Surgical resection for lung cancer with infiltration of the thoracic aorta

Preventive Aortic Stent Graft Implantation Prior to Thoracic Surgery: Early and Midterm Results

Background: There is a paucity of data concerning the feasibility and value of thoracic aortic stent graft implantation (TEVAR) applications for removing tumors infiltrating the aortic wall. This analysis aimed to demonstrate the feasibility of TEVAR and monitor the perioperative risks of morbidity and mortality. Additionally, a literature review was performed. Methods: A retrospective data analysis was performed on patients who received TEVAR prior to thoracic malignancy resection between January 2010 and April 2024. The primary endpoint was technical success. Results: A total of 15 patients (median age: 67 years; range: 23-75; 66.7% female) received TEVAR prior to thoracic surgery of different tumor entities. In 80% of cases (n = 12), the proximal landing zone was in aortic zone 3. In three cases, the supra-aortic debranching of LSA and/or LCCA via bypass implantation or in situ laser fenestration was necessary. No postoperative endograft-related complications were observed. In eight patients, aortic wall infiltration was confirmed intraoperatively. In total, R0 resection was achieved in seven patients (46.7%). The 30-day mortality rate was 6.7% (n = 1). Technical success was achieved in all patients (100%), while procedural success was achieved in 80% due to incomplete tumor resection in three patients. Conclusions: To the best of our knowledge, this is the largest analysis to date that confirms the results of previous smaller studies. Aortic stent grafting prior to thoracic tumor resection allows for extensive resection while maintaining low morbidity and a low 30-day mortality risk.

Investigating the predictive factors of thoracic aortic invasion and surgical outcomes in patients with primary lung cancer: A retrospective study

BACKGROUND

This study aimed to investigate predictors of thoracic aortic invasion in lung cancer patients using preoperative clinical and imaging characteristics and elucidate surgical outcomes in cases of aortic invasion.

METHODS

Of the 4751 lung cancer patients who underwent surgery at our hospital, we included 126 (6.8%) who underwent left-sided surgery and in whom tumor appeared to be in contact with the thoracic aorta on preoperative imaging. The patients were divided into two groups: group A, 23 patients (18%) who underwent combined aortic resection (+); group B, 103 patients (82%) who did not undergo combined aortic resection (-).

RESULTS

The percentage of aortic invasion for tumor diameter <3 cm, 3-4 cm, 4-5 cm, 5-7 cm, and >7 cm was 0%, 13%, 23%, 16%, and 35%, respectively. The percentages of aortic invasion were 27%, 16%, and 0% for tumor localization in the upper division, S6, and S10, respectively. Multivariate analysis revealed that aortic depression due to tumor or loss of fatty tissue between tumor and mediastinum in the chest CT significantly predicted aortic invasion (odds ratio = 23.83, 16.66). Group A demonstrated significantly more blood loss, longer operative time, prolonged hospital stay, and increased percentage of recurrent nerve palsy (13%) compared to group B. The 1-, 3-, and 5-year survival rates for patients in group A were 53.4%, 24.3%, and 24.3%, respectively.

CONCLUSION

If the chest CT of a patient demonstrates aortic depression due to tumor or loss of fatty tissue between tumor and mediastinum, aortic complications should be considered when planning surgery.

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.

T4 Lung Carcinoma with Infiltration of the Thoracic Aorta: Indication and Surgical Procedure

Lung carcinomas infiltrate the aorta mostly on the left side and are altogether rare. As an initial step, complete staging is performed and the results are evaluated in an interdisciplinary tumor board. If the patient's general condition including cardiopulmonary reserves is sufficient, and if there is neither distant metastasis nor an N2 situation, surgical resection may be indicated. The option for neoadjuvant chemotherapy should always be taken into consideration. Depending on the anatomic tumor location, partial lung resection and resection of the affected aortic wall are performed employing a cardiopulmonary bypass. The resected aortic wall is replaced by a vascular prosthesis. In recent years, this proven procedure has partly been replaced by an alternative one, avoiding extracorporeal circulation. An endoaortic stent is implanted in the affected area followed by partial lung resection and resection of the diseased aortic wall. This new procedure has significantly reduced perioperative mortality and morbidity. With proper patient selection, long-term survival can be improved even in this complex malignoma.

Surgical Approaches to Pancoast Tumors

Pancoast tumors, also defined as superior sulcus tumors, still represent a complex clinical condition requiring high technical surgical skills within more articulated multimodality treatment. The morbidity and mortality rates after Pancoast tumor treatments range from 10 to 55% and 0 to 7%, respectively, and the 5-year survival rate has significantly improved in recent years thanks to the advancement of treatments. Although a multimodality approach combining chemotherapy, radiotherapy, and surgery allows for radical resection and effective local control in the vast majority of patients, many patients cannot receive surgical resection or complete the whole programmed therapeutic regimen. Systemic relapse, particularly cerebral recurrence, still poses a significant issue in this cohort of patients. Surgical resection still plays a pivotal role within the multimodality approach. Here, we focus on surgical approaches to both anterior and posterior Pancoast tumors: the anterior transclavicular approach (Dartevelle); the anterior transmanubrial approach (Grunenwald-Spaggiari); the anterior trap-door approach (Masaoka, Nomori); the posterior approach (Shaw-Paulson); the hemiclamshell approach; and hybrid approaches. Global clinical condition, tumor histology, and long-term perspectives should always be taken into consideration when embarking on such a demanding oncologic scenario.

Extended Pulmonary Resection for T4 Non-Small Cell Lung Cancer

T4 non-small cell lung cancer is a locally advanced disease with poor prognosis. The operation can be challenging even for an experienced surgeon. N2 disease has been shown repeatedly as a risk factor for poor outcome, and these patients should not be candidates for surgical treatment. Surgery for locally advanced T4 tumors without mediastinal lymph node involvement (T4N0 and T4N1) has been demonstrated to result in good outcomes in carefully selected patients. Patients with T4N0-1M0 should be rejected for surgery only after consulting an expert surgical center. As with other stages, the decision for resectability and surgery should be made by a multidisciplinary team.

Endovascular Surgery of Descending Thoracic Aorta Involved in T4 Lung Tumor

PURPOSE

Surgical treatment of primary lung T4 tumors is controversial especially when the cancer invades the mediastinal structures or the descending thoracic aorta. Conventional surgical treatment is associated with a high perioperative mortality and morbidity rate. Thoracic EndoVascular Aortic Repair has emerged as a valid off-label alternative to conventional surgery. We aimed to assess perioperative and midterm aortic-related outcome of patients who have undergone aortic stent-graft implantation, followed by en bloc surgical treatment of the involved aorta and lung cancer resection.

MATERIALS AND METHODS

From July 2017 to May 2020, we treated 5 patients diagnosed with a T4 lung cancer by the involvement of the descending thoracic aorta. When only the descending thoracic aorta is involved, a 2-stage procedure was considered, with aortic stent-graft implantation performed before tumor resection. One-stage strategy, with stent-graft implantation carried out before thoracotomy, was preferred for patients with the involvement of cardiac and/or other vascular mediastinal structures.

RESULTS

The mean age was 58.4 ± 6.2 years. All patients were affected by non-small cell lung cancer. All 5 patients required a single stent-graft to completely cover the involved segment of aorta. Four patients underwent a 2-stage procedure. One patient, with the involvement of the left inferior pulmonary vein, required a 1-stage en bloc resection of the left lower lobe, aortic wall adventitia, left inferior pulmonary vein, and reconstruction of the left atrial wall. Primary procedural success was achieved in all. At follow-up, no patient developed aortic-related complications. One patient died 2 years after surgery, due to local recurrence of the tumor.

CONCLUSION

T4 lung resection combined with aortic stent-graft implantation can be safely performed. Endovascular surgery, by avoiding the use of cardiopulmonary bypass, aortic cross-clamping, and graft replacement, can reduce significant morbidity and mortality rate. Postoperative and long-term outcome of these patients treated with endovascular surgery is mainly related to pulmonary disease, not to aortic treatment.

Long-term outcome after en bloc resection and reconstruction of the spinal column and posterior chest wall in the treatment of malignant tumors

BACKGROUND

Malignant tumors occurring around both the spinal column and posterior chest wall are uncommon. Surgical resection of chest wall tumors adjacent to the spinal column is still challenging due to the surrounding anatomical structures. The purpose of the present study was to evaluate the long-term outcomes of surgical management in malignant tumors involving the spinal column and posterior chest wall.

METHODS

Between 1999 and 2007, 10 consecutive patients underwent en bloc resection combined with the posterior chest wall in the treatment of malignant tumors around the spinal column. There were 6 males and 4 females with a mean age at the surgery of 40.9 years old (range, 14-62 years old). The mean postoperative follow-up period was 159.7 months (range, 84-245 months). The clinical history, physical examination, laboratory data, radiological findings, and operative findings for each patient were retrospectively reviewed.

RESULTS

All surgeries were performed via a combined anterior and posterior approach. The mean numbers of partially resected vertebrae and ribs were 3.1 and 4.1, respectively. Lower or upper lobectomy was performed in four patients, and the diaphragm was partially resected in two patients. The surgical margin was wide in seven patients and marginal in two patients. Although five patients had postoperative respiratory problem, all patients improved immediately without life-threatening complications. There were no patients with respiratory insufficiency after surgery. One patient with osteosarcoma died of lung metastases 99 months after surgery. At the final follow-up, only one patient had local recurrence, five had been continuously disease-free, and three were alive with no evidence of disease.

CONCLUSIONS

En bloc resection and reconstruction in selected patients with malignant tumors involving both the spinal column and posterior chest wall demonstrated good long-term results for local control and the respiratory function.

Long term results of surgery for NSCLC and aortic invasion. A multicenter retrospective cohort study. Aorta involvement in NSCLC

BACKGROUND

Aortic invasion from non-small cell lung cancers (NSCLC) is a relative contraindication to surgery for oncological and technical reasons. Only a few studies have been published showing good results. Our aim was to evaluate short and long-term results of surgery for T4 NSCLC with aortic resection.

METHODS

This is a multicenter retrospective study including 47 patients (33 males and 14 females) who received a major lung resection with aortic surgery in our centers between January 2000 and December 2016.

RESULTS

Adenocarcinoma was diagnosed in 31 patients (66.0%). Induction therapy was used in 14 patients. Pneumonectomy was performed in 34 patients (72.3%). A subadventitial dissection with or without endovascular stent graft was carried out in 40 patients (85.1%), a cardiopulmonary bypass was used in 3 patients and left heart bypass in 4. Intraoperatively, two patients had bleeding (4.3%) and one ventricular fibrillation (2.1%). Twenty-three patients (48.9%) experienced at least one postoperative complication. A radical resection was achieved in 39 patients (83.0%). Thirty-day and 90-day mortality were 2.1% and 4.3%. One-, 3- and 5-year overall survival were 85.1%, 57.4% and 53.2%. Overall and disease-free survivals were significantly influenced by pathological lymph node status and R status that were independent predictive factors for poorer survival at the multivariate analyses.

CONCLUSIONS

Aortic resection during surgery for NSCLC is a challenging situation. Nevertheless, oncologic outcomes may be favorable in selected cases justifying a risky procedure that should be performed in experienced hands.

Thoracic stent-graft herniation through the aortic wall in a case of lung cancer

A 67-year-old man had left upper lung cancer with invasion into the descending aorta. He underwent pre-emptive thoracic endovascular aortic repair using a Valiant Navion followed by left lung upper lobectomy with resection of the aortic wall. Because of continuous bleeding, he underwent re-thoracotomy. Since the surgically resected aortic wall was largely cleaved, bleeding around the stent-graft that herniated into the left pleural cavity was observed. Re-thoracic endovascular aortic repair using a GORE TAG was immediately performed to prevent further stent-graft herniation and impending lethal haemorrhage. It may be necessary to consider reinforcement of the resected aortic wall to prevent thoracic endovascular aortic repair-related complications.

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.

Penza's Surgical Maneuver: A Key to Tackle Complex Proximal Descending Thoracic Aortic Infectious or Malignant Issues

We performed off-pump ascending-to-descending aortic grafting with the debranching of left carotid and subclavian arteries and total aortic arch transection in three patients. We have called this technique “Penza's Surgical Maneuver” and propose it for a safe surgery in cases where the aortic arch, the aortic isthmus, the beginning segment of the descending aorta, the esophagus, and a lung are diseased.

Prognostic Factors and Survival in Resected T4 Non-small Cell Lung Cancer: Is There Any Difference in the T4 Subgroups?

INTRODUCTION

The eighth edition of the TNM classification revised the subgroups of T4 non-small cell lung cancer (NSCLC). This study aimed to compare the T4-NSCLC subgroups that underwent surgical treatment in terms of mortality, morbidity, survival, and prognostic factors based on the new classification.

MATERIALS AND METHODS

Between 2000 and 2014, a total of 284 T4-NSCLC patients who underwent lung resection (mediastinal organ invasion, n = 114; ipsilateral different lobe tumors, n = 32; and tumors larger than 7 cm, n = 138) were included in the present study.

RESULTS

Surgical mortality and morbidity were 5.6% (n = 16) and 23.9% (n = 68), respectively. The 5-year survival rates were 46% for ipsilateral different lobe tumors, 45.4% for tumours larger than 7 cm, and 36.6% for mediastinal organ invasion (28% for patients with heart/atrium invasion, 43.3% for carina invasion, 37.5% for large vessel invasion) (p = 0.223). Age above 65 (p = 0.002, HR = 1.781), pN2 versus pN0/1 (p < 0.0001, HR = 2.564), incomplete resection (p = 0.003, HR = 2.297), and pneumonectomy (p = 0.02, HR = 1.524) were identified as poor prognostic survival factors. According to multivariate analysis, mediastinal lymph node metastasis (p = 0.001) and incomplete resection (p = 0.0026) were the independent negative risk factors for survival.

CONCLUSION

According to the results of our study, surgical treatment is a good option in T4-NSCLC patients who have no mediastinal lymph node metastasis and are completely resectable. There is no difference in terms of survival among the T4 subgroups. The eighth edition of the TNM classification has a better prognostic definition than the previous version.

Use of Extracorporeal Membrane Oxygenation for Major Cardiopulmonary Resections

BACKGROUND

In thoracic surgery, utilization of extracorporeal membrane oxygenation (ECMO) is mainly established for patients undergoing lung transplantation. The aim of our study was to summarize our single-center experience with intraoperative use of veno-venous- or veno-arterial-ECMO in patients undergoing complex lung surgery involving the main carina, or the left atrium or the descending aorta.

METHODS

A total of 24 patients underwent combined complex lung, carinal, aortal, or left atrial resections. In cases of carinal resection, percutaneous veno-venous, jugular-femoral cannulation was considered suitable. For combined resection of lung and descending aorta, a percutaneous femoral veno-arterial cannulation was used. In cases of extended left atrial resection, a percutaneous jugular-femoral veno-venous-arterial cannulation was favored.

RESULTS

Procedures were divided into three groups: carinal resections and reconstruction (n = 8), resections of the descending aorta and left lung (n = 7), resections of lung and left atrium (n = 9). No intraoperative complications occurred. Overall 30-day mortality was 25%. A complete resection was achieved in 18 patients. Median survival was 12 months. One- and 5-year survival were 48.1 and 22.7%, respectively.

CONCLUSION

The present study shows that intraoperative use of ECMO for extended carinal, aortic, or atrial resections is feasible with minimal intraoperative complications allowing surgeons increased operating-field safety. Perioperative mortality is high, but this is rather an attribute of local extended disease and patient comorbidities.

The Outcomes of Induction Chemoradiotherapy Followed by Surgery for Clinical T3-4 Non-Small Cell Lung Cancer

Purpose:

Information on the short- and long-term outcomes of induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer is limited. We analyzed the short- and long-term outcomes of induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer.

Methods:

Patients with non-small cell lung cancer who underwent induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer were retrospectively reviewed (initial treatment group, n = 31). Their results were compared to those patients who underwent surgery as an initial treatment during the same period (initial surgery group, n = 35).

Results:

Downstaging was achieved in 14 (45%) patients in the initial treatment group. R0 resection was achieved in 28 (90%) patients in the initial treatment group and 31 (88%) patients in the initial surgery group. The 90-day mortality rate was 3% in each group. Postoperative complications occurred in 16 (52%) patients in the initial treatment group and 13 (37%) patients in the initial surgery group. The 5-year overall survival rate of the initial treatment group was significantly higher than that of the initial surgery group (62.6% vs 43.5%, P = .04). The 5-year overall survival rates of the initial treatment N0-1 group and the initial surgery N0-1 group were 88.9% and 49.3%, respectively; the difference was statistically significant (P = .02). Multivariate analysis using 4 factors (age [≤65 vs >65], cN [cN0-1 vs cN2], general condition [chemoradiotherapy fit vs chemoradiotherapy unfit], and treatment mode [induction chemoradiotherapy followed by surgery vs surgery as an initial treatment]) revealed that treatment mode (induction chemoradiotherapy followed by surgery) and cN status (cN0-1) were significantly associated with good overall survival and disease-free survival.

Conclusions:

Induction chemoradiotherapy followed by surgery for cT3-4 non-small cell lung cancer could be performed with an acceptable degree of surgical risk. At present, it is thought to be one of the reasonable treatment approaches for selected patients with cT3-4 disease, even those with a cN0-1 status.

Salvage surgery combined with descending aorta resection for lung cancer

Background

Recent retrospective studies have shown that salvage surgery can improve survival with acceptable adverse events, and this procedure has been adapted for lung cancer. However, there are no reports demonstrating the efficacy of salvage surgery combined with aortic resection.

Case presentation

A 73-year-old man had received definitive concurrent chemoradiotherapy (carboplatin/paclitaxel, 70 Gy) for lung cancer originated from the left upper lobe and infiltrating the thoracic aorta (cT4N1M0 stage IIIA). Although the tumor has shrunk significantly (ycT4N0M0 stage IIIA), radiation pneumonitis occurred. Due to the steroid therapy, radiation pneumonitis was relieved; however, re-enlargement of the primary tumor was observed during steroid tapering. Nonetheless, the lymphatic and distant metastases were controlled. Moreover, aortic invasion was localized to the periphery of the third branch, and the tumor was considered to be resectable. Intraoperatively, we observed macroscopic evidence of aortic invasion in the periphery of the third branch; thus, left upper lobectomy combined with descending aorta resection was performed under partial extracorporeal circulation. The patient is currently active without any recurrence 21 months post-surgery.

Conclusions

No clear consensus exists regarding salvage surgery combined with aortic resection for primary lung cancer. However, we believe that this surgery may improve the survival of carefully selected patients.

Combined Aortic Arch Resection for Lung Cancer Using Total Rerouting of Supra-Arch Vessels

Surgery for aortic arch involvement in lung cancer cases is challenging, and generally requires extracorporeal circulation with circulatory arrest or a cerebral protection technique. To reduce morbidity, we developed a novel surgical technique for total aortic arch replacement for lung cancer with aortic arch involvement that features total rerouting of supra-arch vessels under a beating heart condition. A 56-year-old man was diagnosed with lung cancer, and aortic arch invasion was suspected. After concurrent chemoradiotherapy, a left upper lobectomy with total arch replacement was performed using our new technique. Thirty-six months after the operation, there was no recurrence.

Early and mid-term outcomes of simultaneous thoracic endovascular stent grafting and combined resection of thoracic malignancies and the aortic wall

Objectives

To aim of this study was to clarify the safety of simultaneous thoracic aortic endografting and combined resection of the aortic wall and thoracic malignancy in a one-stage procedure over the early and mid-term periods.

Methods

From March 2013 to December 2017, 6 patients underwent aortic endografting followed by one-stage en bloc resection of the tumor and aortic wall. Thoracic surgeons and cardiovascular surgeons discussed predicted tumor invasion range and resection site, stent placement position, stent length and size, and the surgical procedure, taking into account the safe margin.

Results

The proximal site of aortic endografting was the: aortic arch in 2 cases (subclavian artery (SCA) occlusion in one, and SCA fenestration in one); distal arch just beneath the SCA in 2; descending aorta in 2. Pulmonary resection involved lobectomy in 2 patients, pneumonectomy in 2, and completion pneumonectomy in 1. Aortic resection was limited to the adventitia in 2 cases, extended to the media in 3, and extended to the intima in 1. An endograft-related complication, external iliac artery intimal damage requiring vessel repair, was observed in one case. No complications associated with aortic resection were observed. Two postoperative complications of atrial fibrillation and chylothorax developed. There were no surgery-related deaths. During follow-up, no late endograft-related complications such as migration or endoleaks occurred.

Conclusions

Early and mid-term outcomes of stent graft-related complications are acceptable. Simultaneous thoracic aortic endografting and combined resection of the aortic wall and thoracic malignancies are feasible in one stage on the same day.

Long-term survival in locally advanced non-small cell lung cancer invading the great vessels and heart

Background

The aim of this study was to analyze the surgical outcomes of locally advanced lung cancer invading the great vessels or heart, according to the extension of cancer invasion.

Methods

From 1995 to 2015, 59 patients who were surgically treated and pathologically diagnosed with T4N0–1 non‐small cell lung cancer with invasion to the great vessels or heart were enrolled. Surgical outcomes were compared between patient groups with and without intrapericardial invasion.

Results

The median age was 64 years (interquartile range [IQR] 57–68) and 56 patients (95%) were male. In‐hospital mortality was 9% and median overall survival was 30 months (IQR 12–83). One and five‐year overall survival rates were 75% and 44%, respectively. The median overall survival in patients with lung cancer invasion to the intrapericardial space (n = 45) was 27 months (IQR 10–63), while it was 42 months (IQR 18–104) in patients without intrapericardial invasion (n = 14). Median disease‐free survival was significantly poorer in patients with intrapericardial invasion (12 months; IQR 6–55), especially in patients with heart invasion (n = 11, 7 months, IQR 5–27), than in patients without intrapericardial invasion (30 months, IQR 13–103).

Conclusion

Patients with lung cancer invading the intrapericardial space showed worse surgical outcomes in both overall and disease‐free survival. Therefore, surgical management should be carefully considered in patients with intrapericardial invasion.

Non-Small Cell Lung Cancer Invading the Descending Thoracic Aorta: Surgical Resection Without Using Cardiopulmonary Bypass and Without Cross-Clamping the Aorta: Long-Term Follow-Up of 2 Cases

Lung cancer can sometimes invade vital adjacent mediastinal structures, such as the descending thoracic aorta. We describe 2 cases where pulmonary resection was performed en bloc including a patch of the descending thoracic aorta. These procedures were easily performed using an aortic endoprosthesis in the same anesthetic procedure. We also comment some aspects about an intraoperative endoleak, postoperative evolution, and long-term follow-up.

[Modern Aspects of Lung Cancer Surgery]

Modern Aspects of Lung Cancer Surgery Abstract. Surgery is still an inherent part of the treatment of non-small cell lung cancer. This article summarizes various aspects of the surgical treatment of early and locally advanced stages of lung cancer. Minimally invasive techniques for lung cancer resection - video- or robotic-assisted - are today standard for early stages. Perioperative mortality is below 1 % and the oncological outcome is equal to open surgery. The learning curve is at 50 VATS lobectomies in a program with a minimum of 25 VATS lobectomies/year to obtain satisfying results. In specialized centers, Locally advanced tumors can be resected technically and oncologically safe, with acceptable morbidity and mortality rates. With careful patient selection and planning, 5-year survival rates can be as high as 48 %.

[Cardiopulmonary bypass in thoracic surgery]

AIM

To analyze advisability of cardiopulmonary bypass in thoracic surgery.

MATERIAL AND METHODS

We estimated early and long-term results of CPB-assisted thoracic interventions in 31 patients with malignant and benign thoracic diseases and invasion into vital mediastinal structures or with concomitant cardiovascular pathology.

RESULTS

Acceptable rates of mortality and morbidity confirm safety of CPB in thoracic surgery while satisfactory long-term outcomes are arguments in favor of this direction of thoracic oncology.

Surgery for T4 lung cancer invading the thoracic aorta: Do we push the limits?

BACKGROUND

Few investigators have described en bloc resection of non-small cell lung cancer (NSCLC) invading the aorta.

AIM OF STUDY

Analysis of outcome and prognostic factors for en bloc resections of NSCLC invading the aorta.

METHODS

Thirty-five patients (27 males, 8 females; mean age 63 ± 8.6 years) were operated between 1994 and 2015 in four European Centers.

HISTOLOGY

12 (34.3%) squamous cell carcinoma, and 6 (17.1%) undifferentiated/large cell carcinoma. The site of aortic infiltration was the descending thoracic aorta in 24 (68.6%) patients, the aortic arch in 9 (25.7%), and the aortic arch and supraortic trunks in 2 (5.7%).

RESULTS

Lung resection consisted of pneumonectomy in 19 (54.3%) patients and lobectomy in 16 (45.7%). Aortic resection management was undertaken by endograft positioning (37.1%), subadventitial dissection (37.1%), cardiopulmonary/aorto-aortic bypass (17.2%), and direct clamping (8.6%). A tubular graft replacement was carried out in five cases, a synthetic patch repair in 6. Mortality was 2.9%, morbidity 37.1%. Patients undergoing pneumonectomy had a significantly higher morbidity rate compared with lobectomy (52% vs 18.7%; P = 0.003), although patients managed with aortic endografting had a lower complication rate. Median overall and disease-free survival rates were 31.3 and 22.2 months, respectively. Gender and site of aortic infiltration were independent prognostic factors.

CONCLUSIONS

Resection of NSCLC combined with an infiltrated aorta is a challenging procedure that can be performed with reasonable morbidity and mortality in highly selected patients.

Collaborative operation with cardiovascular surgeons in general thoracic surgery

OBJECTIVES

The aim of this study was to investigate the feasibility and safety of our surgical experiences conducted in collaboration with cardiovascular surgeons at our institution.

METHODS

From May 2002 to December 2015, among 3595 general thoracic surgeries, 75 (2.1%) operations were carried out collaboratively with cardiovascular surgeons at Nagoya University Hospital. We investigated the surgical procedures, manipulated organs, morbidity and mortality, completeness of surgical resection, and prognosis of these 75 cases.

RESULTS

The study cohort consisted of 56 males and 19 females, ranging in age from 18 to 79 years (median 60 years). Fifty-eight patients had a malignant disease, and 17 had a benign disease. Out of 75 collaborative surgeries, 53 (71%) were scheduled cases (cardiovascular surgeons' support was considered to be necessary preoperatively), and 22 (29%) were emergent cases (cardiovascular surgeons' support was considered to be necessary intraoperatively). No 30- or 90-day mortality was observed. Respiratory failure, defined as the requirement of mechanical ventilation or non-invasive positive pressure ventilation for ≥5 days, was the most common morbidity (n = 14, 18%). Forty-three patients (78%) out of 55 with thoracic neoplasms achieved microscopic complete resection. The resection status of the remaining 12 (22%) was microscopic residual tumor.

CONCLUSION

Collaborative surgeries with cardiovascular surgeons at our institution were feasible. High-quality surgeries with a good balance between safety and completeness of resection are important not only for treatment, but also in terms of education for general thoracic surgeons.

Surgery for malignant lesions of the chest which extensively involved the mediastinum, lung, and heart

OBJECTIVE

Radical resection for thoracic malignancies that invade the great vessels or heart structure is an uncommon, high-risk operation. To help surgeons determine therapeutic strategy, we reviewed the patient characteristics and outcomes of combined thoracic and cardiovascular surgery for thoracic malignancies.

METHODS

Surgical resections of lung cancer, mediastinal tumor and pulmonary artery sarcoma invading great vessels or heart structures were reviewed from the literature.

RESULTS

Pneumonectomy was often performed for lung cancer invading the aorta, superior vena cava, and left atrium. Complete resection (R0), no mediastinal lymph node metastasis and without using cardiopulmonary bypass led to a good prognosis. Induction therapy was often performed for complete resection. Regarding mediastinal tumors, thymic epithelial tumors or germ cell tumors occasionally invaded the great vessels or heart structures. For these malignancies, multimodality therapy was often performed, and complete resection could be one of the prognostic factors. The resection of primary pulmonary artery sarcoma (PPAS) is also a combined thoracic and cardiovascular surgery. The primary treatment for PPAS is surgical resection; specifically, pulmonary endarterectomy and pneumonectomy, because PPAS has substantial resistance to chemotherapy or radiotherapy. The prognosis of PPAS is poor, but surgical resection has potential for long-term survival.

CONCLUSION

Although these surgeries are uncommon and invasive for the patients, selecting appropriate patients, aggressive multimodality therapy, and performing combined thoracic and cardiovascular surgery can contribute to a good outcome.

Surgery for lung cancer invading the mediastinum

Lung cancer infiltrating the mediastinum is a subset of locally advanced lung tumors for which surgery is not routinely offered. Radical operations that involve removal of adjacent mediastinal structures to obtain free margins may provide a realistic cure. Such extended resections are typically reserved to highly motivated patients seeking more aggressive management, and are only offered following complete evaluation on a case-by-case basis. Positive prognosis depends on complete R0 resection and lack of mediastinal nodal metastases. Careful and exhaustive preoperative planning as well as surgical expertise cannot be overemphasized for successful surgical outcomes. Here we provide a brief summary of the literature as well as our own experience managing these rare and sometimes challenging surgeries.

Stereotactic body radiotherapy for T3 and T4N0M0 non-small cell lung cancer

To evaluate the outcomes and feasibility of stereotactic body radiotherapy (SBRT) for cT3 and cT4N0M0 non-small cell lung cancer (NSCLC), 25 patients with localized primary NSCLC diagnosed as cT3 or cT4N0M0, given SBRT between May 2005 and July 2013, were analyzed. All patients had inoperable tumors. The major reasons for tumors being unresectable were insufficient respiratory function for curative resection, advanced age (>80 years old) or technically inoperable due to invasion into critical organs. The median patient age was 79 years (range; 60-86). The median follow-up duration was 25 months (range: 5-100 months). The 2-year overall survival rates for T3 and T4 were 57% and 69%, respectively. The 2-year local control rates for T3 and T4 were 91% and 68%, respectively. As for toxicities, Grade 0-1, Grade 2 and Grade 3 radiation pneumonitis occurred in 23, 1 and 1 patient, respectively. No other acute or symptomatic late toxicities were reported. Thirteen patients who had no local, mediastinal or intrapulmonary progression at one year after SBRT underwent pulmonary function testing. The median variation in pre-SBRT and post-SBRT forced expiratory volume in 1 s (FEV1) values was -0.1 (-0.8-0.8). This variation was not statistically significant (P = 0.56). Forced vital capacity (FVC), vital capacity (VC), %VC and %FEV1 also showed no significant differences. SBRT for cT3 and cT4N0M0 NSCLC was both effective and feasible. Considering the favorable survival and low morbidity rate, SBRT is a potential treatment option for cT3 and cT4N0M0 NSCLC.

Cardiopulmonary Bypass and Extracorporeal Life Support for Emergent Intraoperative Thoracic Situations

Intraoperative thoracic surgical catastrophes may require extracorporeal circulation modes to support the patient while the appropriate repair is made. Teamwork is key and, given the evidence supporting better performance with the use of simulation and surgical-crisis checklists, their use should be encouraged. Anticipation is another important factor because the results of intrathoracic malignancy resection are clearly superior in the setting of planned cardiopulmonary support. In addition, familiarity with the different modes of support that are currently available can direct the decision-making process toward the best option to facilitate resolution of the intraoperative catastrophe with the least related morbidity.

Endovascular stent graft for surgical resection of lung cancer invading aortic arch: report of a 79-year-old patient

Combined resection of the aortic arch and lung with cardiopulmonary bypass (CPB) in patients with locally advanced lung cancer is associated with high morbidity and mortality. Aortic stenting followed by complete resection might be an alternative therapeutic strategy for patients with lung cancer. Here we report a 79-year-old man with respiratory compromise who had lung cancer invading the distal aortic arch. This case study reports that combined resection of the aortic arch with left upper segmentectomy following endovascular stenting can be safely and easily performed without CPB.

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.

Combined resection of great vessels or the heart for non-small lung cancer

OBJECTIVES

The surgical indications for non-small cell lung cancer (NSCLC) infiltrating a great vessel or the heart are controversial. We assessed clinical features and surgical outcomes of patients with non-small cell lung cancer who underwent combined resection of a lung and great vessel.

METHODS

Fourteen patients underwent great vessel resection under a lobectomy (n = 9), sleeve lobectomy (n = 2), or pneumonectomy (n = 3) between 2000 and 2011, in whom the aorta was resected in 6, superior vena cava in 5, right atrium in 1, and left atrium in 2. The histological types were adenocarcinoma (n = 8) and squamous cell carcinoma (n = 6).

RESULTS

Complete resection was performed in 12 patients. Of all patients, 7 had pN0 disease, 2 had pN1, and 4 had pN2. The postoperative morbidity rate was 28.6% and mortality rate was 7.1%. The 5-year survival rate was 26.8% for all patients, 46.9% for those with an adenocarcinoma, 0% for those with a squamous cell carcinoma, 53.6% for those with pN0, and 0% for those with pN1-2.

CONCLUSION

Resection of the great vessels and heart involved by NSCLC can be performed with acceptable morbidity and mortality, and results in prolonged survival in patients, with an adenocarcinoma or N0 status.

Extended resections of non-small cell lung cancers invading the aorta, pulmonary artery, left atrium, or esophagus: can they be justified?

T4 tumors that invade the heart, great vessels, or esophagus comprise a heterogenous group of locally invasive lung cancers. Prognosis depends on nodal status; this relationship has been consistently demonstrated in many of the small series of extended resection. Current National Comprehensive Cancer Network guidelines do not recommend surgery for T4 extension with N2-3 disease (stage IIIB). However, biopsy-proven T4 N0-1 (stage IIIA) may be operable. Localized tumors with invasion of the aorta, pulmonary artery, left atrium, or esophagus represent a small subset of T4 disease. Acquiring sufficient randomized data to provide statistical proof of a survival advantage for patients undergoing extended resections for these neoplasms will likely never be possible.Therefore, we are left to critically analyze current documented experience to make clinical decisions on a case-by-case basis.It is clear that the operative morbidity and mortality of extended resections for locally advanced T4 tumors have significantly improved over time,yet the risks are still high. The indications for such procedures and the anticipated outcomes should be clearly weighed in terms of potential perioperative complications and expertise of the surgical team. Patients with T4 N0-1 have the best prognosis and with complete resection may have the potential for cure. The use of induction therapy and surgery for advanced T4 tumors may improve survival. Current data suggest that for tumors that invade the aorta, pulmonary artery,left atrium, or esophagus, resection should be considered in relation to multidisciplinary care.For properly selected patients receiving treatment at high volume, experienced centers, extended resections may be warranted.

Special treatment issues in non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

BACKGROUND

This guideline updates the second edition and addresses patients with particular forms of non-small cell lung cancer that require special considerations, including Pancoast tumors, T4 N0,1 M0 tumors, additional nodules in the same lobe (T3), ipsilateral different lobe (T4) or contralateral lung (M1a), synchronous and metachronous second primary lung cancers, solitary brain and adrenal metastases, and chest wall involvement.

METHODS

The nature of these special clinical cases is such that in most cases, meta-analyses or large prospective studies of patients are not available. To ensure that these guidelines were supported by the most current data available, publications appropriate to the topics covered in this article were obtained by performing a literature search of the MEDLINE computerized database. Where possible, we also reference other consensus opinion statements. Recommendations were developed by the writing committee, graded by a standardized method, and reviewed by all members of the Lung Cancer Guidelines panel prior to approval by the Thoracic Oncology NetWork, Guidelines Oversight Committee, and the Board of Regents of the American College of Chest Physicians.

RESULTS

In patients with a Pancoast tumor, a multimodality approach appears to be optimal, involving chemoradiotherapy and surgical resection, provided that appropriate staging has been carried out. Carefully selected patients with central T4 tumors that do not have mediastinal node involvement are uncommon, but surgical resection appears to be beneficial as part of their treatment rather than definitive chemoradiotherapy alone. Patients with lung cancer and an additional malignant nodule are difficult to categorize, and the current stage classification rules are ambiguous. Such patients should be evaluated by an experienced multidisciplinary team to determine whether the additional lesion represents a second primary lung cancer or an additional tumor nodule corresponding to the dominant cancer. Highly selected patients with a solitary focus of metastatic disease in the brain or adrenal gland appear to benefit from resection or stereotactic radiosurgery. This is particularly true in patients with a long disease-free interval. Finally, in patients with chest wall involvement, provided that the tumor can be completely resected and N2 nodal disease is absent, primary surgical resection should be considered.

CONCLUSIONS

Carefully selected patients with more uncommon presentations of lung cancer may benefit from an aggressive surgical approach.

Primary synovial sarcoma of the lung successfully resected under temporary bypass

A 48-year old man presented with chest pain and haemoptysis. Chest computed tomography showed a 60-mm mass in the left upper lobe of the lung, adjacent to the distal aortic arch. Bronchoscopic cytology revealed the presence of malignant cells and, in the absence of evidence of distant metastasis, a thoracotomy was performed. Although the tumour was firmly adherent to the distal aortic arch, under temporary bypass from the left subclavian artery to the descending aorta, it was successfully resected en bloc with the section of the aorta attached to it. The tumour was diagnosed as a primary synovial sarcoma of the lung on the basis of histopathological findings and fluorescent chromogenic in situ hybridization, showing SS18 gene rearrangement.

Left upper lobectomy with combined resection of the distal arch aorta after chemoradiotherapy for locally advanced lung cancer

We report a case of complete resection of lung cancer involving the thoracic aorta, after induction chemoradiotherapy in a 55-year-old man. The chemoradiotherapy, which consisted of two courses of platinum-based chemotherapy with concurrent radiation to a total of 40 Gy, resulted in a partial response. Left upper lobectomy with combined resection and reconstruction of the distal arch aorta and left subclavian artery was performed under cardiopulmonary bypass. The patient was given two courses of platinum-based adjuvant chemotherapy, and there has been no sign of recurrence in the 34 months since his operation.

Extensive resections: pancoast tumors, chest wall resections, en bloc vascular resections

Infiltration by lung tumor of adjacent anatomic structures including major vessels, main bronchi, and chest wall not only influences the oncologic severity of the disease but also increases the technical complexity of surgery, requiring extended resections and demanding reconstructive procedures. Completeness of resection represents in every case one of the main factors influencing the long-term outcome of patients. Technical and oncologic aspects of extended operations, including resection of Pancoast tumors and chest wall, bronchovascular sleeve resections, and en bloc resections of major thoracic vessels, are reported in this article.

Induction therapy for lung cancer: sailing across the pillars of Hercules

In spite of numerous clinical trials, the jury is still out on the value of induction therapy for locally advanced lung cancer. We elected to address this topic from the multifaceted views of the clinicians often involved in lung cancer management and according the most recent views on locally advanced NSCLC. The concept of a prognostic stratification of N2 disease subsets, especially single vs multiple zone, has been introduced and this may lead to a new interpretation of locally advanced NSCLC. Ten crucial issues were identified that may have an impact on the approach to patients with locally advanced lung cancer in everyday practice.