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Ann Thorac Surg 1999;67:340-344
© 1999 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria
b Department of Cardiothoracic Anesthesiology, University of Vienna, Vienna, Austria
Accepted for publication July 18, 1998.
Address reprint requests to Dr Klepetko, Department of Cardiothoracic Surgery, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
e-mail: (walter.klepetko{at}akh-wien.ac.at)
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Abstract |
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Methods. Seven patients (mean age, 57.5 years; range, 43 to 78 years) underwent a resection of the infiltrated segment of the thoracic aorta together with a left pneumonectomy (n = 6) or left upper lobectomy (n = 1). Five tumors were primary non-small cell lung carcinomas (T4N2 in 3 patients, T4N1 in 2), one was a metastasis of breast cancer, and one was rhabdomyosarcoma.
Results. No patient died perioperatively. The 2 patients with rhabdomyosarcoma and metastasis of breast cancer died 2 and 7 months postoperatively. Of the 5 patients with bronchial carcinoma, 3 died after 17, 26, and 27 months as a result of distant metastasis. Two patients are alive after 14 and 50 months without evidence of disease recurrence. One-year, 2-year, and 4-year survival rates for patients with bronchial carcinoma were 100%, 75%, and 25%, respectively.
Conclusions. Combined resection of the lung and thoracic aorta can be performed with low morbidity and mortality when offered to highly selected patients. Adequate local control of tumor can be achieved for N1 and single-level N2 non-small cell lung carcinomas, but not for tumors with other histologies.
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TopAbstractIntroductionPatients and methodsCommentReferences |
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Patients and methods |
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TopAbstractIntroductionPatients and methodsCommentReferences |
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The postoperative course was uneventful. The patient stayed in the intensive care unit for 1 day and was discharged 19 days later. The tumor was classified histologically as a highly malignant rhabdomyosarcoma. Because of the poor prognosis, no adjuvant treatment was given, and the patient died 2 months later after further local tumor growth.
Case 2
In a 78-year-old woman, a solitary 10-cm metastasis of breast cancer in the left lung with close contact to the descending aorta was operated on via posterolateral thoracotomy. Exploration of the pleural cavity showed that the tumor infiltrated the wall of the descending aorta to a length of 4 cm. Frozen sections showed the lymph nodes at the hilum and the mediastinum to be free of tumor. Normothermic partial cardiopulmonary bypass was initiated via femoro-femoral cannulation, the involved aortic segment was cross-clamped, and the infiltrated segment of the anterior wall of the aorta was resected together with the entire left lung. Reconstruction was performed with a hemoshield prosthesis. The postoperative course was uneventful. The patient stayed in the intensive care unit for 2 days and was discharged on the 16th postoperative day. The patient received Novantron-based chemotherapy but died 7 months postoperatively from systemic metastasis.
Case 3
In a 58-year-old man a 3-cm adenocarcinoma of the left upper lobe with infiltration of 2 cm of the descending aorta close to the origin of the left subclavian artery was resected. An 8-mm Gore-Tex, (W.L. Gore & Assoc, Flagstaff, AZ) Shunt prosthesis was installed between the ascending and descending aortas. The aorta was cross-clamped proximal and distal to the infiltrated wall, and the infiltrated segment together with an intrapericardial pneumonectomy and complete mediastinal lymphadenectomy was resected en bloc. However, reconstruction of the aorta with a tubular prosthesis became extremely difficult, because the resection line extended into the concavity of the aortic arch. Postoperative bleeding from the proximal anastomosis necessitated rethoracotomy on the first postoperative day. The patient was put on cardiopulmonary bypass and in deep hypothermia to replace the aortic arch. Further recovery was prolonged and complicated by temporary renal failure and paraplegia. After staying in the intensive care unit for 49 days the patient recovered completely, except for persisting weakness in his legs. Tumor involvement was detected histologically in one solitary mediastinal lymph node at the tracheobronchial angle (pT4 pN2 pM0). The patient refused adjuvant therapy. He died after 26 months as a result of systemic metastasis.
Case 4
In a 43-year-old woman a 3-cm adenocarcinoma of the left upper lobe close to the aorto-pulmonary window was resected. Intraoperatively we found that the tumor was in direct continuity with a lymph node that infiltrated the origin of the Botalli duct. With the patient on partial cardiopulmonary bypass via femoro-femoral cannulation, the tumor-infiltrated origin of the duct was excised from the aortic wall. The 1.5-cm defect was closed with an autologous patch of pericardium. Thereafter resection was completed with an intrapericardial pneumonectomy and radical mediastinal lymphadenectomy, and the bronchial stump was covered with a pedicled flap of pericardium.
The postoperative course was uneventful, and the patient was discharged 12 days later. The tumor was classified as adenocarcinoma with a solitary involved subaortal lymph node (pT4, pT2, pM0). The patient refused adjuvant chemotherapy and after an uneventful period of 20 months bone metastases were detected. She died 27 months after the initial operation.
Case 5
In a 54-year-old woman a 3-cm adenocarcinoma of the left upper lobe with invasion of a 2-cm-long segment of the descending aorta was operated on using partial cardiopulmonary bypass and femoro-femoral cannulation. The involved segment of the descending aorta was resected and reconstructed with a hemoshield prosthesis. Thereafter, the tumor was resected en bloc with intrapericardial pneumonectomy and mediastinal lymphadenectomy. The tumor was classified histologically as adenocarcinoma pT4 pN1 pM0.
The postoperative period was uneventful, and the patient was discharged on the seventh postoperative day. She remains alive and free from evidence of tumor recurrence 50 months later.
Case 6
In a 57-year-old man a 5-cm squamous cell carcinoma in the left upper lobe with direct invasion of the concavity of the aortic arch (Fig 1) was operated on using cardiopulmonary bypass with femoro-femoral and ascending aortic double cannulation. The aorta was cross-clamped behind the origin of the brachiocephalic trunk and at its descending part. In addition, the left carotid and subclavian arteries were cross-clamped. The left lung and the aortic arch were resected en bloc, and complete mediastinal lymphadenectomy was done. The bronchial stump was covered with a pedicled pericardial patch, the aorta was reconstructed with a tubular prosthesis, and the carotid and subclavian arteries were reinserted into the graft.
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Case 7
In a 63-year-old patient a 3.5-cm squamous cell carcinoma of the left upper lobe infiltrating the mediastinum between the aortic arch and the origin of the left subclavian and carotid arteries was detected. After preoperative chemotherapy the patient was operated on by femoro-femoral cardiopulmonary bypass via trap-door incision (hemisternotomy with anterior thoracotomy and supraclavicular incision) (Fig 2). With the patient in deep hypothermia and temporary complete circulatory arrest, the tumor was resected together with the left upper lobe, the anonymous vein, the roof of the aortic arch, and the origin of the left carotid and subclavian arteries. The aortic arch was reconstructed using a large patch of hemoshield prostheses and two tubular grafts to the carotid and subclavian arteries. Postoperative course was uneventful, except for an episode of bleeding from the femoral cannulation site. The patient stayed in the intensive care unit for 4 days and was discharged at the 18th postoperative day. The tumor was classified histologically as T4 N1 M0 squamous cell carcinoma. The patient received four more cycles of chemotherapy together with local radiotherapy. Fourteen months postoperatively he is free from tumor recurrence.
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Comment |
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TopAbstractIntroductionPatients and methodsCommentReferences |
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The technical aspects of aortic resection in cases with local tumor involvement have been described in the general thoracic surgical literature differently. Resection by means of a temporary graft between the ascending and descending aorta has been emphasized [2, 4]. In the present series, the only complication was in the one patient who was operated on using that technique. All other patients operated on using cardiopulmonary bypass had an uncomplicated operative course. This observation suggests that a combined resection should be performed with cardiopulmonary bypass as a standard. If the tumor is located in the descending aorta, normothermic partial bypass of the lower part of the body, with the upper half being perfused by the beating heart, is sufficient to prevent typical complications of aortic resections, such as hemiplegia and renal dysfunction. For tumors invading the aorta close to, or directly into, the aortic arch, cardiopulmonary bypass with selective cerebral perfusion [5] or deep hypothermia with complete circulatory arrest is the preferred approach. This technique was applied in our case of emergency repair of the aorta (patient 1) as well, where direct access to the defect in the aortic wall was impossible because of the large and bulky tumor mass.
Such resections leave almost no tissue around the bronchial stump, which will be in closer contact with the aortic prosthesis. Surprisingly, we found no studies regarding the ideal handling of the bronchial stump in this situation. Because we were concerned about the possibility of graft infection and late stump insufficiency, we covered the bronchial stump in all our patients with a pedicled, caplike pericardial flap. The resulting defect in the pericardium was reconstructed with Vicryl mesh (Ethicon, Somerville, NJ). The results we obtained suggest that this technique contributed to the absence of infectious complications and late bronchial stump insufficiency.
In all 6 patients operated on under these conditions, the postoperative course was uncomplicated. Intensive care unit stay was fewer than 4 days and further recovery was straightforward in the 5 patients who had a radical resection, which indicate that the operative burden of such a complex resection can be well tolerated by selected patients, which is important when one considers surgical resection as a treatment option to gain local control.
Despite these technical aspects and the favorable early postoperative outcome, the main issue that must be debated is the long-term benefit that can be attained with such an extensive operation. The long-term result in the patient who was operated on for metastatic disease was disappointing and shows that the operation was not justified in those circumstances. However, all 5 patients who were operated on for primary lung cancer survived the first year and 3 of 4 were alive after 2 years. None of the patients later had local tumor recurrence, which shows that local tumor control can be achieved with such an extensive resection. Even more, this result was independent of the depth of tumor infiltration into the aortic wall. Conversely, the only 2 patients that are presently free from tumor are the patients who had N1 disease only. All other patients who had single level N2 disease ultimately had systemic tumor relapse, which indicates that the value of the operative procedure as an operation for cure is limited in patients with a higher stage of lymph node involvement.
A major deficiency in this study was that only the last patient received preoperative and postoperative chemotherapy. For neoadjuvant chemotherapy, an improvement in survival of approximately double has been reported for patients with stage III non-small cell lung carcinoma in several studies [6]. Roth [7] demonstrated a highly significant improvement in 3-year survival for patients with stage IIIA disease who received chemotherapy and resection (56%) compared with those who had resection alone (15%). For patients operated on with use of cardiopulmonary bypass, adjuvant chemotherapy could have a specific role in prophylaxis or therapy of potential micrometastasis. Conversely, there is a significantly higher mortality rate for patients who have pneumonectomy after neoadjuvant chemotherapy [8].
When analyzing the results obtained with surgical resection in these patients, one must compare them with the results described for chemoradiotherapy alone in patients with stage IIIB disease. In general the latter are poor and mean survival time is 8 to 14 months [9, 10]. However, it is difficult to compare results of operated patients, who necessarily have a complete and exact intrathoracic staging, with results of patients who were treated with chemoradiation therapy alone. In addition, most studies of chemoradiation therapy for stage IIIB disease are comprised of a heterogeneous group of patients, who belong to stage IIIB because of either advanced N2 disease or T4 tumor size.
The present group of patients were highly selected, and we have treated other patients with aortic infiltration during the same time, who were withdrawn from operation because of extensive N2 disease or significantly compromised lung function.
We demonstrated that the combined resection of lung tumors with the infiltrated segment of the thoracic aorta with the use of cardiopulmonary bypass can be performed with reasonable morbidity and mortality rates. Local tumor control can be achieved for primary non-small cell lung tumors with N1 or single level N2 disease; however, long-term results are limited by systemic relapse. Chemotherapy, most likely in its neoadjuvant form, should therefore be added routinely as part of the treatment protocol.
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