Extended Resections of Non-small Cell Lung Cancers Invading the Aorta, Pulmonary Artery, Left Atrium, or Esophagus: Can They Be Justified?

doi:10.1016/j.thorsurg.2014.07.012

Thoracic Surgery Clinics

Volume 24, Issue 4, November 2014, Pages 457-464

https://doi.org/10.1016/j.thorsurg.2014.07.012 Get rights and content

Section snippets

Key points

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T4 tumors that invade the heart, great vessels, or esophagus comprise a heterogenous group of locally invasive lung cancers.
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Prognosis depends on nodal status.
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Resection should be considered in relation to multidisciplinary care.
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Notable improvements in imaging, surgical techniques, and perioperative care during the past several decades have resulted in an increase in survival for highly selected patients.

Historical background

With the advent of cardiopulmonary bypass (CBP) in the late 1950s, surgeons realized the potential for extracorporeal circulation to facilitate resection of pulmonary malignancies involving the great vessels or atria. In 1965, Neville and colleagues⁴ reported a series of 6 patients with lung cancer in whom CPB was used during carinal resection or sleeve lobectomy. One more patient underwent left intrapericardial pneumonectomy with resection and interposition graft repair of the descending

More recent experience

The value of surgical resection for the treatment of T4 NSCLCs invading the aorta, pulmonary artery, left atrium, and esophagus remains open to debate. Presently, most patients are not offered resection in part because of the potential for significant morbidity and mortality. However, perioperative risk in this subset of patients has improved over time (Table 1). In 1987, Burt and colleagues⁶ published a retrospective review of 225 patients who underwent thoracotomy for primary NSCLC invading

Aorta

If there is no evidence of intrapleural dissemination or mediastinal nodal involvement, and there is direct tumor invasion of the aorta, en bloc pulmonary and aortic resection can be considered. Of particular note is the fixation of the tumor to the distal arch and proximal descending aorta, which limits one’s ability to manipulate the hilum. The extent of the tumor within the lung dictates whether lobectomy or pneumonectomy is necessary. The arch of the aorta is mobilized and control of the

Preoperative workup

The principles of en bloc pulmonary and mediastinal excision for T4 lung cancer must follow a well-defined algorithm during which the patient is thoroughly staged preoperatively and intraoperatively before definitive resection. Criteria should include appropriate pulmonary reserve for pneumonectomy, if indicated, and no evidence of mediastinal nodal or distant metastatic disease. Although incapable of definitively documenting aortic invasion by tumor, cardiac MR scans have emerged as highly

Neoadjuvant therapy

The use of neoadjuvant therapy to achieve the goals of down-staging locally advanced lung cancers, by reducing tumor size and lymph node involvement, and potentially eradicating micrometastatic disease, can be applied to T4 tumors with invasion of the aorta, pulmonary artery, left atrium, or esophagus. Induction therapy used for this subset of T4 tumors is an extension of stage IIIA (N2) preoperative chemotherapy or chemoradiotherapy, which is still heavily debated.40, 41, 42, 43 To date,

Summary

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.¹ Localized tumors with invasion of the

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Extended Resections for Lung Cancer
2022, Surgical Clinics of North America
Citation Excerpt :
The 5-year survivals range from 44% to 22% depending on the structure involved. All studies confirm that N0 status and achieving an R0 resection confers improved overall survival.10 It is crucial to have a fluid knowledge of the incisions at the thoracic surgeon’s disposal because each provides its own unique advantages for a wide variety of operations and approaches.
Long term results of surgery for NSCLC and aortic invasion. A multicenter retrospective cohort study
2022, European Journal of Surgical Oncology
Citation Excerpt :
In the multivariate analyses, pathological stage, R-status and pathological nodal status were found to be independent predictive factors for OS and R-status and pathological nodal status for DFS (Table 3). T4 lung cancers include a heterogeneous group with various types of infiltration including aortic wall infiltration [14]. In the past, aortic invasion was considered a relative technical and oncological contraindication for surgery [15].
Aortic invasion from non-small cell lung cancers (NSCLC) is a relative contraindication to surgery for oncological and technical reasons. Only a few studies have been published showing good results. Our aim was to evaluate short and long-term results of surgery for T4 NSCLC with aortic resection.
This is a multicenter retrospective study including 47 patients (33 males and 14 females) who received a major lung resection with aortic surgery in our centers between January 2000 and December 2016.
Adenocarcinoma was diagnosed in 31 patients (66.0%). Induction therapy was used in 14 patients. Pneumonectomy was performed in 34 patients (72.3%). A subadventitial dissection with or without endovascular stent graft was carried out in 40 patients (85.1%), a cardiopulmonary bypass was used in 3 patients and left heart bypass in 4. Intraoperatively, two patients had bleeding (4.3%) and one ventricular fibrillation (2.1%). Twenty-three patients (48.9%) experienced at least one postoperative complication. A radical resection was achieved in 39 patients (83.0%). Thirty-day and 90-day mortality were 2.1% and 4.3%. One-, 3- and 5-year overall survival were 85.1%, 57.4% and 53.2%. Overall and disease-free survivals were significantly influenced by pathological lymph node status and R status that were independent predictive factors for poorer survival at the multivariate analyses.
Aortic resection during surgery for NSCLC is a challenging situation. Nevertheless, oncologic outcomes may be favorable in selected cases justifying a risky procedure that should be performed in experienced hands.
Direct Cross-Clamping for Resection of Lung Cancer Invading the Aortic Arch or the Subclavian Artery
2021, Annals of Thoracic Surgery
Citation Excerpt :
Up to now, few and limited experiences of resection of lung cancer invading the thoracic aorta have been reported.1,4,9-11,17,22-25 It is a very delicate and complex procedure, and different techniques have been described.6 Although difficult to achieve, radical resection allows good oncologic results with reasonable morbidity and mortality rates.1,2,4
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.
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.
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.
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.
Should we distinguish between intra and extrapericardial pulmonary artery involvement in NSCLC? A multicenter retrospective case-control study
2021, European Journal of Surgical Oncology
Citation Excerpt :
The surgery varies from tangential resection and simple suture to complete circumference resection and end-to-end anastomosis or reconstruction with a pericardial patch. Multiple studies demonstrated the safety and good long-term outcomes for the reconstruction of the pulmonary artery [11–16]. Nevertheless, T4 tumours that invade the heart, great vessels or oesophagus comprise a heterogeneous group of locally invasive lung cancers [11–17] and their prognosis is strictly correlated to nodal status (N0-1 VS N2-3) [16].
T4 tumours comprise a heterogeneous group of locally invasive non-small cell lung cancers (NSCLC). Intrapericardial and extrapericardial involvement of the pulmonary artery (PA) may have a different prognosis. We compared the short and long-term surgery outcomes for NSCLC of the PA with intrapericardial or extrapericardial involvement.
This is a multicenter retrospective study that included 129 patients who received an anatomical resection with PA resection and reconstruction in our centres between January 2000 and December 2018. Extrapericardial group included 70 patients, while the intrapericardial included 59.
Differences in outcomes were found in terms of left side surgery (more common in extrapericardial, p = 0.010), type of lung resection (p < 0.001), Clavien-Dindo score (p = 0.012) and 90-day mortality (1.4 vs 16.9%, p = 0.002). Overall survival (OS, 91.11 ± 63.78 vs 63.78 ± 58.241 months, p = 0.008) and tumour-free survival (TFS, 68.17 ± 71.57 vs 45.44 ± 61.32 months, p = 0.007) were statistically different. OS stratification for performed pneumonectomy, pathological lymph node status and pattern of recurrence were statistically different (p = 0.017, 0.040, <0.001). Differences were found in terms of recurrence months stratified for recurrence pattern (p < 0.001).
According to our results, the difference between PA involvement is significant in terms of survival and complications. A T4 subset or a shift to T3 for extrapericardial involvement of the PA may lead to a change in staging and surgical approach for these patients.
The Surgical Management of Pulmonary Adenocarcinoma
2018, Pulmonary Adenocarcinoma: Approaches to Treatment
This chapter introduces the surgical management of lung cancer. The chapter begins by discussing the steps necessary to help safely establish whether a patient is a surgical candidate by reviewing concepts of staging, assessing cardiovascular risk, and interpreting pulmonary function testing. Included is a discussion of the role of surgery in the management of lung cancer and general surgical principles including approach, extent of resection, and mediastinal lymphadenectomy.
Executive summary of the SEPAR recommendations for the diagnosis and treatment of non-small cell lung cancer
2016, Archivos de Bronconeumologia
La Sociedad Española de Neumología y Cirugía Torácica (SEPAR), a través de las áreas de Cirugía Torácica y de Oncología Torácica, ha promovido la realización de un manual de recomendaciones para el diagnóstico y el tratamiento del cáncer de pulmón de células no pequeñas. Las elevadas incidencia y mortalidad de esta patología hacen necesaria una constante actualización de las mejores evidencias científicas para su consulta por parte de los profesionales de la salud.
Para su confección se ha contado con un amplio grupo de profesionales de distintas especialidades que han elaborado una revisión integral, que se ha concretado en 4 apartados principales. En el primero se ha estudiado la prevención y el cribado de la enfermedad, incluyendo los factores de riesgo, el papel de la deshabituación tabáquica y el diagnóstico precoz mediante programas de cribado. En un segundo apartado se ha analizado la presentación clínica, los estudios de imagen y el riesgo quirúrgico, incluyendo el cardiológico y la evaluación funcional respiratoria. Un tercero trata sobre los estudios de confirmación cito-histológica y de estadificación, con un análisis de las clasificaciones TNM e histológica, métodos no invasivos y mínimamente invasivos, así como las técnicas quirúrgicas para el diagnóstico y estadificación. En un cuarto y último capítulo se han abordado aspectos del tratamiento, como el papel de las técnicas quirúrgicas, la quimioterapia, la radioterapia, el abordaje multidisciplinar por estadios y otros tratamientos dirigidos frente a dianas específicas, terminando con recomendaciones acerca del seguimiento del cáncer de pulmón y los tratamientos paliativos quirúrgicos y endoscópicos en estadios avanzados.
The Thoracic Surgery and Thoracic Oncology groups of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) have backed the publication of a handbook on recommendations for the diagnosis and treatment of non-small cell lung cancer. Due to the high incidence and mortality of this disease, the best scientific evidence must be constantly updated and made available for consultation by healthcare professionals.
To draw up these recommendations, we called on a wide-ranging group of experts from the different specialties, who have prepared a comprehensive review, divided into 4 main sections. The first addresses disease prevention and screening, including risk factors, the role of smoking cessation, and screening programs for early diagnosis. The second section analyzes clinical presentation, imaging studies, and surgical risk, including cardiological risk and the evaluation of respiratory function. The third section addresses cytohistological confirmation and staging studies, and scrutinizes the TNM and histological classifications, non-invasive and minimally invasive sampling methods, and surgical techniques for diagnosis and staging. The fourth and final section looks at different therapeutic aspects, such as the role of surgery, chemotherapy, radiation therapy, a multidisciplinary approach according to disease stage, and other specifically targeted treatments, concluding with recommendations on the follow-up of lung cancer patients and surgical and endoscopic palliative interventions in advanced stages.

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