Results of superior vena cava resection for lung cancer

Long term outcome of complex surgical resection and reconstruction for rare thoracic cancers

BACKGROUND

Complex surgical resection and reconstruction for rare thoracic cancers (RTCs) represent a major challenge, given their very low frequency, extreme variability of presentation, multi-modality treatment options and inadequate outcome prediction. We analysed the experience of a tertiary referral centre on a consecutive series of patients with thoracic germ cell tumours, thymomas and sarcomas, with the aim of reporting the long-term outcome by cancer type and complexity of surgical procedures.

METHODS

From Jan 2003 to Dec 2018, 768 surgical procedures were performed with curative intent on 644 RTC patients. Study endpoints were: post-operative hospital stay (Pod), 30-day and 90-day mortality, 5-year and 10-year overall survival (OS). Median follow-up of alive patients was 7.2 years.

RESULTS

Median Pod was 7 days, with a 1.2% 30-day and 2.9% 90-day mortality. OS was 90.8% at one year, 74.2% at five years and 62.8% at 10 years. Ten-year OS was 73.0% in low, 65.3% in intermediate, and 55.6% in high complexity score (Log-rank tests p<0.0001); 66.6% in patients with one or two reconstructions and 46.4% in patients with three or more reconstructions (p<0.0001); 46.0% with vascular and 50.0% with chest wall reconstruction; 71.8% in germ cell tumours, 64.6% in thymoma and 51.3% in sarcoma (p<0.0001).

CONCLUSION

Complex surgical resection and reconstruction was associated with acceptable 90-day mortality and good 10-year survival in all RTC types. A predictive score based on surgical complexity and cancer type can help the clinical decision making.

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.

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 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.

Case Report: Superior Vena Cava Resection and Reconstruction for Invasive Thyroid Cancer: Report of Three Cases and Literature Review

Background: Thyroid cancer with massive invasion into the cervical and mediastinal great veins is extremely rare, and the surgical treatment is controversial, thus posing a great challenge for head and neck surgeons. Here, we report our successful experiences in reconstructing the superior vena cava (SVC) system to treat thyroid cancer with an extensive tumor thrombus growing intraluminally into the SVC.

Case Presentation: From September 2019 to September 2020, three patients with superior vena cava syndrome(SVCS) caused by tumor thrombus invasion from thyroid cancer were continuously included in this series. After preoperative evaluation, radical resection and reconstruction of the SVC system with expanded polytetrafluoroethylene (EPTFE) grafts were performed. In addition, bypass support from the right internal jugular vein to the right femoral vein was routinely prepared intraoperatively to prevent a rise in central venous pressure (CVP). Postoperatively, SVC-related syndrome improved immediately after the operation. Imaging examination showed good function of the reconstructed venous system. The patients recovered well with no surgical complications and remain under continuous follow-up.

Conclusions: Tumor growth into the SVC does not seem to be an absolute contraindication for surgery for thyroid carcinoma. Comprehensive treatment, including reconstruction of the SVC, is effective for relieving symptoms and preventing disease progression and is thus worth advocating. In addition, bypass support from the internal jugular vein to the femoral vein is easy to implement and can improve the safety of the operation.

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.

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.

T4 extension alone is more predictive of better survival than a tumour size >7 cm for resected T4N0-1M0 non-small-cell lung cancer†

OBJECTIVES

T4N0-1 non-small-cell lung cancer (NSCLC) was historically considered curable but now includes tumours of size >7 cm according to the 8th edition tumour, node and metastasis (TNM) staging. This study was set out to evaluate the role of surgery and predictors of long-term survival after surgery in this renewed group of patients.

METHODS

Patients, with clinical T4N0-2M0 NSCLC diagnosed in 2010-2013, in the National Cancer Database were queried. A Cox regression analysis was applied to investigate independent predictors of survival in 1588 N0-1 surgical cases. For previous T3 cases, the efficacy of treatment including and not including surgery was compared after propensity score matching by age, gender, race, facility type, comorbidity, laterality, clinical N stage, histology and tumour grade.

RESULTS

In newly defined T4N0-1 NSCLC patients undergoing surgery, age, gender, comorbidity, nodal status, resection margin, tumour grade, chemotherapy and extension-size group were shown to be independent predictors of survival. In particular, patients with only T4 extension showed better survival than patients with tumour size >7 cm only [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.62-0.92, P = 0.016]. In the latter group, surgical treatment was associated with better survival than non-surgical treatment after matching (HR 0.45, 95% CI 0.42-0.48, P < 0.001).

CONCLUSIONS

In the newly defined T4 NSCLC, tumour size >7 cm is a descriptor that is more predictive of worse survival than local extension alone for patients whose treatment included surgery. For T4-extended, N0-1 NSCLC with a tumour size ≤7 cm, surgery might be associated with favourable long-term outcomes and should be further encouraged as a treatment option.

Superior Vena Cava Resection in Locally Advanced Thymoma-Surgical and Survival Outcomes

This study was aimed at reporting the surgical management of superior vena cava invasion in patients with locally advanced thymoma and to evaluate surgical and survival outcomes. This is a retrospective analysis of 12 patients operated for superior vena cava resection for locally advanced thymoma over 8 years in a thoracic surgery centre in India. An analysis of peri-operative variables including complications was carried out. The influence of various predictors on survival was assessed by log-rank test. Intra-operatively, superior vena cava (SVC) alone was involved in 3 (25%) cases, SVC with BCV involvement was there in 8 cases (66.7%) and in 1 patient, the SVC involvement extended into the right atrium also. In all cases, the tumour was resected en bloc with the involved part of SVC. Repair with primary closure was sufficient in 2 cases (16.6%) in view of < 1/3rd of circumferential involvement. However, in remaining 10 cases, SVC was replaced with PTFE graft (single graft in 6 cases, Y-graft in 2 cases and twin grafts in 2 cases). No peri-operative deaths. Overall survival (OS) at 1, 3 and 5 years was 100%, 91.6% and 83.3%, respectively. Myasthenia gravis and higher Masaoka stage (IV A) of the disease were poor predictors of survival. Superior vena cava resection and reconstruction is a feasible and oncologically superior option in invasive thymoma with SVC involvement. This challenging surgical procedure should only be attempted by an experienced team of thoracic and cardiac surgeons at high-volume centre to achieve best outcomes.

Preliminary Results of Extracorporeal Membrane Oxygenation Assisted Tracheal Sleeve Pneumonectomy for Cancer

OBJECTIVE

Tracheal sleeve pneumonectomy is a challenge in lung cancer management and in achieving long-term oncological results. In November 2018, we started a prospective study on the role of extracorporeal membrane oxygenation (ECMO) in tracheal sleeve pneumonectomy. We aim to present our preliminary results.

METHODS

From November 2018 to November 2019, six patients (three men and three women; median age: 61 years) were eligible for tracheal sleeve pneumonectomy for lung cancer employing the veno-venous ECMO during tracheobronchial anastomosis.

RESULTS

Only in one patient, an intrapericardial pneumonectomy without ECMO support was performed, but cannulas were maintained during surgery. The median length of surgery was 201 minutes (range: 162-292 minutes), and the average duration of the apneic phase was 38 minutes (range: 31-45 minutes). No complications correlated to the positioning of the cannulas were recorded. There was only one major postoperative complication (hemothorax). At the time of follow-up, all patients were alive; one patient alive with bone metastasis was being treated with radiotherapy.

CONCLUSION

ECMO-assisted oncological surgery was rarely described, and its advantages include hemodynamic stability with low bleeding complications and a clean operating field. As suggested by our preliminary data, ECMO-assisted could be a useful alternative strategy in select lung cancer patients.

Orthotopic heart transplantation with reconstruction of persistent left superior vena cava

BACKGROUND

Persistent left superior vena cava is a not uncommon congenital vascular abnormality. We report a case of heart transplantation with reconstruction of persistent left superior vena cava using a prosthetic vascular graft.

CASE PRESENTATION

A 20-year-old man with idiopathic dilated cardiomyopathy and persistent left superior vena cava underwent orthotopic heart transplantation 2 years and 3 months after left ventricular assist device implantation. Because the persistent left superior vena cava had a larger diameter than the right superior vena cava, the transected persistent left superior vena cava was reconstructed with a prosthetic vascular graft anastomosed to the free wall of the right atrium. Postoperative enhanced computed tomography revealed good patency of the graft. The patient's postoperative course has been uneventful during 2 years of follow-up, despite the risk of complications.

CONCLUSIONS

Reconstruction of a persistent left superior vena cava with a prosthetic vascular graft may be one option at the time of heart transplantation.

Thoracic tumor resection combined with SVC replacement using autologous pericardium

Background

Invasion of the superior vena cava (SVC) by thoracic tumors and occurrence of SVC syndrome are often encountered in clinical practice; but the prognosis in these cases is poor. Replacement of the SVC with autologous pericardial tissue is rarely performed. In this study, we sought to investigate the postoperative outcomes of this rare procedure.

Methods

We performed a retrospective analysis of six patients who underwent SVC replacement using autologous pericardial tissue between October 2010 and November 2016. We collected data on the patients’ pathological features, operative characteristics, postoperative outcomes, and survival.

Results

All six patients were male with an average age of 52 years (range, 18–62 years). Three of the patients had lung cancer, one had stage III thymoma, and two had germinoma. Four of the six patients had mild or moderate superior vena cava compression and no corresponding clinical symptoms. The other two patients had severe compression and obvious symptoms of SVC syndrome, with the typical swelling of the face, eyelids, and upper extremities. All six patients underwent complete tumor resection, with two of the lung cancer patients undergoing right lobectomy and one undergoing right pneumonectomy. With respect to the postoperative outcomes, one patient died, whereas the others did not develop any major complications. At the end of the follow-up period, five of the patients were alive and none of the patients had developed thrombosis in the grafts.

Conclusions

Our findings indicated that SVC replacement with autologous pericardium is technically feasible and safe, with few postoperative complications and favorable long-term effects. Although it has some limitations, this method appears to be useful in achieving SVC reconstruction of moderate size. SVC replacement with autologous pericardium appears to have the potential for widespread clinical use.

Initial extended resection or neoadjuvant therapy for T4 non-small cell lung cancer-What is the evidence?

Locally advanced non-small cell lung cancer (NSCLC) tumors that invade surrounding structures within the chest (T4) are a heterogeneous group, and, as such, there are no straightforward guidelines for their management. Advances in imaging, invasive mediastinal staging, and neoadjuvant therapies have expanded the role of surgery with curative intent for this patient group and have also diminished the rate of explorative thoracotomies. Unlike for T4 superior sulcus tumors, the use of neoadjuvant therapy for central T4 tumors is not clearly defined. The most important determinants of a successful outcome after surgery are achieving an R0 resection and avoiding incidental pathologic N2 disease. Use of neoadjuvant therapy in this setting may yield better outcomes after surgery, as both of these variables can be altered if the tumor responds to neoadjuvant therapy. Moreover, response to induction therapy has been shown to have prognostic value.

[A Programmed Procedure of Prosthetic Reconstruction of the Superior Vena Cava for Thoracic Tumors via Median Thoracotomy]

背景与目的

上腔静脉系统受累是局部晚期胸部肿瘤较常见的一种情况，手术可能获益，但风险极高。本研究针对正中开胸入路，提出一种程序化的手术方案，旨在优化流程，使得这一类以往认为风险极高的手术能够更加安全地实施。

方法

35例胸部疾患累及上腔静脉系统，经正中开胸进行人工血管置换的患者资料，分期检查明确为局部晚期。包括肺部肿瘤16例，纵隔肿瘤19例。手术方法采用从左至右的单向推进，先游离左无名静脉起始部，阻断后切断，掀起瘤体，打开心包，用人工血管桥接左无名静脉和右心耳。游离上腔静脉近心端未受侵部分后，向尾侧牵拉肿瘤，剪开右侧纵隔胸膜，结扎切断右侧乳内血管，可以充分显露右无名静脉。向左上方牵拉瘤体，于肺门上方结扎切断奇静脉，此时可以阻断右无名静脉和上腔静脉，切除中间受侵的血管，以人工血管行右无名静脉-上腔静脉桥接，完成受侵的上腔静脉系统全部替换。

结果

全组病例均顺利完成手术。术后并发症包括：心律失常6例，低氧血症5例，肌无力危象1例，心脏疝1例，真菌感染2例。2例患者死亡，死亡率5.12%，分别死于心梗和肺部感染。其余33例顺利出院。平均术后住院日15 d。在10例术前出现上腔静脉综合征的患者中，除2例术中即出现人工血管内血栓形成的患者，其余8例症状均明显改善。

结论

上腔静脉人工血管置换手术经程序化的处理，规范治疗的细节，在手术操作过程中可降低手术风险，本组病例手术能够安全实施的实践也支持这一点。

Superior vena cava resection and reconstruction in mediastinal tumors and benign diseases

BACKGROUND

This study aims to evaluate our results of resection and reconstruction of the superior vena cava invaded by mediastinal tumors and benign diseases.

METHODS

Seventeen patients (8 males, 9 females; mean age 46±17 years; range 9 to 74 years) undergoing superior vena cava resection and reconstruction due to mediastinal pathologies between September 2006 and September 2016 were retrospectively reviewed. Patients who had angioplasty with primary suturing or partial resection with stapler were excluded. Mortality and morbidity rates were analyzed based on the demographic, and intra- and postoperative measures.

RESULTS

Majority of patients (94%) had mediastinal tumors. Twelve patients (71%) had thymic epithelial tumors. Tubular graft interposition was performed using ringed polytetrafluoroethylene prosthesis in nine patients (53%), while patch plasty using autologous pericardium, polytetrafluoroethylene or Dacron grafts was performed in eight patients (47%). Eleven patients (65%) necessitated concomitant resections of neighboring structures. Mean length of hospital stay was 11±6 days. There was no intraoperative death. Mortality occurred in three patients (18%). Five patients (29%) developed complications. Mortality occurred commonly in elderly patients (p<0.0001). Postoperative complications were more common in patients with concomitant resections (p=0.05). Neither acute nor chronic thrombosis developed in any patients. Median survival in patients with malignant diseases was 57 months, with a oneyear and three-year probability of survival of 83% and 74%, respectively.

CONCLUSION

Replacement of superior vena cava should be included in the therapeutic algorithm of selected patients with mediastinal tumors and benign diseases. Mortality rates may be higher in older patients, while the need for concomitant resections may increase morbidity rates.

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.

Reconstruction of mediastinal vessels for invasive thymoma: a retrospective analysis of 25 cases

BACKGROUND

Discuss an appropriate strategy for treatment of invasive thymoma invading adjacent great vessels.

METHODS

A retrospective study on 25 patients with invasive thymoma invading neighboring great vessels was performed. The corresponding data including clinical presentation, operation procedure, adjuvant radio-chemotherapy and follow-up were reviewed.

RESULTS

Twenty of 25 (80%) patients with invasive thymoma underwent complete resection of the tumor along with vessel reconstruction. Intraoperatively, different types of operation were conducted, namely, brachiocephalic vein (BCV)-right atrial appendage (RAA) reconstruction in 11 cases, complex vessel reconstruction (more than one graft) in 1 case and superior vena cava (SVC)-SVC reconstruction in the remaining cases. Ringed polytetrafluoroethylene (PTFE) grafts were used for vessel reconstruction. Postoperatively, three cases suffered from pulmonary infection, and three cases had haemothorax, chylothorax and atelectasis, respectively. Two patients died due to acute respiratory distress syndrome within 90 days after the surgery. Within the remaining patients, 11 cases (44%) experienced a relapse and finally 8 (32%) patients died. Compared to R1 resection group, R0 resection group had a better prognosis (Log-rank P=0.0196). The 3- and 5-year survival rates were 79.6% and 59.1%, with median survival time of 84 months.

CONCLUSIONS

Reconstruction of mediastinal vessels for invasive thymoma is a feasible technology method. Radical resection of the tumor with involved neighboring structures is the key to prolong overall survival for patients suffered from invasive thymoma.

[Progress on the Therapeutic Approaches for Malignant Tumor with Superior Vena Cava Syndrome]

上腔静脉综合症（superior vena cava syndrome, SVCS）作为胸部恶性肿瘤严重的并发症之一，患者生存期短、生活质量差，大部分采用姑息治疗，随着多学科的发展与治疗技术的进步，越来越多的专家采用各种治疗方式，明显改善了患者的预后，本文对病因表现进行简单归纳，并从内科治疗、介入治疗、放射治疗、外科手术治疗以及质子治疗等几个方面对目前较新的治疗方式进行综述。

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.

Long-term survival after superior vena cava resection and reconstruction for bulky local recurrence from lung cancer

A 65-year old man who had undergone right pneumonectomy for lung cancer presented with superior vena cava (SVC) syndrome due to recurrent bulky disease on follow-up after 14 months. Complete resection of the tumour was achieved, and the SVC system was reconstructed with separated double grafts. The right graft was anastomosed between the SVC and the right subclavian vein, because the right brachiocephalic vein was involved by the tumour. Graft-subclavian vein anastomosis was created in the extra-thoracic portion. Although postoperative right graft occlusion occurred, right arm oedema improved conservatively. He is alive, well and has been disease-free for 39 months since the second surgery. This is the first report of SVC resection and reconstruction for 'recurrent' disease from lung cancer. Extended resection for recurrent disease should not be excluded as a treatment option.

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.

Temporary extravascular shunt for reconstruction of a superior vena cava invaded by a lung tumor

Advanced central lung cancers can invade the superior vena cava (SVC). Although the indications for resection of the vessel remain controversial, it has been suggested that it increases the long-term survival of selected patients; however, little consensus has been reached regarding the optimal method of vascular reconstruction. While the SVC is often replaced during unprotected cross-clamp, the placement of a temporary venous shunt with a view to preserve the periprocedural safety and facilitate the postoperative management seems preferable. We describe an SVC reconstruction procedure using an autologous pericardial patch and placement of a temporary extravascular shunt via a lateral thoracotomy.

Superior vena cava syndrome due to a leiomyosarcoma of the anterior mediastinum: A case report and literature overview

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Leiomyosarcomas are rare causes of superior vena cava syndrome.

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Surgery is the treatment of choice.

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Specific approaches depend on the neoplasm's size and invasion of neighbouring tissues.

INTRODUCTION

Leiomyosarcomas are an infrequent cause of malignant superior vena cava syndrome (VCS).

PRESENTATION OF CASE

A 51-year old male patient was admitted for a three-day history of dyspnoea, dysphagia and erythema of the head and neck. Computed tomography and magnetic resonance imaging showed a lesion arising on the anterior mediastinum, which was in close proximity with a thrombus in the superior vena cava. Surgical excision was performed, including open resection of the primary tumour and an atrio-innominate vein bypass with 8-mm polytetrafluoroethylene (PTFE). Histology confirmed a leiomyosarcoma and postoperative radiotherapy sessions were performed. Due to evidence of enlargement of the thrombus, a second intervention was undertaken. In this procedure, a remainder of the primary tumour was resected and the superior vena cava reconstructed with an autologous pericardium patch. The patient recovered satisfactorily and was discharged on the seventh postoperative day, with no evidence for relapse after 10 months of follow-up.

DISCUSSION

Leiomyosarcomas comprise less than 2% of the tumours of the mediastinum and are a rare cause of paraneoplastic VCS. Male patients in their sixties are most commonly affected. Relapses seem to be common, and thus a careful follow-up is often recommended.

CONCLUSION

In spite of the limited data on the management of thoracic leiomyosarcomas, surgery is currently considered the mainstay of treatment.

Superior vena caval resection in lung cancer

Lung cancer with involvement of the SVC is uncommon but presents a unique management challenge. Discovery of N2 disease should be given its due diligence and these patients should undergo induction therapy. Patients can attain favorable long-term outcomes with surgery, but they need to be carefully selected at specialized centers.

Results of T4 surgical cases in the Japanese Lung Cancer Registry Study: should mediastinal fat tissue invasion really be included in the T4 category?

INTRODUCTION

T4 lung cancer is a heterogeneous group of locally advanced disease. We hypothesized that patients in whom T4 lung cancer invaded only mediastinal fat tissue would show better prognosis after surgery than patients in whom T4 disease invaded other organs. The present study aimed to investigate how different invasive features of T4 disease impacted prognosis, and what types of patients with T4 disease could benefit most from surgical treatment.

METHODS

A nationwide registry study on lung cancer surgical cases during 2004 was conducted by the Japanese Joint Committee of Lung Cancer Registry, including registries of 11,663 cases within Japan. The present study analyzed 215 of these cases involving T4 structures or with ipsilateral nonprimary lobe pulmonary metastasis (PM).

RESULTS

Reasons for T4 classification included invasion of only mediastinal tissue in 32 cases (15%), invasion of other structures in 96 cases (45%), and ipsilateral different lobe PM in 87 cases (40%); among these three groups, there were no significant differences in survival, nodal status, and patterns of first recurrence. Multivariate analysis showed an age of 70 years or above (p = 0.022) and nodal status (p = 0.004) to be significant prognostic factors. T4N0 patients less than 70 years of age showed significantly better prognosis than those who were T4N1-2 and 70 years of age or older (p = 0.0001; 5-year survival rate 50.3 versus 19.9%).

CONCLUSIONS

There was no significant difference in survival between T4 patients with only mediastinal fat invasion and those with other T4 organ invasion and ipsilateral different lobe PM, demonstrating appropriateness of the T4 category definition in the current tumor, node, metastasis staging system. Age and nodal status were significant independent prognostic factors in T4 patients, and the best surgical candidates were shown to be T4N0 patients who were less than 70 years of age and had a 5-year survival rate of more than 50%.

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.

Reconstruction of the superior vena cava by biologic conduit: assessment of long-term patency by magnetic resonance imaging

BACKGROUND

To assess the long-term patency of the biologic prosthetic conduit used for reconstruction of the superior vena cava (SVC) by magnetic resonance imaging (MRI).

METHODS

Patients undergoing oncologic resection and reconstruction of the SVC by a bovine pericardial prosthesis (January 2003 to April 2010) have been studied after 1 year (if surviving) by MRI for the assessment of the conduit long-term patency. Results were compared with those of a control group of patients with normal SVC. Blood flow and area of lumen section at 3 different levels (proximal, middle, distal) were analyzed.

RESULTS

Sixteen consecutive patients surviving after 1 year from surgery out of 17 (9 lung cancer, 8 mediastinal malignancy) undergoing SVC reconstruction were included. One patient died postoperatively and was not included. Sixteen patients with similar demographic characteristics were studied in the control group. Mean blood flow was 18.4±3.5 mL/sec (range 14.3 to 25.7) in patients with reconstructed SVC and 20.8±4.1 mL/sec (range 15.3 to 27.7) in the control group. Mean area of the conduit lumen section was 2.2±0.6 cm2 (range 1.6 to 3.6) at proximal level, 2.9±1.3 cm2 at middle level (range 1.3 to 5.7), and 2.1±0.9 cm2 (range 0.5 to 4) at distal level in the reconstructed group, and 2.6±0.7 cm2 (range 1.8 to 4.2), 2.7±0.7 cm2 (range 1.9 to 4.3), and 2.4±0.3 cm2 (range 1.8 to 3.1), respectively, at proximal, middle, and distal levels in the control group. Differences between the 2 groups were not significant (p>0.05).

CONCLUSIONS

The MRI assessment in terms of blood flow and area of lumen section at 3 different levels confirms that bovine pericardial conduit used for SVC replacement shows an optimal patency over the long term.

Absolute and relative contraindications to pulmonary resection: effect of lung cancer surgery guidelines on medical practice

Patients with primary lung cancer that has not spread beyond a lung should be considered for an operation provided their general health is good, their functional capacity is adequate, and survival benefits outweigh the operative risk. Not all patients are suitable for pulmonary resection. Alternative forms of treatment should be considered for patients who have disseminated cancer, limited cardiopulmonary reserve, advanced chronologic and physiologic age, and those who decline treatment.

Triple plasty of bronchus, pulmonary artery, and superior vena cava for non-small cell lung cancer

BACKGROUND

It has been technically challenging to perform simultaneous triple plasty on the superior vena cava (SVC), pulmonary artery (PA), and main bronchus for central-type lung cancers. In the present study, the authors describe a corresponding technique and clinical outcomes of this surgical manipulation.

METHODS

Clinical data from 4 patients with non-small cell lung cancer (NSCLC) who underwent triple plastic resections and reconstructions were retrospectively reviewed. Three patients received neoadjuvant chemotherapy for pathologically proven locally advanced disease. For pulmonary arteries, sleeve resection with end-to-end anastomosis was performed in 2 patients; tangential resection was used in the other 2 patients. SVC resection with ringed polytetrafluoroethylene (PTFE) graft interposition was performed in 1 patient; the other 3 patients underwent tangential SVC resection. Sleeve resection of the bronchus was performed in all 4 patients. Systemic lymphadenectomy was accomplished in all patients.

RESULTS

There was histologic confirmation of large cell carcinoma, adenocarcinoma, squamous cancer, and adenosquamous cancer, respectively, in these 4 patients. Stage pT4N2M0-IIIB was confirmed in 2 patients, and stage T4N1M0-IIIA and stage T2aN2M0-IIIA were confirmed in the other 2 patients. There were no perioperative deaths. Postoperative atrial fibrillation and prolonged air leakage occurred in 2 patients, respectively. Four patients underwent postoperative chemotherapy and 2 patients were administered radiotherapy. Patients were followed for 21 to 38 months: Two patients had disease-free survival at their 32-month and 38-month follow-ups, and the other 2 patients died 21 and 22 months, respectively, after operation because of remote metastasis.

CONCLUSIONS

Triple plasty of bronchus, PA, and SVC is both practical and safe for patients with locally advanced NSCLC. For patients with strict indications, the long-term survival is favorable.

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.

Effect of ageing and pulmonary inflammation on the incidence and number of cross-bridging structures in pneumothorax patients

BACKGROUND

There is an improved prognosis for T4 non-small-cell lung cancer in patients who show particular patterns of direct mediastinal invasion. The particular patterns suggest the presence of direct pathways other than the pulmonary hilum between each of the lungs and the mediastinum/chest wall.

PURPOSE

To determine the incidence and number of such direct pathways in pneumothorax patients as well as the factors that affect the development of these pathways.

MATERIAL AND METHODS

Two radiologists independently analyzed multidetector computed tomographic images of 81 patients with pneumothorax to assess the incidence and distribution pattern of the cross-bridging structures in the pleural cavity.

RESULTS

Cross-bridging structures were observed in the right pneumothorax in 34/54 (63%) patients and in the left pneumothorax in 19/32 (59%) patients. The number of cross-bridging structures was found to be positively correlated with ageing and pulmonary disease. The distribution patterns of cross-bridging structures were found to be specific in formation and often in repeated locations, regardless of the presence of pulmonary disease or the age of the patient.

CONCLUSION

Cross-bridging structures in pneumothoraces were found more frequently in older patients and in patients with pulmonary disease. However, some of the cross-bridging structures may have been congenital because of their specific formations and repeated locations.

Azygos flap as a novel method for superior vena cava reconstruction

In the surgical treatment of lung cancers invading the superior vena cava (SVC), primary closure is preferred for reconstruction when the resected area is small, but the repaired vessel can become constricted. A novel method for SVC repair with azygos flap, which is a longitudinally opened azygos arch, is a facile and effective treatment, and may prevent a reduction in the lumen if the area of tumor invasion is small and close to the azygos arch. When the azygos arch is not invaded by the tumor, this procedure should therefore be considered as one alternative method for SVC reconstruction.

Surgical reconstruction of the superior vena cava system: indications and results

BACKGROUND

Obstruction of the superior vena cava (SVC) secondary to malignant or benign diseases is rarely treated by surgical reconstruction. The purpose of this retrospective study is to report our experience and compare our results with previous data in the literature.

METHODS

From 1993 to 2006, 24 patients underwent operative reconstruction of the SVC. Mean patient age was 58 years. The underlying disease was primary bronchopulmonary malignant neoplasm in 50%, mediastinal malignant neoplasm in 21%, and symptomatic benign disease in 29%. Forty-six percent of patients presented clinical signs of superior vena cava compression (SVCC). Our indications were based on two criterions: clinical symptoms of superior vena caval compression or histological examination of the superior vena caval lesion that indicates potential for complete surgical excision.

RESULTS

Median duration of postoperative intensive care was two days. Mortality at 30 days was 12% for malignant diseases. All patients presenting clinical signs of SVCC improved. Mean follow-up was 28 months (range, 1-129). No thrombosis was observed during follow-up. Overall survival was 53% at 1 year and 35% at 5 years. For patients with malignant bronchopulmonary disease, survival was 50% at 1 year and 25% at 5 years. Mortality was 0% for patients with benign disease.

CONCLUSION

Review of the literature indicates that replacement of the SVC is an uncommon procedure. Our experience suggests that the need for SVC reconstruction should not, however, be considered as a contraindication for resection of a bronchopulmonary or mediastinal neoplasm in an otherwise potentially curable patient, provided it can be achieved in a single block with clear margins. Replacement of the SVC can also be performed with low mortality and morbidity for effective treatment of SVCC secondary to benign disease that fails to respond to medical therapy.

Treatment of non-small cell lung cancer, stage IIIB: ACCP evidence-based clinical practice guidelines (2nd edition)

OBJECTIVE

To develop evidence-based guidelines on best available treatment options for patients with stage IIIB non-small cell lung cancer (NSCLC).

METHODS

A review was conducted of published English-language (abstract or full text) phase II or phase III trials and guidelines from other organizations that address management of the various categories of stage IIIB disease. The literature search was provided by the Duke University Center for Clinical Health Policy Research and supplemented by any additional studies known by the authors.

RESULTS

Surgery may be indicated for carefully selected patients with T4N0-1M0. Patients with N3 nodal involvement are not considered to be surgical candidates. For individuals with unresectable disease, good performance score, and minimal weight loss, treatment with combined chemoradiotherapy results in better survival than radiotherapy (RT) alone. Concurrent chemoradiotherapy seems to be associated with improved survival compared with sequential chemoradiotherapy. Multiple daily fractions of RT when combined with chemotherapy have not been shown to result in improved survival compared with standard once-daily RT combined with chemotherapy. The optimal chemotherapy agents and the number of cycles of treatment to combine with RT are uncertain.

CONCLUSION

Prospective trials are needed to answer important questions, such as the role of induction therapy in patients with potentially resectable stage IIIB disease. Future trials are needed to answer the questions of optimal chemotherapy agents and radiation fractionation schedule. The role of targeted novel agents in combination with chemoradiotherapy is just starting to be investigated.