Extended operation for lung cancer invading the aortic arch and superior vena cava

Prognostic Implication of Direct Cardiac Invasion from Lung Cancer in Non-Operatively Treated Patients Based on Lung Computed Tomography Imaging

BACKGROUND

Lung cancer with direct cardiac invasion (LCCI⁺) exerts a significant influence on the survival of patients. There is a paucity of comparative research into the prognosis of advanced lung cancer with and without direct cardiac invasion.

METHOD

In this study, 50 LCCI⁺ patients and 50 sex-, age-, and TNM stage-matched patients without direct cardiac invasion (LCCI^-) were retrospectively analysed. LCCI⁺ was defined as lung cancer directly invading the heart by penetrating mediastinum or extending into the atrium via the pulmonary vein. The study endpoint was all-cause death. In this study, the survival time was defined as the time from the first detection of direct cardiac invasion to the end of the event.

RESULTS

During a median follow-up period of 31 months, all-cause death occurred in 44 patients (88.0%) in the LCCI⁺ group and in 36 patients (72.0%) in the LCCI^- group; the overall survival (OS) time among patients in the LCCI⁺ group was significantly lower compared with those in the LCCI^- group (5.0 [interquartile range (IQR), 2.0-12.0] vs 13.8 [IQR, 4.0-18.4] months; p<0.001); the OS rate in the LCCI⁺ group was significantly lower compared with patients in the LCCI^- group (log-rank, p=0.0002). Multivariate Cox regression analysis showed that direct cardiac invasion was an independent predictor of survival in patients with advanced lung cancer (hazard ratio, 2.255; 95% confidence interval, 1.443-3.524). Further analysis indicated that in patients with small cell lung cancer, the survival rate between the LCCI⁺ group and LCCI^- group was insignificant (log-rank, p=0.075; survival time: 4.0 [IQR, 2.0-11.5] vs 11.5 [IQR, 5.0-18.3] months); in patients with non-small cell lung cancer (NSCLC), the survival rate in the LCCI⁺ group was lower than that of the LCCI^- group (log-rank, p=0.01; survival time: 6.0 [IQR, 3.0-13.3] vs 16.3 [IQR, 10.4-27.2] months).

CONCLUSIONS

Direct cardiac invasion from lung cancer was an independent prognostic factor for survival time in patients with lung cancer. Patients with direct cardiac invasion by NSCLC have a poorer clinical outcome than those without direct cardiac invasion. A careful preoperative evaluation is mandatory and appropriate management of cardiac involvement should be considered in the treatment of NSCLC.

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.

Computed tomography angiography study of the azygos vein course and termination into superior vena cava: gender and age impact

PURPOSE

The study highlights azygos vein (AV) topography, arrangement and confluence morphometry in dyspnoea and tachycardia patients of extrapulmonary and extracardiac aetiology.

METHOD

Computed-tomography angiography of 25 male and 26 female patients (mean age 66.5 years) were studied for: thoracic vertebral (T) height of AV- superior vena cava-SVC confluence, AV course and deviations from vertebral column (VC) midline, AV and SVC diameters, distance (AV arch- lower border of carina) and gender and age impact.

RESULTS

Commonest heights of the AV-SVC confluence were T5 (56.9%), T4 (31.4%), T6 (9.8%) and T3 (2%). The AV terminated into SVC after crossing the left side of VC midline in 56.9%, slightly deviated right of the midline in 37.3% and coursed right of VC in 5.9%. Mean AV and SVC diameters were 0.96 ± 0.18 cm and 1.86 ± 0.27 cm. Male predominance in AV and SVC diameters and a slight AV diameter significant increase with the age were found. The (AV highest point-lower border of carina) mean distance was 2.05 ± 0.44 cm and male predominance existed.

CONCLUSION

The commonest termination height of the AV was T5, while T3 was the rarest one. Aging induces the AV leftward displacement, while gender had no impact. AV and SVC diameters had higher significant values in males, while ageing had a significant impact only in AV diameter. The AV higher diameters will be used as predictors for higher values of SVC diameter and mediastinum pathology. Such findings can be useful in mediastinal surgery, mediastinoscopy and surgery of VC deformations, neurovascular surgery of retroperitoneal organs, disc herniation and T fractures.

Intraoperative aortic endograft placement for an unexpected plaque rupture during lung surgery

BACKGROUND

Surgical resection of tumors invading the aorta is a challenging procedure. More recently, the use of thoracic aortic endografts has been reported to facilitate en bloc resection of tumors invading the aortic wall. The best treatment option is to keep the procedure separated before lung resection to reduce the risks of bleeding, therefore avoiding adverse consequences for the patient. However, an aortic stent placement before surgery is not mandatory with no clear signs of tumor or atherosclerotic plaque infiltrating the entire aortic wall.

CASE PRESENTATION

A 72-year-old man came to our Department for a persistent cough. Computed tomography (CT) scan with enhancement showed a mass located in the left upper lobe of the lung with no clear sign of infiltration or calcified plaques along the entire vascular wall. A positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro-d-glucose integrated with computed tomography (PET/CT with 18F-FDG) was positive for hypermetabolic mass with negative lymph node stations bilaterally. Patient was undergone surgery for major lung resection by left thoracotomy. For an unexpected intraoperative bleeding due to the rupture of a calcified plaque, a stent was placed before proceeding with lung surgery. Patient was persistently stable, discharged after six days from surgery with no morbidities.

CONCLUSIONS

In our case, no signs of the atherosclerotic plaque infiltration as well as no tumor infiltration were shown. In these situations, the aortic stent placement is possible in emergency, even during another operation. Nevertheless, surgeon experience and the good coordination among specialists is mandatory to yield a satisfying solution.

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.

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.

Surgical management of lung cancer invading the aorta or the superior vena cava

OBJECTIVE

Invasion of mediastinal structures (T4) is considered as an absolute contraindication to surgical management of non-small cell lung cancer (NSCLC). The authors studied the role of surgical treatment in case of direct aortic and superior venous caval involvement.

PATIENTS

From 1995 to 2000, 13 patients with left lung NSCLC invading descending aorta and 9 patients with right upper lobe NSCLC and superior vena cava (SVC) invasion were subjected to thoracotomy for lung resection. Surgery was indicated in case of absence of intraluminal extension. All patients were cN2 negative. The pathology results and 5-year survival were recorded and analyzed.

RESULTS

In three cases (23%) the tumor was adhered to the parietal pleura overlying descending aorta, which was resected en block with tumor-associated lung parenchyma. Aortic adventitia invasion by tumor led to local resection of adventitia (<1cm(2)) in nine patients (69%). Invasion deeper than adventitia was encountered in one case (8%), which was managed with aortic partial occlusion, resection of aortic wall and repair of the defect with Gore graft patch. In three patients (33%) the SVC wall was involved by the tumor 1-3cm in length and 2-4mm of the circumference. The defect was repaired with direct suturing. In five patients (56%) the area of SVC wall that was invaded was 3cmx2cm. The defect was repaired with Dacron patch. In 1 patient (11%) an arterial 14 graft was end-to-end interposed. All resections were radical (R0). Neither associated postoperative complications nor operative mortality was recorded. Five-year survival was 30.7% for the cases with aortic invasion and 11% for the ones with SVC involvement.

CONCLUSIONS

Radical surgical resection of lung tumors with localized aortic invasion can be considered after exclusion of N2 involvement.

Long-term graft patency after replacement of the brachiocephalic veins combined with resection of mediastinal tumors

OBJECTIVE

We sought to investigate the correlation between type of vascular reconstruction and long-term graft patency after replacement of brachiocephalic veins combined with resection of mediastinal malignancies.

METHODS

Eighteen patients underwent surgical resection of tumors and the superior vena cava with concomitant vascular reconstruction using ringed polytetrafluoroethylene grafts. Graft patency was verified by means of venography or contrast-enhanced computed tomography at time points ranging from 3 to 77 months (median, 33 months) postoperatively.

RESULTS

Seven patients underwent sole reconstruction of the right brachiocephalic vein, with occlusion observed in only 1 patient. In 6 patients who underwent reconstruction of the bilateral brachiocephalic veins with 2 separate grafts, the grafts remained patent in 2, whereas 4 patients experienced occlusion of one of the two grafts yet remained asymptomatic. Both patients who underwent reconstruction with a Y graft experienced left brachiocephalic vein graft occlusion. In the 3 patients who underwent reconstruction of a left brachiocephalic vein, the graft became occluded, and superior vena cava syndrome developed in 2 of these patients.

CONCLUSION

When replacing the superior vena cava, reconstruction of a left brachiocephalic vein alone results in a significant rate of occlusion and development of superior vena cava syndrome. Thus we advocate sole right brachiocephalic vein reconstruction or bilateral brachiocephalic vein reconstruction in this setting, and separate reconstruction of the veins is preferable to use of a Y graft.

Resection of Locally Advanced (T4) Non-Small Cell Lung Cancer With Cardiopulmonary Bypass

BACKGROUND

Resection of T4 non-small cell lung cancer (NSCLC) on cardiopulmonary bypass (CPB) has rarely been reported in the literature. Hence, we have reviewed our experience in the role of CPB for the surgical treatment of locally advanced NSCLC.

METHODS

All patients undergoing lung resection for bronchogenic carcinoma on CPB in our institution between January 1998 and June 2004 were reviewed.

RESULTS

Seven patients underwent lung resections on CPB for bronchogenic carcinoma during the study period. Cardiopulmonary bypass was performed for tumors invading the subclavian artery down to the aortic arch (n = 2), the descending aorta (n = 1), or the origin of the left pulmonary artery with the left atrium (n = 2). All patients were discharged home after 9 to 21 days (median, 15 days). In the long term, 2 patients are alive without recurrence 17 and 25 months after their operations, and 3 are alive with recurrence 8, 13, and 54 months postoperatively. Two additional patients required CPB while undergoing carinal resection for difficulty ventilating the left lung. Both patients had a difficult postoperative course, but were eventually discharged from hospital. One patient died without recurrence 6 months later, and the other is alive without recurrence after 72 months.

CONCLUSIONS

This study confirms the safety of CPB for NSCLC invading the great vessels and/or the left atrium in well-selected patients, and its utility when pulmonary edema develops during carinal resection. Further studies, however, are required to confirm long-term survival.

Surgical resection for lung cancer with infiltration of the thoracic aorta

OBJECTIVE

The purpose of this study was to evaluate the results of a combined resection of the thoracic aorta and primary lung cancer.

METHODS

Sixteen patients underwent thoracic aorta resection along with a left pneumonectomy (n = 6), left upper lobectomy (n = 9), or partial lung resection (n = 1), of whom 10 also received preoperative induction therapy. Cardiopulmonary bypass was used in 10 patients, and a passive shunt between the ascending aorta and the descending aorta was used in 4 patients.

RESULTS

Six postoperative major complications occurred in 5 patients, including postoperative bleeding (n = 3), intraoperative bleeding (n = 1), chylothorax (n = 1), and respiratory failure (n = 1). The postoperative morbidity rate was 31%, and the mortality rate was 12.5% (2/16). Furthermore, 4 patients died of systemic tumor relapse, and 1 patient died of intrapleural recurrence. Nine patients were alive after a median follow-up of 54 months (range, 12-199 months). The median survival time of patients with postoperative pathologic N0 disease was 31 months, whereas it was 10 months for those with pathologic N2 or N3 disease. Five-year survivals were 70% for patients with N0 disease and 16.7% for patients with N2 or N3 disease ( P = .0070).

CONCLUSIONS

Although pulmonary resection with the involved aorta might cause high surgical morbidity and mortality rates, encouraging long-term survivals were obtained in patients without mediastinal nodal involvement.

Combined Resection of Superior Vena Cava for Lung Carcinoma: Prognostic Significance of Patterns of Superior Vena Cava Invasion

BACKGROUND

Combined resection of the superior vena cava (SVC) for lung carcinoma remains challenging in terms of technical aspect and prognosis. We attempted to clarify the surgical outcome of combined resection and reconstruction of the SVC for lung carcinoma.

METHODS

Between March 1980 and May 2001, among 3,499 lung resections, 40 (1.1%) patients underwent combined resection of the SVC. Thirty-four were men and 6 were women. Ages ranged from 37 to 77 years, with median of 64 years. Lobectomy and pneumonectomy was performed in 19 and 21 patients, respectively. The SVC system was totally resected and reconstructed with grafts in 11 patients, and partially resected in 29 patients. For the latter patients, autologous pericardial patches were used in 8 patients, and a running direct suture was performed in 21 patients. The survival curves were constructed by the method of Kaplan-Meier, and the curves were compared using the log-rank test.

RESULTS

Thirty-day mortality was 10%. The 5-year survival rate was 24%, with the median follow-up period for living patients 67 months (actual 5-year survivors were 7). The prognoses were compared between patients with SVC invasion by metastatic nodes (n = 15) and those with SVC invasion by a direct tumor extension (n = 25), and the survival difference was statistically significant (5-year survival rate, 6.6% versus 36%; p = 0.05).

CONCLUSIONS

The pattern of SVC invasion was considered to be a significant prognostic factor, and this factor should be taken into consideration for evaluating the outcome of clinical trials for T4 lung cancer.

Twelve-year experience with left atrial resection in the treatment of non–small cell lung cancer

BACKGROUND

We retrospectively reviewed our 12-year experience in the surgical treatment of non-small cell lung cancer invading the left atrium. End points of the study were overall survival and factors potentially affecting survival.

METHODS

Nineteen consecutive patients with lung cancer invading the left atrium underwent surgery. Three patients with N2 disease underwent induction chemotherapy. Patients with either incomplete resections or pN2 disease received postoperative chemoradiotherapy.

RESULTS

Five-year survival was 14%, and the median survival time was 25 months. These figures refer to a very homogeneous group of patients with respect to the extent of atrial infiltration. Patients with N2 disease tended to have a worse outcome than patients with N0 or N1 disease (p = 0.06). The 3 patients with N2 disease who underwent induction chemotherapy were alive and disease-free at 30, 15, and 11 months from surgery. Survival was not affected by histology, type of surgery, or completeness of resection. Three patients with residual cancer in the atrial resection margin underwent postoperative chemoradiotherapy and are alive at 25, 17, and 15 months after surgery.

CONCLUSIONS

In spite of the poor survival rates we report, the present experience suggests that more-favorable results could be expected by the routine preoperative use of positron emission tomographic scan staging, a more-extensive assessment of atrial invasion, the application of induction chemotherapy in patients with N2 disease, and postoperative chemoradiotherapy in patients with tumors abutting the atrial resection margin.

Results of superior vena cava resection for lung cancer

AIMS

The benefits of superior vena cava (SVC) resection for lung cancer remain controversial. Data obtained in four international centers were analyzed in order to identify prognostic factors and thus guide in future patient selection.

MATERIALS AND METHODS

Retrospective study. Prognostic factors were examined by logistic regression for postoperative morbidity/mortality using the Kaplan-Meier method (log rank test) and the Cox proportional-hazard model for survival.

RESULTS

From 1963 to 2000, 109 patients underwent SVC resection. Induction treatment was given to 23 (21%) patients. The SVC was resected for T involvement in 78 (72%) cases and for N involvement in 31 (28%) cases. Fifty-five (50.5%) patients underwent pneumonectomy (20 with carinal resection), while the remaining underwent lobar resections. Prosthetic SVC replacement was performed in 28 (26%) patients; partial resection with running suture (53%), vascular stapler (13%), or patch (7%) was performed in 80 patients; 1 patient did not undergo reconstruction. Pathological examination identified direct involvement (T4) in 66 (60%) patients and N2 disease in 55 (50%) patients. Major postoperative morbidity and mortality were 30 and 12%, respectively. Median intensive care unit stay was 3 days, while median hospital stay was 16 days. Five-year survival was at 21%, with median survival at 11 months. In multiple regression analysis, induction treatment was associated with an increased risk of major complications (P = 0.016). None of the factors assessed demonstrated an association with postoperative death. In multivariate survival analysis, both pneumonectomy and complete resection of the SVC with prosthetic replacement were associated with a significant increased risk of death (P = 0.0013 and 0.014, respectively).

CONCLUSIONS

The radical resection of lung cancer involving the SVC may result in a permanent cure in carefully selected patients. The type of pulmonary resection (i.e., pneumonectomy) and the type of SVC resection (i.e., complete resection with prosthetic replacement) are the prognostic factors with the greatest adverse effect on survival.

Aortic arch resection under temporary bypass grafting for advanced thymic cancer

Extensive surgery for malignant disease requiring cardiopulmonary bypass may cause postoperative immunosuppression. We conducted resection of the aortic arch and total arch replacement under temporary bypass grafting in a patient with advanced thymic cancer invading the aortic arch. No major postoperative complications such as brain damage or paraplegia occurred. Temporary bypass grafting is thus applicable in extensive surgery for malignant disease invading the aortic arch.

Radical resections for T4 lung cancer

T4 lung cancers are a heterogeneous group of locally advanced lung cancers. Treatment is palliative for the majority of patients, ranging from supportive care to chemoradiotherapy. In certain patients, however, surgery is beneficial and may be curative. Patients with T4N0M0 cancers invading the distal trachea, carina, left atrium, aorta, superior vena cava, or vertebral bodies may be surgical candidates. Radical resections of these T4 lung cancers have potential for cure if no mediastinal lymph node metastases (N2 or N3) occur and if resection is complete. Increased postoperative mortality exists and extends beyond 30 days, as evidenced by a 30-day mortality of 8% and a 90-day mortality of 18%. Improved palliation (median survival of 19 months) and cure (31% five-year survival) are possible in patients who meet the criteria, who undergo radical resection, and who are followed by physicians in facilities with special interests in extended resections. The use of induction therapy and surgery in T4 patients may further increase survival and the number of T4 patients in whom radical resection is possible. Radical resections are contraindicated in patients with T4 lung cancers associated with malignant pleural effusions. Unfortunately, these patients have the worst prognosis. If surgical palliation is an option, only pulmonary resection with pleurectomy and not pleuropneumonectomy should be considered. In contrast, lung cancers with the best prognosis are those T4 tumors diagnosed because of a satellite tumor nodule within the same lobe. Because radical resections are usually not required, operative mortality is not increased. Five-year survival in patients with satellite intralobar tumor nodules without mediastinal nodal metastases is comparable to survival of highly selected T4N0M0 patients who undergo radical resection. These two extremes of T4 lung cancers, malignant pleural effusion and satellite intralobar tumor nodules, generally are not considered for or do not require radical resections. It is debatable that the definition of T4 should include these entities.

Surgical treatment of stage III non-small cell lung cancer

The resectability of NSCLC is determined by its stage. The surgical treatment in stage I and II NSCLC remains a golden standard. Stage IIIA NSCLC constitutes a non-homogenous group, and many patients are potentially non-resectable. The patients in stage IIIA NSCLC also constitute a non-homogenous group. The patients in stage T3N1 usually undergo surgical resection, but many patients with N2 disease are disqualified from surgical treatment due to the negative prognostic factors. The negative prognostic factors comprise: (1) metastases to upper paratracheal (no 2), anterior paratracheal (no 3), and subcarinal (no 7) lymph nodes; (2) metastases to multiple mediastinal lymph nodes; (3) occurrence of the so called 'bulky disease'; (4) capsular lymph node invasion. The occurrence of one of these negative prognostic factors disqualifies the patient with N2 disease from radical surgical treatment. In more advanced cases, i.e. stage IIIB, and stage IV NSCLC, patients are rarely operated. It regards the patients in stage T4 N1, and in M1 disease with a single metastasis (mainly to CNS) accompanied by the stage I, or II, of the primary focus. In these cases N2 disease always constitutes the contraindication to the surgical treatment. Multidisciplinary approach in the treatment of NSCLC is supposed to improve the results of the treatment of NSCLC.

Risk analysis and long-term survival in patients undergoing resection of T4 lung cancer

OBJECTIVE

The aim of this study is to identify the risk group of patients with T4 lung cancer who could more likely benefit from surgical resection.

METHODS

Between January 1, 1990, and December 31, 1998, 77 patients underwent pulmonary resection for T4 lung cancer: lobectomy (n = 20), bilobectomy (n = 4) and pneumonectomy (n = 53). The T4 sites of mediastinal involvement were: Intrapericardiac portions of the pulmonary artery (n = 30), left atrium (n = 19), aorta (n = 8), superior vena cava (n = 8), carina (n = 7), the esophagus (n = 8) and the vertebral body (n = 6). Ten patients had multiple neoplastic nodules in the same lobe of the lung.

RESULTS

Overall survival rates at 1, 2 and 3 years were 46, 31 and 21%, respectively. Factors adversely affecting survival with univariate analysis included the localization of tumours in the lower lobe (P = 0.04) and both the involvement of superior and inferior mediastinal lymph nodes (P = 0.03). Multivariate analysis included two factors adversely affecting survival: the location of the primary tumour and the nodal stations involved. Regression tree analysis classified the patients into low-risk group (primary tumour in upper lobe or in main stem bronchus and pN0 or pN1 or superior or inferior mediastinal nodes involved), intermediate-risk group (primary tumour in upper lobe or in main stem bronchus and both superior and inferior mediastinal nodes involved, primary tumour in inferior lobe and pN0 or pN1 or inferior mediastinal nodes involved) and high-risk group (primary tumour in inferior lobe and both superior and inferior nodes involved). The 3-year survival rates were 36% for the low-risk group, 4% for the intermediate-risk group and 0% for the high-risk group (P = 0.006).

CONCLUSIONS

In patients with T4 lung cancer, the surgery can justify itself for tumours in the upper lobe or in the main stem bronchus and with pN0 or pN1.

Superior vena cava syndrome

Lung cancer is the most common cause of superior vena cava syndrome (SVCS) and requires timely recognition and management. The syndrome is rarely an oncologic emergency in the absence of tracheal compression and airway compromise. Treatment depends on the etiology of the obstructive process. Treatment should also be individualized and should not be undertaken until a diagnosis is obtained. Most patients with SVCS secondary to lung cancer can be treated with appropriately directed chemotherapy or radiotherapy. With the refinement of endovascular stents, percutaneous stenting of the SVC is being increasingly used as primary treatment modality. Thrombotic occlusion can be treated with appropriate lytic agents. In rare circumstances, surgical decompression can be performed; bypass or replacement of the SVC results in immediate improvement in the majority of cases and can be accomplished with low morbidity.

Pulmonary vein and left atrial invasion by lung cancer: assessment by breath-hold gadolinium-enhanced three-dimensional MR angiography

PURPOSE

The purpose of this work was to evaluate the ability of breath-hold gadolinium-enhanced three-dimensional (3D) MR angiography to assess the invasion of the pulmonary vein and the left atrium by lung cancer.

METHOD

Gadolinium-enhanced 3D MR angiography was performed in 20 consecutive patients with lung cancer.

RESULTS

At two sites with left atrial invasion shown by MR angiography, associated partial resection of the left atrium was performed. At five sites with invasion of the proximal pulmonary vein within 1.5 cm from the left atrium on MR, partial resection of the left atrium was performed at one site, and the pulmonary vein was resected at the intrapericardial portion at three sites. At two sites with invasion of the proximal pulmonary vein 1.5 cm more distal to the left atrium, the pulmonary vein was resected at the extrapericardial portion.

CONCLUSION

Breath-hold gadolinium-enhanced 3D MR angiography is suitable for assessing invasion of the pulmonary vein and the left atrium by lung cancer.

Staging and the surgical management of lung cancer

Small cell lung cancer remains a nonsurgical disease with the majority (80%) of cases presenting in higher stages. The primary treatment modalities for small cell lung cancer are radiation therapy and systemic chemotherapy, often administered concomitantly. This article focuses on the staging and surgical management of non-small-cell lung cancer.

Surgery for advanced stage lung cancer

Therapeutic strategy in advanced stage disease remains controversial. Theoretically resectable, Stage IIIa disease includes a high proportion of non-resectable nodal diseases. Overall 5-year survival after surgery remains lower than 15%. Randomized trials comparing the results of surgery alone with induction chemotherapy followed by surgery showed a significant benefit to induction therapy. Currently, Stage IIIb diseases are considered unresectable; nevertheless, selected patients are able to undergo an extended resection after induction treatments. In highly selected cases, a surgical resection can be performed in T4 tumors. Surgical resection must be included in a combined multidisciplinary strategy of treatment, and is proposed only for responders. Resectability criteria have to be defined with clinical trials designed to increase the local control by surgery. Thus, so-called Stage IIIb tumors can be divided in two subcategories: potentially resectable and definitively non-resectable. Some locally advanced, initially unresectable tumors (Stage IIIb) can become operable after induction chemoradiotherapy. The French staging system, based upon prognostic and therapeutic subcategories, splits N2 involvement into two subcategories: mN2 (minimal), found at the thoracotomy; and cN2 (clinical), histologically proven at the pre-treatment staging. T4 tumors are divided in potentially resectable T4(1) (invasion of superior vena cava, carina, lower trachea, left atrium), and definitively non-resectable T4(2) (malignant pleural or pericardial effusion, invasion of oesophagus, and vertebrae). Thus, Stage III can be separated into three subcategories, A, B, and C, instead of the two current substages. Stage IIIA includes T3 N1 M0 and T1-T3mN2M0 tumors. Stage IIIB includes T1-T3cN2M0 and T4(1)N0-N2MO tumors. Stage IIIC includes T4(2)N0-N3M0 and T1-T4(1)N3M0 tumors. In this way, the therapeutic options in non-small-cell lung cancer (NSCLC) will be clarified with 1) a "primary surgery" subgroup, including Stages I, II, and IIIA, 2) an "induction treatment" subgroup, including Stage IIIB, and 3) a "non-surgical" subgroup, including Stages IIIC and IV.

Combined thoracic aortic or upper digestive tract resection for lung cancer and malignant mediastinal tumor

OBJECTIVE

We studied possible indications and combined resection in patients with lung cancer and mediastinal tumors requiring combined thoracic aortic or upper digestive tract resection.

METHODS

Ten patients with lung cancer and malignant mediastinal tumors (9 men and 1 woman aged 39 to 72 years; mean: 60.5) underwent combined aortic or upper digestive tract resection.

RESULTS

Five--3 [corrected] with primary lung cancer, 1 with thymic cancer, and 1 with liposarcoma--, underwent combined aortic resection. In 2 each, lung cancer and malignant mediastinal tumor had infiltrated the thoracic aorta. The remaining case of lung cancer was complicated by aortic aneurysm in the distal arch. Cardiopulmonary bypass was conducted in 4, and selective cerebral perfusion in 2. Three patients are alive after 11, 22, and 61 months without disease recurrence. Those undergoing combined upper digestive tract resection all had lung cancer, with 4 having tumors infiltrating the esophagus or corpus ventriculi. The remaining patient had both lung and esophageal cancer. The patient treated with combined corpus ventriculi resection has survived 24 months and the patient treated with combined esophageal resection has survived 12 months without disease recurrence. The 1-year survival rate was 60%, 2-year 23%, and 3-year 23%. Prognosis was generally poor with the longest survival 13 months with N2 lung cancer.

CONCLUSIONS

In combined resection due to malignant mediastinal tumor, T4N0-1 lung cancer, or diseases such as aortic aneurysm, prognosis can be expected to improve. Despite the often poor prognosis in T4N2 lung cancer, surgical intervention may be indicated to avoid complications due to tumor invasion and to lengthen survival and improve quality of life.

Extended resection for lung cancer invading mediastinal organs

We analyzed 49 patients with non-small-cell lung cancer invading mediastinal organs such as the left atrium (15), superior vena cava (13), trachea (11), aorta (5), thoracic vertebral body (4) and esophagus (1). Lung resection included lobectomy (37), pneumonectomy (8) and limited resection (4). Twenty-seven patients underwent carina- or bronchoplasty. Complete resection was possible in 35 patients. Operative mortality was 12% and overall 5-year survival was 13%. Median survival time was 519 days. Factors significantly affecting survival were the completeness of resection, node status, and histological type. Five-year survival was 18% with complete resection and 0% with incomplete resection (p < 0.0001). Five-year survival for patients with squamous cell carcinoma was 36% and for those with other types of lung cancer, 0% (p < 0.02). Five-year survival for patients classified pathologically as N0 or N1 was 36% and, for those classified as N2 or N3, 0% (p < 0.05). We concluded that aggressive resection for lung cancer invading the mediastinal organs involves a high mortality rate, making selectivity important. Patients undergoing complete resection, classified as N0 or N1, and having squamouse cell carcinoma may benefit most from surgery.

Ventilatory muscle recruitment and work of breathing in patients with respiratory failure after thoracic surgery

OBJECTIVES

Increased work of breathing (WOB) and respiratory muscle weakness have been identified as major causes of respiratory failure after thoracic surgery. This study was undertaken firstly to characterize the mechanical impairment in patients with respiratory failure after cardio-thoracic surgery, and secondly, to determine how diaphragmatic paralysis affects deterioration in the ventilatory mechanics.

METHODS

We evaluated the respiratory mechanics of 24 patients following cardiac and thoracic surgery. Ten patients without respiratory problems were examined as control subjects. There were nine patients with phrenic nerve injury and five patients without phrenic nerve injury who required mechanical ventilation for more than 7 days. Phrenic nerve injury was assessed with a phrenic nerve stimulation test. We measured the respiratory variables, the esophageal, gastric and transdiaphragmatic pressure swing (deltaPes, deltaPga and deltaPdi, respectively), and the work of breathing during quiet tidal breathing.

RESULTS

Both the groups requiring mechanical ventilation exhibited abnormally negative deltaPga/deltaPes values, compared with the control subjects. A significant increase in WOB with the normal generation of deltaPdi was seen in the patients without phrenic nerve injury. In contrast, the poor generation of deltaPdi with a slight increase in work of breathing was noted in patients with phrenic nerve injury.

CONCLUSIONS

These results demonstrated two different types of respiratory failure in thoracic surgery patients, focusing on the impact of phrenic nerve paralysis. Diaphragmatic dysfunction should not be overlooked in postoperative care, and the amelioration of this compromise in respiratory mechanics is an important aspect of good patient management.

Type of lymph node involvement and survival in pathologic N1 stage III non-small cell lung carcinoma

BACKGROUND

Survival of patients with stage II non-small lung cancer by the 1986 classification depends on the type of lymph node involvement (by direct extension or by metastases in lobar or hilar lymph nodes). The influence of these types of lymph node involvement on survival was investigated in pathologic N1 stage III patients.

METHODS

Of 2,009 patients having operation from 1977 through 1993, the cases of 123 patients with pathologic N1 stage III disease (80 T3 N1 and 43 T4 N1) were reviewed. The N1 status was refined by the specific type of lymph node involvement.

RESULTS

The cumulative 5-year survival rate of all hospital survivors (n = 111) was 27.2%. A significant difference in mean 5-year survival rate was observed between patients who underwent complete resection and those with incomplete resection (34.4% versus 11.4%; p = 0.0001). Further analysis was performed with hospital survivors having complete resection only (n = 76). The cumulative 5-year survival rate was 34.4%. Type of lymph node involvement did not relate to survival for the group as a whole or for the T3 and T4 subsets. Survival was not related to age, histology, type of resection, or tumor size.

CONCLUSIONS

Moderately good results can be obtained with surgical resection for stage III patients with pathologic N1 disease. In contrast with stage II, complete resection of pathologic N1 higher-stage non-small cell lung carcinoma is not influenced by type of lymph node involvement.

Induction chemotherapy for T4 centrally located non-small cell lung cancer

OBJECTIVE

We used induction chemotherapy in a prospective, single-institution clinical trial intended to achieve resectability in patients with centrally located, unresectable T4 non-small cell lung cancer. Other types of IIIB disease were excluded.

METHODS

Between January 1990 and April 1996, we enrolled 57 patients with histologically confirmed non-small cell lung cancer. Eligibility criteria for T4 were clinical (superior vena cava syndrome, 9 patients), vocal cord paralysis (6 patients), dysphagia from esophageal involvement (1 patient), radiologic (computed tomography and magnetic resonance evidence of infiltration, 10 patients), bronchoscopic (tracheal infiltration, 11 patients), and thoracoscopic (histologically proven mediastinal infiltration, 20 patients). After 3 cycles of cisplatin (120 mg/m2), vinblastine (4 mg/m2), and mitomycin (2 mg/m2), patients were reevaluated.

RESULTS

Forty-two patients (73%; 36 men, 6 women; age range, 42-75 years; mean, 58 years) responded to therapy and underwent thoracotomy; 11 patients did not respond, and 4 patients had major toxicity. Thirty-six patients (63% of the entire group) had complete resection. We performed 4 exploratory thoracotomies, 6 pneumonectomies, 32 lobectomies (20 procedures were associated with reconstruction of hilar-mediastinal structures). Overall, 4 patients had no histologic evidence of disease. We had 2 bronchopleural fistulas with 1 death and 5 other major complications. Overall survival at 1 and 4 years is 61.4% and 19.5%, respectively. Forty-two patients (73%) underwent exploratory operation, with a 4-year survival of 25.9%; 36 patients (63%) had complete resection, with a 4-year survival of 30.5%.

CONCLUSIONS

Induction chemotherapy is effective for downstaging and surgical reconversion of centrally located T4 non-small cell lung cancer. Survival is promising, especially in patients whose disease becomes resectable.

T4 lung tumors with infiltration of the thoracic aorta: is an operation reasonable?

BACKGROUND

Only anecdotal reports about the results of combined resection of T4 lung tumors infiltrating the thoracic aorta exist.

METHODS

Seven patients (mean age, 57.5 years; range, 43 to 78 years) underwent a resection of the infiltrated segment of the thoracic aorta together with a left pneumonectomy (n = 6) or left upper lobectomy (n = 1). Five tumors were primary non-small cell lung carcinomas (T4N2 in 3 patients, T4N1 in 2), one was a metastasis of breast cancer, and one was rhabdomyosarcoma.

RESULTS

No patient died perioperatively. The 2 patients with rhabdomyosarcoma and metastasis of breast cancer died 2 and 7 months postoperatively. Of the 5 patients with bronchial carcinoma, 3 died after 17, 26, and 27 months as a result of distant metastasis. Two patients are alive after 14 and 50 months without evidence of disease recurrence. One-year, 2-year, and 4-year survival rates for patients with bronchial carcinoma were 100%, 75%, and 25%, respectively.

CONCLUSIONS

Combined resection of the lung and thoracic aorta can be performed with low morbidity and mortality when offered to highly selected patients. Adequate local control of tumor can be achieved for N1 and single-level N2 non-small cell lung carcinomas, but not for tumors with other histologies.

[Value and limits of surgery in stage IIIB non-small-cell bronchial cancers]

According to the TNM staging system for lung cancers, stage III is divided into IIIA and IIIB. This division was based upon the principle that patients with IIIA disease could theoretically benefit from complete resection, contrasting with IIIB patients for whom surgery is not feasible. The poor prognosis of stage IIIB is largely due to its classical inoperability. From the surgical point of view, stage IIIB can be subdivided into four subgroups: 1) N3 where resection is possible in selected patients through median sternotomy; 2) T4 where extended surgery can be considered in selected patients; 3) N3 + T4; 4) malignant pleural or pericardial effusion contraindicating any radical surgery. Criteria for resectability could be defined to include some IIIB patients in multimodality protocols in which surgery would become possible after induction therapy: definitive inoperability excludes any possibility of surgery, even in cases in which radiotherapy alone or combined with chemotherapy leads to complete remission; immediate inoperability allows patients to be included in protocols evaluating induction treatments designed to render tumours resectable.

Resection of a pulmonary malignancy invading the intrapericardial inferior vena cava

Resection of extensive lung cancers invading thoracic vascular structures (T4 lesions) can yield long-term survival provided the margins and nodes are free of tumor. We report the resection of the suprahepatic inferior vena cava for direct tumor involvement by a pulmonary malignancy. The resection was performed without bypass, and the cava was subsequently reconstructed with a 22-mm-diameter Dacron graft. Patency was documented on postoperative magnetic resonance angiograms. The patient was discharged home on postoperative day 10 without complications and remains well 8 months after the operation. Potentially curative resections and reconstructions of suprahepatic inferior vena cava involved with pulmonary malignancies are possible and can be done without cardiopulmonary bypass.

Extended operation for non-small cell lung cancer invading great vessels and left atrium

OBJECTIVE

We analyzed the results of surgical treatment in patients with non-small cell lung cancer invading the great vessels (GV) and left atrium (LA) by direct extension and without distant metastases.

METHODS

From 1976 to 1993, 42 patients (37/male, 5/female) with lung cancer invading the GV and LA were treated surgically, 13 had invasion of the superior vena cava and innominate vein, 15 of the aorta and subclavian artery, and 14 of the left atrium. In all 42 the diagnosis was confirmed by pathological examination. Surgical resection included pneumonectomy (16 patients) and lobectomy (26 patients). The histologic type was squamous cell carcinoma in 27 patients, adenocarcinoma in 12, and large cell carcinoma in 3. Preoperatively, 13 patients were treated with radiation and chemotherapy. Postoperatively, further treatment was given to 22 patients. All were staged according to the international TNM staging system. Survival was calculated by the Kaplan-Meler method.

RESULTS

A total of 15 patients underwent complete resection. Reliability of clinical N factor was 80%. The overall survival was 17% at 3 years (median survival time (MST), 14 months). The operative mortality was 2.4%. Patients with lung cancer invading GV (MST, 19 months) had significantly longer survival than did those with cancer invading LA (MST, 10 months, P = 0.036). There were significant prognostic differences between N0-1 and N2-3 (MST, 22 months; MST, 9 months, respectively, P = 0.0013). Cox regression analysis identified pathological N factor, completeness of resection, and pre- and postoperative radiotherapy as important in affecting survival.

CONCLUSIONS

We conclude that patients with pathological N0-1 non-small cell lung cancer invading great vessels can achieve long-term survival with adequate surgical treatment.

Management of non-small cell lung cancer with direct mediastinal involvement

The results of surgical treatment were analyzed for 102 patients with non-small cell lung cancer invading the mediastinum by direct extension (T3 and T4), but those who had N2 disease were excluded to eliminate the adverse prognostic effect of this nodal subset. The histologic type was squamous cell carcinoma in 55 patients, adenocarcinoma in 40, and large cell carcinoma in 7. There were 58 T3 tumors invading the mediastinal pleura or fat, phrenic nerve, vagus nerve, pericardium, or pulmonary vessels and 44 T4 lesions invading the aorta, vena cava, esophagus, trachea, spine, or atrium. Resection included lobectomy (33 patients), pneumonectomy (32 patients), and limited resection (6 patients). Complete resection was possible in 46 patients and incomplete or no resection was possible in 56. The interstitial implantation of radioactive sources to control residual tumor also was undertaken in 43 patients. The operative mortality was 6%. The overall survival (Kaplan-Meier) was 19% at 5 years (median survival time, 18 months). Factors found to be significantly affect survival were complete resectability and the histologic type. With complete resection, the 5-year survival was 30% (p = 0.005). The 5-year survival in patients with adenocarcinoma or large-cell carcinoma was 30%, compared with 14% in patients with squamous cell carcinoma (p = 0.002). The extent of mediastinal involvement (T3 versus T4) influenced resectability and survival, and this approached statistical significance (p = 0.055). We conclude that most patients with non-small cell carcinoma and mediastinal invasion do poorly with primary surgical treatment.

Extended resection of the left atrium, great vessels, or both for lung cancer

One hundred one patients with locally advanced lung cancer underwent combined resection of the lung and the left atrium with or without the great vessels. A single additional organ was resected in 92 patients, two organs in 8 patients, and three organs in 1 patient. The left atrium was resected in 44 patients, the superior vena cava in 32, the adventitia of the aorta in 21, the aorta in 7, and the pulmonary artery in 7. The most important factors affecting survival defined by multivariate analysis were postoperative pneumonia, complete resection, postoperative bleeding, and lymph node metastasis (p < 0.05). Thirteen patients survived 3 years or more and 10 of the 13 survived 5 years or more. The 5-year survival rate for all patients, including 8 with operative death, was 13%, and the median survival time was 9.2 months. The 5-year survival and median survival time were 19% and 13.8 months after complete resection and 0% and 6.5 months after incomplete resection (p < 0.01). The 5-year survival and median survival time for patients with pathologic stage IIIA, IIIB, and IV were 16.8% and 16.8 months; 18.3% and 9.8 months; and 0% and 5.4 months, respectively. There was a significant difference between stages IIIA plus IIIB and stage IV (p < 0.05). The 5-year survival after left atrium resection was 22%. Extended resection was worthwhile for the patients undergoing complete resection and without postoperative complications.

Pulmonary complications in patients undergoing thoracotomy for lung carcinoma

One hundred three consecutive patients undergoing 106 thoracotomies for primary lung carcinoma were reviewed to determine factors associated with the development of postoperative pulmonary complications. Pulmonary complications occurred in 40 of 104 (39 percent) patients. Minor complications occurred in 17 of 104 (16 percent) patients and major in 23 of 104 (22 percent). There were six deaths in the entire series of 103 patients (6 percent), two of which were directly caused by a pulmonary complication and one where it was a contributing factor. Extended surgical resections were associated with an increased risk of complications. Pulmonary complications occurred in 9 of 11 (82 percent) patients undergoing extended resections involving chest wall resection. The use of neoadjuvant chemotherapy also was associated with an increase in the rate of major complications. Poor nutritional status as measured by a history of weight loss and preoperative serum albumin levels also was associated with an increased risk of any pulmonary complication. Cardiac complications were significantly increased in the group of patients having pulmonary complications. Pulmonary complications continue to present a major source of morbidity and mortality for patients undergoing thoracotomy for lung carcinoma. Determination of factors associated with increased risk is important in order to identify patients who might be predisposed to the development of these complications.

Extended resection for higher-stage non-small-cell lung cancer

This report reviews the results of extended surgical resection for advanced lung cancer (stage IIIa, IIIb, IV) reported in the Anglo-American literature between 1980 and 1993. Complete resection of stage IIIa (T3) tumors with minimal or no nodal involvement resulted in a 5-year survival approaching 40%. Ipsilateral mediastinal nodal involvement (N2) lowered 5-year survival to 10-15% and to near 0% if bulky disease was present. Historically, resection of stage IIIb disease has failed to improve survival. Radiation therapy has decreased local recurrence in advanced-stage disease but has not improved survival. Preliminary results have recently been reported using induction chemotherapy or chemoradiotherapy followed by resection in subsets of patients with stage IIIa and IIIb disease. Induction chemotherapy for bulky N2 (IIIa) disease resulted in major response rates of up to 77% and a 5-year survival of up to 26% after complete resection. Preliminary results of resection of stage IIIb tumors following induction chemotherapy have achieved 2-year survivals of 40%. Metastatic lung cancer (stage IV) with disseminated disease remains virtually incurable with poor response rates to chemotherapy. However, resection of isolated brain metastases (M1 disease) resulted in a 5-year survival near 25%. Resection of other sites of isolated metastatic disease including the adrenal gland is under investigation. The major prognostic factor in these studies has been the ability to completely resect all tumor. To improve resectability rates, induction therapy and radical resections are being combined more frequently. The increased morbidity and mortality of these aggressive approaches requires careful patient selection.

Surgical treatment for higher stage non-small cell lung cancer

Locally advanced lung cancer (stage IIIa, IIIb) in which the primary tumor is proximal (T3) or has invaded adjacent structures (T3) or organs (T4) or in which mediastinal lymph nodes are involved (N2, N3) worsens the prognosis significantly. However, in stage IIIa (T3 or N2), when surgical treatment results in total removal of the primary tumor and involved lymph nodes, there still is a reasonable chance for ultimate cure. On the other hand, total excision can be very rarely performed in T4 or N3 tumors. Therefore, this group (stage IIIb) usually indicates unresectability. Disseminated lung cancer with distant metastasis (stage IV) is still considered to be incurable. Nevertheless, solitary metastatic sites (M1), especially brain, have been treated on occasion by resection of the primary tumor and removal of the solitary metastasis. This appears to improve median survival and does yield 5-year survival in selected patients. The results after surgical treatment in these patients with higher stage lung cancer reported over the last 10 years are reviewed.

Usefulness of transesophageal echocardiography in evaluation of paracardiac neoplastic masses

Mediastinal paracardiac tumors may cause both cardiovascular complications and problems in differential diagnosis of cardiac diseases. Transesophageal echocardiography (TEE) may give an additional new window to mediastinal neoplasms, but only a few studies have been reported. TEE was performed in 70 patients with paracardiac neoplastic masses. The procedure was indicated to solve particular clinical problems in 20 patients, and as a prospective study on 50 unselected patients with mediastinal neoplasms. Twenty-three patients underwent follow-up studies; a total of 101 echocardiograms were recorded. The procedure was tolerated well or very well by most patients, and provided additional anatomic or hemodynamic data in every patient in group a and in 45 of 50 in group b. The additional data were relevant for clinical management in 14 of 20 patients in group a, and in 3 of 45 in group b. Based on the results of this study, TEE is useful in association with other radiologic techniques in patients with paracardiac neoplasms. As an imaging technique, it may represent a reliable alternative to computed tomography whenever the latter is not feasible.