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J Thorac Cardiovasc Surg 2005;129:804-808
© 2005 The American Association for Thoracic Surgery
General Thoracic Surgery |
a Department of General Thoracic Surgery, Osaka University, Graduate School of Medicine, Osaka, Japan
b Department of General Thoracic Surgery, Toneyama National Hospital, Osaka, Japan
c Department of Cardiothoracic Surgery, Dokkyo University School of Medicine, Tochigi, Japan
Received for publication January 27, 2004; revisions received May 17, 2004; accepted for publication May 24, 2004. * Address for reprints: Mitsunori Ohta, MD, Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, E1, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan (E-mail: ohta{at}surg1.med.osaka-u.ac.jp).
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Abstract |
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 Top Abstract Patients and methodsResultsDiscussionReferences |
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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.
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Many studies have described a combined resection of the thoracic aorta in patients with thoracic malignancies1–5 and provided information regarding prognostic factors, surgical techniques, and early postoperative results. However, long-term benefits have been rarely attained with an extended operation, and thus lung cancer with aortic invasion has been considered inoperable.6–8
Preoperative induction therapy has been recommended for treatment of tumors invading the aorta, as well as other types of T4 lung cancer, to improve survival.1,5,9,10 In addition, the hemi-clamshell approach has been proposed as a suitable method to obtain a wide mediastinal view.1,5 We have used both as effective methods for complete and en bloc resections of tumors and the involved aorta. Although en bloc resection, especially after preoperative treatment, is technically demanding, it is not more complicated than resection of other types of T4 lung cancer, such as tumors with infiltration to the trachea, carina, superior vena cava, or vertebrae. The goal of the present study was to determine the effect of a combined resection of primary non-small cell lung cancer and the involved thoracic aorta on patient outcome.
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Patients and methods |
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TopAbstractPatients and methodsResultsDiscussionReferences |
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Treatment strategies
The first 7 patients in the present series were treated on an ad hoc basis between 1986 and 1994. Of those, 5 underwent surgical resection as the first therapy, and 2 underwent chemoradiotherapy with subsequent surgical resection (patients 1–7 in Table 1).
On the basis of the surgical results from these first 7 patients, subsequent patients (ie, from 1995) underwent induction therapy before surgical resection. Patients with tumor infiltration at the origin of the left pulmonary artery or with left atrial invasion alongside the pulmonary vein underwent a resection of the primary tumor and involved aorta. Other patients were not considered for operative management, including those with tumor infiltration over the aorta to the trachea, distant metastasis, or local disease progression after induction therapy. One patient (patient 9) with chronic hepatitis was treated surgically without any adjuvant therapy.
Operative procedures
The surgical approach used was a hemi-clamshell thoracotomy (n = 10) or posterolateral thoracotomy (n = 6). Partial cardiopulmonary bypass (CPB) between the femoral vein and femoral artery was used in 9 patients, a temporary bypass graft from the ascending aorta to the descending aorta was used in 3 patients, and isolated brain perfusion and deep hypothermia was used in 1 patient, whereas the remaining 3 patients did not require any bypass technique (Table 1). The aorta was replaced with a prosthetic graft in 10 patients, a partial defect of the aortic wall was closed with a prosthetic patch in 5 patients, and direct closure of a small defect was performed in 1 patient. Seven patients underwent reconstruction of the subclavian artery, 2 patients underwent reconstruction of the common carotid artery, and 1 patient underwent partial vertebral resection. We attempted to avoid recycling blood aspirated from the pleural cavity during the procedure.
All patients were informed that the operative morbidity and mortality were high and that chemotherapy and chemoradiotherapy were alternative treatments with lower treatment-related morbidity and mortality. Written informed consent was obtained from all 16 patients.
Major complications were defined as those that would be lethal unless treated adequately. Survival was calculated by the Kaplan-Meier method from the start of preoperative therapy for 10 patients and from the time of the operation for the 6 patients who did not undergo induction therapy. Differences among the curves were analyzed by a log-rank test. Postoperative pathologic N and T status were evaluated as predictors of survival.
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Results |
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TopAbstractPatients and methodsResultsDiscussionReferences |
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Twelve (75%) patients underwent complete surgical resection. Postoperative adjuvant therapy was performed for 4 patients in whom complete resection could not be achieved or who did not receive preoperative therapy. Follow-up was completed for all patients in 12 to 199 months (mean, 43 months) after the initial treatment. Four patients died of systemic metastasis, and 1 died of intrapleural recurrence within 33 months of the operation. Nine patients were alive after a median follow-up period of 54 months.
The median survival time of all patients was 26 months, and the 5-year survival was 48.2%. The median survival time and 5-year survival were 31 months and 70%, respectively, for the 10 patients with postoperative pathologic N0 disease and 10 months and 17%, respectively, for the 6 patients with pathologic N2 or N3 disease (P = .0070, Table 3 and Figure 1). Pathologic T factor (P = .0539) did not appear to have an influence on survival (Table 3).
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Discussion |
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TopAbstractPatients and methodsResultsDiscussionReferences |
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Preoperative induction therapy is an effective method for achieving complete resection of lung cancer and has been applied extensively for treatment of stage IIIA and IIIB disease.13,14 In those studies mediastinal lymph node status after induction treatment showed prognostic significance for surgical treatment.7,13,14 Those reports are consistent with findings from the present study, which demonstrated that survival outcome was relatively favorable for patients with postoperative pathologic N0 disease, although outcome was still poor for those with pathologic N2 or N3 disease; and these results underscore the importance of accurate diagnosis of mediastinal lymph node involvement before surgical treatment. On the basis of our results, we suggest the following operative strategy. Patients with a T4 tumor infiltrating the aorta, as confirmed by CT imaging, and with or without clinical N2 disease should undergo preoperative induction therapy. When these patients show no tumor progression after therapy, further examinations, such as video-assisted thoracoscopy, a Chamberlain procedure, or mediastinoscopy, are required for assessment of the para-aortic, subaortic, or paratracheal lymph nodes before definitive surgical management. When no histologic evidence of mediastinal nodal involvement is found after these examinations, a radical resection of the affected aorta should be performed.
Some surgeons prefer the use of a passive shunt between the ascending and descending aorta to avoid extracorporeal circulation1,2 and to maintain perfusion in the lower part of the body. However, recent technical advances and implementation of a vortex pump with a low dose of heparin have allowed for safe and reliable circulatory support without renal failure, cerebral complications, or spinal cord injury.15 In the present study 10 patients underwent surgical intervention with CPB without critical complications, and the intensive care unit stay was less than 3 days for each. Operations with CPB usually use a cell salvage system, which washes and concentrates erythrocytes aspirated from the surgical field for subsequent transfusion to the patient. However, in lung cancer operations, blood in the pleural cavity might be contaminated with tumor cells. Therefore, although evidence is limited, we consider that blood aspirated from the surgical field should not be transfused back into the patient.
Radical en bloc resection of the tumor and invaded organ is essential for preventing intrapleural local recurrence.16 One of our patients (patient 13), who underwent discontinuous resections of the lung and tumor during CPB, had local recurrence in the chest wall pleura approximately 1 year after the operation. We suspected that the local recurrence was due to intrapleural tumor spread resulting from the discontinuous resection.
In conclusion, surgical morbidity and mortality rates were high in patients who underwent resection of the tumor and involved aorta, although similar to those of patients with other T4 organ involvement7,13,14 treated with preoperative induction therapy. The encouraging long-term survivals obtained in patients with N0 disease suggest that radical resection is a valid intervention for selected patients with aortic involvement of non-small cell lung cancer.
| See related editorial on page 727.
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Acknowledgments |
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References |
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This article has been cited by other articles:
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  B. Yildizeli, P. G. Dartevelle, E. Fadel, S. Mussot, and A. Chapelier Results of primary surgery with T4 non-small cell lung cancer during a 25-year period in a single center: the benefit is worth the risk. Ann. Thorac. Surg., October 1, 2008; 86(4): 1065 - 1075. [Abstract] [Full Text] [PDF]
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 K. R. Shen, B. F. Meyers, J. M. Larner, and D. R. Jones Special Treatment Issues in Lung Cancer: ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition) Chest, September 1, 2007; 132(3_suppl): 290S - 305S. [Abstract] [Full Text] [PDF]
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 W. Klepetko Surgical intervention for T4 lung cancer with infiltration of the thoracic aorta: Are we back to the archetype of surgical thinking? J. Thorac. Cardiovasc. Surg., April 1, 2005; 129(4): 727 - 729. [Full Text] [PDF]
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