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Ann Thorac Surg 2000;69:971
© 2000 The Society of Thoracic Surgeons

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Correspondence

Combined resection of T4 lung cancer with invasion of the descending thoracic aorta

^a Second Department of Surgery, Kagoshima University Faculty of Medicine, 8–35–1 Sakuragaoka, Kagoshima 890–8520, Japan

To the Editor

We read with great interest the article by Klepetko and colleagues [1] about combined resection of lung tumors with the infiltrated segment of the thoracic aorta with the use of cardiopulmonary bypass. We congratulate the authors on successful surgical treatment in such complicated cases.

We agree that the combined resection of T4 lung tumors with the infiltrated segment of the thoracic aorta can be performed with reasonable morbidity and mortality rates. However, we do not agree that the combined resection should be performed with cardiopulmonary bypass as a standard. We have experienced a case in which combined pneumonectomy and aortic wall resection for lung cancer were successfully performed using a heparinized bypass tube [2]. On April 24, 1987, a 59-year-old man with an 8-cm squamous cell carcinoma of the left lower lobe was operated on through a posterolateral thoracotomy. The tumor had invaded the aortic wall of a midportion of the descending thoracic aorta. The tumor was first resected with pneumonectomy to facilitate the operation, its invading portion being cut as close as possible to the aortic wall. Then a heparinized tube was inserted from the proximal to the distal descending aorta for a temporary bypass. The aorta was cross-clamped proximal and distal to the invaded wall without systemic heparinization. The invaded anterior aortic wall was partially resected (4 x 3 cm), and the defect was closed with a polyethylene terephthalate fiber prosthetic patch. Complete mediastinal lymphadenectomy was performed. During the operation, an adequate urine output was obtained. He was extubated on the first postoperative day. He stayed in the intensive care unit for 3 days. There were no postoperative complications such as thromboembolism, renal failure, paraplegia, and infection. Microscopically, the invasion reached only to the aortic adventitia. The tumor was classified histologically as squamous cell carcinoma (pT4 pN2 pM0). He was discharged 4 months postoperatively after receiving chemotherapy. Although he was in good condition 10 months postoperatively, he died of systemic metastasis 1 year after the operation.

In the seven cases reported by Klepetko and colleagues [1], three resections included the aortic arch and four resections only the descending aorta. The use of cardiopulmonary bypass is favorable in resection and reconstruction of the aortic arch. Therefore, it seems that the use of a temporary bypass was not optimal in their one case (patient 3). The complication that occurred in that case is not directly attributed to the use of a temporary bypass. On the other hand, should cardiopulmonary bypass be required for resection and reconstruction of a midportion of the descending aorta? En bloc resection of the lung tumor (lobectomy or pneumonectomy) and the invaded aorta is desirable. However, it may be practical to cut the invaded portion as close as possible to the aortic wall for facilitating the operation. During this procedure, cardiopulmonary bypass is unnecessary. A temporary bypass is easily installed after lobectomy or pneumonectomy to obtain enough exposure of the aorta. In general, cardiopulmonary bypass produces postoperative pulmonary dysfunction. Therefore, the use of cardiopulmonary bypass is not optimal in every case. A temporary bypass procedure is safe and useful, especially in resection of a midportion of the descending thoracic aorta. The indications for such combined resection include a curative operation and prevention of lethal complication because of aortic wall invasion of the tumor. Our patient lived only for 1 year postoperatively because of a higher stage of lymph node involvement. However, no intrathoracic dissemination developed postoperatively.

Although long-term results are limited by systemic relapse, surgeons should try such combined resection in highly selected patients.

References

1. Klepetko W., Wisser W., Bîrsan T., et al. T4 lung tumors with infiltration of the thoracic aorta. Ann Thorac Surg 1999;67:340-344.[Abstract/Free Full Text]
2. Shimokawa S., Uehara K., Watanabe S., Taira A. Combined pneumonectomy and aortic wall resection for lung cancer with the use of a heparinized bypass tube. Nippon Kokyuki Geka Gakkai Zasshi 1988;2:66-70.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Shimokawa, S. Articles by Sakasegawa, K. Search for Related Content PubMed PubMed Citation Articles by Shimokawa, S. Articles by Sakasegawa, K. Related Collections Related Article