall survival and DFS were 39 and 30 months, respectively. The median overall survival and DFS in patients with Masaoka Stage IVa disease were 67 and 21 months, respectively. Undergoing only preoperative chemotherapy (p=0.007) or receiving no chemotherapy (p=0.009) had a disease-free survival that was significantly higher than receiving both pre- and postoperative chemotherapy.

CONCLUSIONS

SVC resection and reconstruction in Masoaka Stage III and IVa TETs can be performed with acceptable morbidity and mortality. Stage IVa patients with SVC involvement can be treated with similar results as Stage III patients with multimodality treatment.

Superior vena cava replacement for epithelioid haemangioendothelioma

Epitheloid haemangiothelioma is extremely rare malignant tumour of vascular origin. Mediastinal location of this neoplasm with large veins involving is not common. We report a case of epitheloid haemangiothelioma in superior vena cava treated by radical resection and superior vena cava replacement with polytetrafluoroethylene prosthetic graft. There is a certain risk of neurological injury during the cross-clamping of superior vena cava in patient with incompletely obstructed veins. Venovenous shunt is a useful surgical strategy in this type of lesion without necessity of cardiopulmonary bypass use.

Autogenous pericardial angioplasty for thymic malignancies: a narrative review

Locally advanced thymic tumor usually invades adjacent great vessels, while the optimal treatment strategy for vessels resection and prosthetic replacement is still in controversial. We hereby present our series of patients undergoing autologous pericardial angioplasty for thymic malignancies. For invasive thymic tumors involving the superior vena cava (SVC), the replacement vessel was prepared by autologous pericardium and placed between the right atrium and distal left innominate vein stump to establish a SVC bypass. Then, the distal right innominate vein and proximal SVC were blocked, and the thymic tumor and involved vessel were completely resected, followed by SVC reconstruction using pericardium. We retrospectively analyzed the clinical characteristics and short-term outcomes of six related patients with autologous pericardial angioplasty. Due to the homologous advantages of autologous pericardial transplantation, those patients didn't need to receive anticoagulant therapy during the perioperative period, so as to avoid the occurrence of hemorrhage, embolism and other graft-related complications. There were no postoperative long-term thoracic drainage (>7 days), anastomotic bleeding, reconstructed vascular stenosis, embolism or even secondary thoracotomy and other related complications occurred in this case series. The application of autologous pericardium for the replacement of mediastinal great vessels in the surgery of locally advanced thymoma is a safe and effective technique. Compared with former artificial materials, such as polytetrafluoroethylene synthetic prosthesis, autologous pericardial transplantation avoids the occurrence of high risk graft-related complications such as postoperative hemorrhage and vascular stenosis, and its clinical application prospect is worth expecting.

Percutaneous transluminal stenting for superior vena cava syndrome caused by malignant tumors: a single-center retrospective study

Objectives

To evaluate the efficacy of percutaneous stent placement in the treatment of superior vena cava syndrome caused by malignant tumors.

Methods

We retrospectively analyzed the clinical data of 32 patients with superior vena cava syndrome who underwent percutaneous endovascular stent treatment in our department from 2015 to 2019 due to malignant tumors and summarized the patient’s sex, age, tumor type, endovascular treatment plan, complications and postoperative follow-up.

Results

All patients successfully underwent percutaneous intraluminal stent placement with digital subtraction angiography (DSA). Thirty-seven endovascular stents were implanted in 32 patients, including 21 Eluminexx stents, 12 Wallstent stents and 4 covered stents. The technical success rate was 100%, and there were no serious surgery-related complications. The remission rate of clinical symptoms was 53.1% (17/32) at 24 h and 84.4% (27/32) at 48 h. After 48 h, the symptoms of the remaining patients were slowly relieved, and the symptom relief rate was 100% at 7 days. The follow-up period was 1.5–24 months, with an average follow-up period of 6.5 months. During the follow-up, 3 patients had restenosis and 1 patient had secondary thrombosis in the stent. Their symptoms were relieved after the second treatment.

Conclusion

For superior vena cava syndrome caused by malignant tumors, percutaneous endoluminal stent therapy can quickly and effectively relieve the clinical symptoms of patients, and the incidence of complications is low.

Surgical feasibility and long-term outcome of superior vena cava replacement for advanced thymoma in patients undergoing preoperative chemotherapy or chemoradiotherapy

Background

The aim of this study was to investigate the long‐term outcome of superior vena cava (SVC) replacement after chemotherapy or chemoradiotherapy for advanced thymoma.

Methods

The medical information of patients with advanced thymoma who underwent thymoma resection and SVC replacement in Beijing Tongren Hospital from 2002 to 2017 were reviewed. We compared surgical outcomes, postoperative complications and long‐term prognosis in the chemoradiotherapy + surgery group (CRT + surgery group, 19 cases) and the surgery group (26 cases).

Results

The operation time (486.05 ± 148.01 vs. 370.77 ± 124.32 min; p = 0.007) and intraoperative blood loss (1400 ml [IQR 1125–2105 ml] vs. 855 ml [IQR 555–1682.5 ml], p = 0.036), poor wound healing (three cases [15.79%] vs. zero cases [0.0%], p = 0.036) in the CRT + surgery group were significantly higher than those of the surgery group. There was no significant difference between the CRT + surgery group and the surgery group in postoperative chest tube drainage time, hospitalization time, postoperative arrhythmia and incidence of pneumonia. Kaplan Meier analysis showed that the recurrence‐free survival (RFS) curves of the CRT + surgery group patients were better than those of the surgery group (p = 0.031). However, overall survival (OS) between the two groups was not significantly different (p = 0.069).

Conclusions

Thymoma resection and SVC replacement is feasible for patients undergoing preoperative induction chemotherapy or chemoradiotherapy for advanced thymoma. Although patients in the CRT + surgery group had a longer operation time and increased intraoperative bleeding, the RFS rate seemed to be better than that in the surgery group.

Resection of a Giant Epithelioid Hemangioendothelioma Arising from the Superior Vena Cava

Epithelioid hemangioendothelioma is a rare malignant vascular sarcoma. Here we present a patient with a very large tumor arising from the superior vena cava (SVC), in whom a resection with negative margins was accomplished using veno-venous bypass and bovine pericardial patch reconstruction of the SVC.

Intravenous Lobular Capillary Haemangioma (Pyogenic Granuloma) of the Superior Vena Cava: Case Report and Literature Review

Introduction

Intravascular lobular capillary haemangioma is a rare benign intravascular tumour, especially in large vessels. This is the report of a case and associated literature review.

Report and literature review

This is the report of the first case of an intravenous lobular capillary haemangioma (ILCH) of the superior vena cava (SVC). A 30 year old female presented with a collateral thoraco-abdominal venous circulation. Chest computed tomography angiography, thoracic magnetic resonance imaging, and positron emission tomography revealed an intraluminal SVC tumour extending from the left brachiocephalic venous trunk to the distal third of the SVC. No pre-operative biopsy was indicated. An en bloc tumour excision was performed, followed by reconstruction of the SVC with an L shaped, ringed polytetrafluoroethylene (PTFE) prosthesis. Histopathology revealed the presence of an ILCH with free margins. A review of the literature identified 64 cases of ILCH to date, all of which underwent total resection. When reported, no recurrences were found during follow up.

Discussion

In this case, the ePTFE reconstruction of the SVC must be checked regularly for any adverse events. Although ILCH is a benign tumour with no risk of recurrence, regular surveillance is advised.

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Report of the first case of intraluminal capillary haemangioma involving the superior vena cava.

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Literature review of intraluminal capillary haemangioma.

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Successful en bloc tumour excision followed by an L shaped prosthetic repair.

Direct Cross-Clamping for Resection of Lung Cancer Invading the Aortic Arch or the Subclavian Artery

BACKGROUND

Resection of lung cancer infiltrating the aortic arch or the subclavian artery can be accomplished in selected patients with the use of cardiopulmonary bypass (CPB). Direct cross-clamping of the aortic arch and the left subclavian artery without CPB for radical resection of the tumor can be an alternative. This study presents one group's experience with this technique.

METHODS

Between October 2016 and May 2019, 9 patients (5 male, 4 female) underwent radical resection of lung cancer infiltrating the aortic arch (n = 5) or the left subclavian artery (n = 4) by direct cross-clamping technique at Sapienza University of Rome, Italy. Seven left upper lobectomies, 1 left pneumonectomy, and 1 left upper sleeve lobectomy were performed. Reconstruction of the aortic arch was performed by direct suturing or polyethylene terephthalate (Dacron) patch, whereas the subclavian artery was reconstructed with a Dacron conduit. Three patients received neoadjuvant chemotherapy.

RESULTS

Patients' mean age was 64.7 ± 13.3 years (range, 36 to 78 years). Aortic arch resection was partial in all cases (adventitial in 1 and full thickness in 4); left subclavian artery resection was adventitial in 2 patients and circumferential in 2. All the resections were complete. Prosthetic reconstruction was performed in 4 cases. Mean operative time was 130 ± 25.6 minutes; mean vascular clamping time was 28.2 ± 3.2 minutes. No mortality occurred. The major complication rate was 11.1 %. At a mean follow-up of 17 ± 9 months (range, 5 to 29 months), the recurrence rate was 33.3%. Median survival was 20 months.

CONCLUSIONS

Direct cross-clamping as an alternative to CPB for resection of lung cancer infiltrating the aortic arch or the subclavian artery is a feasible, safe, and reliable procedure in selected patients.

Outcomes and Safety Analysis in Superior Vena Cava Resection for Extended Thymic Epithelial Tumors

BACKGROUND

In stage III to IVa thymic epithelial tumors (TETs), infiltration of the superior vena cava (SVC) is not rare. The extent of SVC resection depends on the width of the area of neoplastic invasion. Our article aims to evaluate the safety and long-term outcomes of extended thymectomy for TETs with SVC resection compared with advanced-stage TETs patients without SVC resection.

METHODS

Retrospective review of the experience on patients who underwent extended thymectomy for TETs in the last 20 years, according to STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) methodology. Progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan-Meier method. A backward stepwise Cox regression multivariate analysis was performed to determine factors associated with long-term outcomes.

RESULTS

A total of 78 patients underwent surgery for advanced-stage TETs (Masaoka-Koga stages III-IVa) from January 1998 to April 2019. Fourteen (17.9%) underwent thymectomy with resection of SVC. Presence of a thymic carcinoma (hazard ratio , 2.26; 95% confidence interval, 1.82-6.18; P = .038) and the SVC resection (hazard ratio, 1.89; 95% confidence interval, 1.11-3.96; P = .041) were adverse prognostic factors at multivariate analysis. The median OS and the PFS of all SVC resected patients were 50 (range, 5-207) months and 31 (range, 5-151) months, respectively. There was no significant difference in OS (P = .28) and PFS (P = .32) between SVC-resected and non-SVC-resected patients.

CONCLUSIONS

SVC resection is a safe and effective procedure to restore the venous system continuity and does not seem to affect survival and disease recurrence. This surgical approach allows radical resection of locally advanced TETs, even after neoadjuvant chemotherapy.

Superior vena cava replacement combined with venovenous shunt for thymic carcinoma

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SVC replacement for lung cancer or thymoma is infrequently performed and technically challenging.

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We experienced SVC replacement for thymic carcinoma en bloc radical resection.

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We were able to safely performed this surgery using our usual approach.

Introduction

Advanced-stage thymic malignancies are a heterogeneous group of mediastinal tumors that include thymoma and thymic carcinoma infiltrating the surrounding thoracic structures. When the tumor infiltrates the superior vena cava (SVC), radical resection can be selectively achieved via en bloc SVC resection and its prosthetic conduit replacement. We herein report a case of SVC replacement for thymic carcinoma en bloc radical resection.

Case presentation

A 75-year-old Japanese man presented at our hospital due to progressive dyspnea and edema of his face and upper extremities. CT showed a 55 × 40 × 38-mm tumor located at the anterior mediastinum lesion. This tumor had invaded the superior vena cava and both brachiocephalic veins. We performed surgical resection for the thymic carcinoma located at the mediastinum that invaded the superior vena cava and both brachiocephalic veins. The surgery was performed through a full median sternotomy and transmanubrial approach without using an artificial heart and lung. The tumor involved the SVC, right brachiocephalic vein (RBCV) and left brachiocephalic vein (LBCV). We performed SVC replacement for thymic carcinoma en bloc radical resection.

Discussion

This report has two important implications. First, a venovenous shunt (VVS) from the distal LBCV to the right auricle was very useful and safe before performing an SVC complete clamp. The second implication of our study was that using a PTFE with a large inner diameter may prevent thrombus occlusion.

Conclusions

We experienced SVC replacement for thymic carcinoma en bloc radical resection. We were able to safely performed this surgery using our usual approach.

Prosthetic Reconstruction of Superior Vena Cava System for Thymic Tumor: A Retrospective Analysis of 22 Cases

OBJECTIVE

This study aimed to report our experience in superior vena cava (SVC) resection and reconstruction for 22 thymic tumor patients and to make comparisons with previous related reports.

METHODS

A retrospective study on 22 patients (15 thymomas, 7 thymic cancers) who underwent tumor resection with concomitant SVC reconstruction. All the patients underwent vascular conduit reconstruction by the cross-clamping technique. The corresponding data were reviewed, including clinical presentation, operation management (surgery procedure, selection of suitable graft, strategies against SVC syndrome, etc.), postoperative cares (antithrombotic agent application, treatments on brain edema, etc.), and follow-up information.

RESULT

Two patients were myasthenic, well controlled by oral pyridostigmine. All resections were radical (R0). Ten patients received induction treatment. All the 15 thymoma patients were Masaoka stage III (type B1-B3). As for thymic cancer, six patients were Masaoka stage III and one was stage IVa. Wedge pulmonary resection was performed in three patients (two right upper lobe, one both upper lobe). Procedures included were single graft replacement in 12 patients, bilateral grafts in 9, and Y-shaped graft in 1 patient. Anticoagulation and dehydration agents were routinely applied after operation. No perioperative mortalities were observed. Major complication rate was 9.1%. The median survival time was 44.2 months (range, 4-92 months). Three- and 5-year overall survival rates were 80.8 and 44.0%, respectively. As for conduit patency, two grafts (9.1%) demonstrated evidence of occlusion during long-term follow-up, but no additional interventions were required due to no complications related.

CONCLUSION

Our study, confirming data from existing literature, showed that the prosthetic reconstruction of the SVC system is a feasible additional procedure during resection of thymic tumor infiltrating the venous mediastinal axis, minimally increasing postoperative complications in experienced hands.

Salvage resection of advanced mediastinal tumors

The surgical treatment of locally advanced mediastinal tumors invading the great vessels and other nearby structures still represent a tricky question, principally due to the technical complexity of the resective phase, the contingent need to carry out viable vascular reconstructions and, therefore, the proper management of pathophysiologic issues. Published large-number series providing oncologic outcomes of patients who have undergone extended radical surgery for invasive mediastinal masses are just a few. Furthermore, the wide variety of different histologies included in some of these studies, as well as the heterogeneity of chemo and radiation therapies employed, did not allow for the development of clear oncologic guidelines. Usually in the past, surgical resections of large masses along with the neighbouring structures were not offered to patients because of related morbidity and mortality and limited information available on the prognostic advantage for long term. However, in the last decades, advances in surgical technique and perioperative management, as well as increased oncologic experience in this field, have allowed radical exeresis in selected patients with invasive tumors requiring resections extended to the surrounding structures and complex vascular reconstructions. Such aggressive surgical treatment has been proposed in association or not with adjuvant chemo- or radiotherapy regimens, achieving encouraging oncologic results with limited morbidity and mortality in experienced institutions. Congestive heart failure or impending cardiovascular collapse due to the compression by the large mass are the most frequent immediately life-threatening problems that some of these patients can experience. In this setting, medical palliation is usually ineffective and an aggressive salvage surgical treatment may remain the only therapeutic option.