Original articleExtended resection of the left atrium, great vessels, or both for lung cancer
Abstract
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 parient. 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 B 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.
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Cited by (144)
Reconstruction of the heart and the aorta for radical resection of lung cancer
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Twenty-seven patients underwent surgery for lung cancer presenting full-thickness infiltration of the heart (n = 6) or the aorta (n = 18) and/or the supra-aortic branches (subclavian n = 3). Cardiac reconstruction was performed in 6 patients (5 atrium, 1 ventricle), with (n = 4) or without (n = 2) cardiopulmonary bypass, using a patch prosthesis (n = 4) or with deep clamping and direct suture (n = 2). Aortic or supra-aortic trunk reconstruction (n = 21) was performed using a heart-beating crossclamping technique in 14 cases (8 patch, 4 conduit, 2 direct suture), or without crossclamping by placing an endovascular prosthesis before resection in 7 (4 patch, 3 omental flap reconstruction). Neoadjuvant chemotherapy was administered in 13 patients, adjuvant therapy in 24.
All resections were complete (R0). Nodal staging of lung cancer was N0 in 14 cases, N1 in 10, N2 in 3. No intraoperative mortality occurred. Major complication rate was 14.8%. Thirty-day and 90-day mortality rate was 3.7%. Median follow-up duration was 22 months. Recurrence rate is 35.4% (9/26: 3 loco-regional, 6 distant). Overall 3- and 5-year survival is 60.9% and 40.6%, respectively.
Cardiac and aortic resection and reconstruction for full-thickness infiltration by lung cancer can be performed safely with or without cardiopulmonary bypass and may allow long-term survival of adequately selected patients.
Prognostic Implication of Direct Cardiac Invasion from Lung Cancer in Non-Operatively Treated Patients Based on Lung Computed Tomography Imaging
2022, Heart Lung and CirculationLung 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.
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.
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] mo; 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] mo); 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] mo).
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.
Superior vena cava reconstruction in mediastinal tumors
2021, American Journal of SurgerySafe resection of the aortic wall infiltrated by lung cancer after placement of an endoluminal prosthesis
2015, Annals of Thoracic SurgeryFew 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.
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.
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.
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.
Non small-cell lung cancer: Surgical approaches and techniques in 2014
2014, Revue des Maladies Respiratoires ActualitesLes exérèses pulmonaires pour cancer bronchique non à petites cellules reposent sur une résection anatomique adaptée à la taille et à la topographie de la tumeur pour permettre une résection histologiquement complète, associée systématiquement à une lymphadénectomie. Depuis les dernières recommandations de la Société française de chirurgie thoracique et cardiovasculaire (SFCTCV) en 2009, on constate l’évolution des pratiques concernant les voies d’abord et l’étendue des résections parenchymateuses. Les voies d’abord tendent vers une chirurgie minimalement invasive, notamment dans le traitement des tumeurs de stades précoces. Ces approches incluent la chirurgie thoracique vidéo-assistée (CTVA), la chirurgie robotique et la chirurgie à trocart unique. On constate aussi le renouveau des résections infralobaires anatomiques, ou segmentectomies, largement utilisées il y a un demi-siècle pour le traitement de la tuberculose, en conséquence du diagnostic plus précoce des cancers du poumon, alors que des politiques nationales de dépistage s’organisent en Amérique du Nord et en Europe. On observe enfin l’augmentation du nombre de lésions en verre dépoli qui correspondent souvent à des adénocarcinomes peu invasifs. Les techniques d’exérèses conservatrices (lobectomie bronchoplastique et/ou angioplastique) permettent dans certaines conditions d’éviter la pneumonectomie. Enfin l’intérêt du curage systématique par rapport à l’évaluation ganglionnaire a été récemment remis en question dans des groupes de patients sélectionnés pour des tumeurs de stade précoces.
Lung surgery for non-small cell lung cancer (NSCLC) is currently based on anatomical pulmonary resections tailored to tumor size and tumor location in order to achieve a complete resection associated to a lymphadenectomy. Since the last guidelines of the French society of thoracic and cardiovascular surgery (FSTCVS) in 2009, we have faced the development of new surgical techniques of approaches and parenchymal resections. Surgical approaches are moving toward minimally invasive procedures especially for early stage tumors. These surgical approaches include video-assisted thoracic surgery (VATS), robotic-assisted thoracic surgery (RATS) and single-port surgery. Limited, so-called sublobar, resections (segmentectomy) have been revived from the old times of tuberculosis surgery, and are expected to increase with the high proportion of lung abnormalities detected with low-dose spiral computed tomography scan such as small nodules and ground glass opacities along with the implementation of screening programs. Conservative surgical resections (angio and/or bronchoplastic lobectomies) have been refined to allow avoidance of pneumonectomy. At last, benefits of a systematic lymphadenectomy compared to sampling have been put back into question in a subgroup of patients with early stage cancer.
Atrial resection for T4 non-small cell lung cancer with left atrium involvement: a systematic review and meta-analysis of survival
2023, Surgery Today