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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.
Extended Resections of Non-small Cell Lung Cancers Invading the Aorta, Pulmonary Artery, Left Atrium, or Esophagus: Can They Be Justified?
Section snippets
Key points
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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Cited by (22)
Extended Resections for Lung Cancer
2022, Surgical Clinics of North AmericaCitation 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 OncologyCitation 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].
Direct Cross-Clamping for Resection of Lung Cancer Invading the Aortic Arch or the Subclavian Artery
2021, Annals of Thoracic SurgeryCitation 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
Should we distinguish between intra and extrapericardial pulmonary artery involvement in NSCLC? A multicenter retrospective case-control study
2021, European Journal of Surgical OncologyCitation 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].
The Surgical Management of Pulmonary Adenocarcinoma
2018, Pulmonary Adenocarcinoma: Approaches to TreatmentExecutive summary of the SEPAR recommendations for the diagnosis and treatment of non-small cell lung cancer
2016, Archivos de Bronconeumologia
Disclosures: None.