Five-year survival after sleeve pneumonectomy combined with the superior vena cava replacement for lung cancer
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《血管的通路杂志》
a The 1st Department of Surgery, University Hospital Olomouc, I.P.Pavlova 6, 77520 Olomouc, Czech Republic
b Department of Radiology, University Hospital Olomouc, Czech Republic
Abstract
The authors report an excellent long-term survival after sleeve pneumonectomy combined with the superior vena cava (SVC) replacement for T4N2M0 non-small cell lung cancer. N2 disease was objectified by mediastinoscopy before an inductive treatment. After three cycles of platinum-paclitaxel combination a partial response was proved. Right pneumonectomy with ePTFE graft replacement of directly invaded SVC was performed. The carinal resection was forced intraoperativelly, because of the positive resection margins of the right main bronchus. The direct invasion into SVC, residual N2 disease and definitive free resection margins were confirmed histologically. This patient has survived for 5 years after combined extended lung resection without any relapse; the SVC graft still remains functional.
Key Words: Extended resection; Lung cancer; Survival
1. Introduction
A direct invasion of the superior cava vein (SVC) by lung carcinomas has been considered to be a contraindication to a curative surgery for a long time. Therefore, these operations were indicated rarely and the experience was limited to a few institutions worldwide. In general, when the involvement of the venous wall is smaller than 50% of the original diameter, the tangential excision followed by a direct suture or patch is recommended to avoid a risk of a graft infection or thrombosis, respectively. A total SVC replacement is rarely indicated when the vessel is extensively invaded or occluded by the tumor [1]. The SVC reconstruction can be performed using the spiral saphenous vein graft or the pericardium. The ringed ePTFE graft has been preferred to avoid wrinkling or external compression in the last years [2].
In the past, sleeve pneumonectomy for advanced lung cancer invading the main bronchus or carina was associated with a high operative mortality and morbidity [3]. Recent advances in anesthesia, surgery and postoperative care have enabled the surgeon to resect these structures with an acceptable risk [4]. Combined resection (sleeve pneumonectomy combined with SVC replacement) was first reported by Nakahara in 1989 [1]. Its technical feasibility, early and late postoperative outcomes have been analyzed in another study by Spaggiari (2000) [5]. Rendina and associates have reported their experience with inductive chemotherapy for T4 centrally located non-small lung cancer. Sixty-three percent of the group of their 57 patients underwent a complete resection [6]. A neoadjuvant chemotherapy is generally accepted in patients with stage III NSCLC. In those rare cases with direct invasion into the upper mediastinum, the induction therapy shows impressive results [7,8].
In recent studies regarding SVC resections or carinal resections, few 5-year survivors were reported in N0 or N1 patients, whereas a 5-year survival was described only exceptionally in the subgroup with N2 disease. A 5-year survival after combined tracheal and carinal resection has not been reported, yet.
2. Case report
A 56-year-old man complained of cough and bloody sputum with 4-month duration. The chest X-ray showed a right upper lobe mass. The chest computed tomography demonstrated a tumor in the right upper lung lobe invading the mediastinum and encircling SVC. Biopsy specimens obtained from the right main bronchus showed poorly differentiated squamous cell carcinoma. Benign lymph nodes were found at levels 2R, 4L and 7 via mediastinoscopy, positive specimens were obtained of the lymph nodes at level 4R. Systemic metastases were excluded by upper abdominal CT and bone scintigraphy. An induction therapy was administered using double-combination of cis-platinum and paclitaxel. Response to the neoadjuvant chemotherapy was assessed after three cycles of chemotherapy. Restaging procedure included routine blood tests, pulmonary function tests, CT scan and bronchoscopy. Repeated mediastinoscopy was not performed. Surgical exploration was performed 4 weeks after completion of the chemotherapy.
Lateral thoracotomy in the fourth intercostal space revealed that the tumor originated in the right upper lobe and invaded the right tracheobronchial region and the lateral wall of SVC. Right pneumonectomy with intrapericardial dissections of the pulmonary artery and upper pulmonary vein were followed by resection and replacement of SVC with the ringed ePTFE graft of 14 mm in diameter. Before clamping, intravenous sodium heparin 5000 U, Solumedrol 4 mg and Mannitol 250 ml were given to prevent any brain damage. Unfortunately, microscopically positive resection margins were found in the right main bronchus and carina, respectively. We had to perform the carinal resection in addition to the SVC replacement to guarantee radicality of the surgery (Fig. 1). The tracheal carina was resected and right sleeve pneumonectomy was accomplished by anastomosing the trachea to the left main bronchus by an interrupted suture with braided polyglactin 3/0 stitches (Fig. 2). The closure of thoracotomy was followed by re-thoracotomy after a few minutes, because of herniation of the heart from the pericardium. This major complication was managed successfully; the pericardial opening was sutured immediately after reposition of the heart. Direct invasion into SVC, residual N2 disease and definitive free resection margins were confirmed histologically. The tumor was classified as T4 N2 M0 disease. The adjuvant chemotherapy was recommended, but the patient did not tolerate it well, that is why the postoperative therapy was finished after the first cycle of the double-combination of platinum – vinorelbin.
However, this patient has survived for 5 years after performed combined extended lung resection without any relapse; the SVC graft still remains functional.
3. Discussion
Resection of non-small lung cancer involving carina offers a reasonable chance of long-term survival with a relatively low mortality rate and acceptable number of major postoperative complications. An involvement of another mediastinal structure aggravates risk of local or systemic treatment failure dramatically. However, with no local control, i.e. a radical resection, the therapeutic success is inconceivable. The extended combined lung resections are therefore justified only by curative intent after a careful pre-treatment staging [9]. In rare cases of T4N0-N1 carcinomas, an extended operation can achieve a long-term control of the disease. In patients with N1 and N2 disease, neoadjuvant chemotherapy is clearly indicated to reduce the tumor mass, lymphatic metastases and sterilize possible occult distant metastases [10]. With no systemic therapy, any excellent local operation could not have always the presupposed effect.
4. Conclusion
The combined extended resection in T4 lung carcinomas should be limited to patients who are expected to have curative operation. More research is necessary to determine which patient should be selected to some kind of a therapy, as well as how a previous treatment predicts a benefit of the subsequent treatment.
Acknowledgments
The study was supported in part by the grant of IGA MZCR No. 7772-3/2004.
References
Dartevelle PG, Chapelier AR, Pastorino U, Corbi P, Lenot B, Cerrina J, Bavoux EA, Verley JM, Neveux JY. Long-term follow-up after prostetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumor. J Thorac Cardiovasc Surg 1991;102:259–265.
Spaggiari L, Regnard JF, Magdeleinat P, Jauffret B, Puyo P, Levasseur P. Extended resections for bronchogenic carcinoma invading the superior vena cava system. Ann Thorac Surg 2000;69:233–236.
Mathisen DJ, Grillo HC. Carinal resection for bronchogenic carcinoma. J Thorac Cardiovasc Surg 1991;102:16–23.
Pitz CC, Brutel de la Riviere A, van Swieten HA, Westermann CJJ, Lammers JWJ, Bosch JMM. Results of surgical treatment of T4 non-small cell lung cancer. Eur J Cardiothorac Surg 2003;24:1013–1018.
Spaggiari L, Pastorino U. Combined tracheal sleeve and superior vena cava resections for non-small cell lung cancer. Ann Thorac Surg 2000;70:1172–1175.
Rendina EA, Venuta F, De Giacomo T, Ciccone AM, Ruvolo G, Coloni GF, Ricci C. Induction chemotherapy for T4 centrally located non-small lung cancer. J Thorac Cardiovasc Surg 1999;117:225–229.
Klein J, Kral V, Neoral C, Bohanes T, Aujesky R, Kolek V, Grygarkova I, Hajduch M, Tichy T. Lung resection in a neoadjuvant protocol. Med Sci Monit 2000;6:937–940.
Rendina EA, Venuta F, De Giacomo T, Flaishman I, Fazi P, Ricci C. Safety and efficacy of bronchovascular reconstruction after induction chemotherapy for lung cancer. J Thorac Cardiovasc Surg 1997;114:830–834.
Schutzner J, Pafko P, Stolz A, Belohlavek O, Skacel Z, Kosatova K. A surgeon’s view on the importance of positron emission tomography – PET (with emphasis on lung neoplasms). Rozhl Chir 2004;82:596–599.
Bernard A, Bouchot O, Hagry O, Favre JP. Risc analysis and long-term survival in patients undergoing resection of T4 lung cancer. Eur J Cardiothorac Surg 2001;20:344–349.(Jiri Klein, Vladimir Kral)
b Department of Radiology, University Hospital Olomouc, Czech Republic
Abstract
The authors report an excellent long-term survival after sleeve pneumonectomy combined with the superior vena cava (SVC) replacement for T4N2M0 non-small cell lung cancer. N2 disease was objectified by mediastinoscopy before an inductive treatment. After three cycles of platinum-paclitaxel combination a partial response was proved. Right pneumonectomy with ePTFE graft replacement of directly invaded SVC was performed. The carinal resection was forced intraoperativelly, because of the positive resection margins of the right main bronchus. The direct invasion into SVC, residual N2 disease and definitive free resection margins were confirmed histologically. This patient has survived for 5 years after combined extended lung resection without any relapse; the SVC graft still remains functional.
Key Words: Extended resection; Lung cancer; Survival
1. Introduction
A direct invasion of the superior cava vein (SVC) by lung carcinomas has been considered to be a contraindication to a curative surgery for a long time. Therefore, these operations were indicated rarely and the experience was limited to a few institutions worldwide. In general, when the involvement of the venous wall is smaller than 50% of the original diameter, the tangential excision followed by a direct suture or patch is recommended to avoid a risk of a graft infection or thrombosis, respectively. A total SVC replacement is rarely indicated when the vessel is extensively invaded or occluded by the tumor [1]. The SVC reconstruction can be performed using the spiral saphenous vein graft or the pericardium. The ringed ePTFE graft has been preferred to avoid wrinkling or external compression in the last years [2].
In the past, sleeve pneumonectomy for advanced lung cancer invading the main bronchus or carina was associated with a high operative mortality and morbidity [3]. Recent advances in anesthesia, surgery and postoperative care have enabled the surgeon to resect these structures with an acceptable risk [4]. Combined resection (sleeve pneumonectomy combined with SVC replacement) was first reported by Nakahara in 1989 [1]. Its technical feasibility, early and late postoperative outcomes have been analyzed in another study by Spaggiari (2000) [5]. Rendina and associates have reported their experience with inductive chemotherapy for T4 centrally located non-small lung cancer. Sixty-three percent of the group of their 57 patients underwent a complete resection [6]. A neoadjuvant chemotherapy is generally accepted in patients with stage III NSCLC. In those rare cases with direct invasion into the upper mediastinum, the induction therapy shows impressive results [7,8].
In recent studies regarding SVC resections or carinal resections, few 5-year survivors were reported in N0 or N1 patients, whereas a 5-year survival was described only exceptionally in the subgroup with N2 disease. A 5-year survival after combined tracheal and carinal resection has not been reported, yet.
2. Case report
A 56-year-old man complained of cough and bloody sputum with 4-month duration. The chest X-ray showed a right upper lobe mass. The chest computed tomography demonstrated a tumor in the right upper lung lobe invading the mediastinum and encircling SVC. Biopsy specimens obtained from the right main bronchus showed poorly differentiated squamous cell carcinoma. Benign lymph nodes were found at levels 2R, 4L and 7 via mediastinoscopy, positive specimens were obtained of the lymph nodes at level 4R. Systemic metastases were excluded by upper abdominal CT and bone scintigraphy. An induction therapy was administered using double-combination of cis-platinum and paclitaxel. Response to the neoadjuvant chemotherapy was assessed after three cycles of chemotherapy. Restaging procedure included routine blood tests, pulmonary function tests, CT scan and bronchoscopy. Repeated mediastinoscopy was not performed. Surgical exploration was performed 4 weeks after completion of the chemotherapy.
Lateral thoracotomy in the fourth intercostal space revealed that the tumor originated in the right upper lobe and invaded the right tracheobronchial region and the lateral wall of SVC. Right pneumonectomy with intrapericardial dissections of the pulmonary artery and upper pulmonary vein were followed by resection and replacement of SVC with the ringed ePTFE graft of 14 mm in diameter. Before clamping, intravenous sodium heparin 5000 U, Solumedrol 4 mg and Mannitol 250 ml were given to prevent any brain damage. Unfortunately, microscopically positive resection margins were found in the right main bronchus and carina, respectively. We had to perform the carinal resection in addition to the SVC replacement to guarantee radicality of the surgery (Fig. 1). The tracheal carina was resected and right sleeve pneumonectomy was accomplished by anastomosing the trachea to the left main bronchus by an interrupted suture with braided polyglactin 3/0 stitches (Fig. 2). The closure of thoracotomy was followed by re-thoracotomy after a few minutes, because of herniation of the heart from the pericardium. This major complication was managed successfully; the pericardial opening was sutured immediately after reposition of the heart. Direct invasion into SVC, residual N2 disease and definitive free resection margins were confirmed histologically. The tumor was classified as T4 N2 M0 disease. The adjuvant chemotherapy was recommended, but the patient did not tolerate it well, that is why the postoperative therapy was finished after the first cycle of the double-combination of platinum – vinorelbin.
However, this patient has survived for 5 years after performed combined extended lung resection without any relapse; the SVC graft still remains functional.
3. Discussion
Resection of non-small lung cancer involving carina offers a reasonable chance of long-term survival with a relatively low mortality rate and acceptable number of major postoperative complications. An involvement of another mediastinal structure aggravates risk of local or systemic treatment failure dramatically. However, with no local control, i.e. a radical resection, the therapeutic success is inconceivable. The extended combined lung resections are therefore justified only by curative intent after a careful pre-treatment staging [9]. In rare cases of T4N0-N1 carcinomas, an extended operation can achieve a long-term control of the disease. In patients with N1 and N2 disease, neoadjuvant chemotherapy is clearly indicated to reduce the tumor mass, lymphatic metastases and sterilize possible occult distant metastases [10]. With no systemic therapy, any excellent local operation could not have always the presupposed effect.
4. Conclusion
The combined extended resection in T4 lung carcinomas should be limited to patients who are expected to have curative operation. More research is necessary to determine which patient should be selected to some kind of a therapy, as well as how a previous treatment predicts a benefit of the subsequent treatment.
Acknowledgments
The study was supported in part by the grant of IGA MZCR No. 7772-3/2004.
References
Dartevelle PG, Chapelier AR, Pastorino U, Corbi P, Lenot B, Cerrina J, Bavoux EA, Verley JM, Neveux JY. Long-term follow-up after prostetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumor. J Thorac Cardiovasc Surg 1991;102:259–265.
Spaggiari L, Regnard JF, Magdeleinat P, Jauffret B, Puyo P, Levasseur P. Extended resections for bronchogenic carcinoma invading the superior vena cava system. Ann Thorac Surg 2000;69:233–236.
Mathisen DJ, Grillo HC. Carinal resection for bronchogenic carcinoma. J Thorac Cardiovasc Surg 1991;102:16–23.
Pitz CC, Brutel de la Riviere A, van Swieten HA, Westermann CJJ, Lammers JWJ, Bosch JMM. Results of surgical treatment of T4 non-small cell lung cancer. Eur J Cardiothorac Surg 2003;24:1013–1018.
Spaggiari L, Pastorino U. Combined tracheal sleeve and superior vena cava resections for non-small cell lung cancer. Ann Thorac Surg 2000;70:1172–1175.
Rendina EA, Venuta F, De Giacomo T, Ciccone AM, Ruvolo G, Coloni GF, Ricci C. Induction chemotherapy for T4 centrally located non-small lung cancer. J Thorac Cardiovasc Surg 1999;117:225–229.
Klein J, Kral V, Neoral C, Bohanes T, Aujesky R, Kolek V, Grygarkova I, Hajduch M, Tichy T. Lung resection in a neoadjuvant protocol. Med Sci Monit 2000;6:937–940.
Rendina EA, Venuta F, De Giacomo T, Flaishman I, Fazi P, Ricci C. Safety and efficacy of bronchovascular reconstruction after induction chemotherapy for lung cancer. J Thorac Cardiovasc Surg 1997;114:830–834.
Schutzner J, Pafko P, Stolz A, Belohlavek O, Skacel Z, Kosatova K. A surgeon’s view on the importance of positron emission tomography – PET (with emphasis on lung neoplasms). Rozhl Chir 2004;82:596–599.
Bernard A, Bouchot O, Hagry O, Favre JP. Risc analysis and long-term survival in patients undergoing resection of T4 lung cancer. Eur J Cardiothorac Surg 2001;20:344–349.(Jiri Klein, Vladimir Kral)