HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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 Author home page(s): Lorenzo Spaggiari Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Spaggiari, L. Search for Related Content PubMed PubMed Citation Articles by Spaggiari, L. Related Collections Lung - cancer Mediastinum Related Article

---

Original Articles: General Thoracic

Invited Commentary

Department of Thoracic Surgery, European Institute of Oncology, Via Ripamonti 435, Milan, 20141 Italy

(Email: lorenzo.spaggiari{at}ieo.it).

The article by Lanuti and colleagues [1] is important not only in terms of content but also because it offers further evidence that superior vena cava (SVC) resection is indicated to treat pulmonary and mediastinal malignancies. Technically speaking, the article confirms the feasibility of resection without cardiopulmonary support in all patients if selection is appropriate.

I would like to add our personal contribution on a biologic prosthesis we routinely use in all patients undergoing SVC resection. Our first patient with lung cancer to receive a bovine pericardial tube was operated on in 2003. He is still alive without any anticoagulant regimen, with a fully patent prosthesis, and no graft calcification. To date, we have used biologic bovine pericardial patch in 8 patients, and no graft-related complications have developed. Figure 1 shows the Y-bovine prototype pericardial tube we are studying for maximal SVC resection in mediastinal tumors.

View larger version (105K): [in this window] [in a new window]   Fig 1. A photograph of the Y-bovine prototype pericardial tube we are studying for maximal superior vena cava resection in mediastinal tumors.

Considering the few patients operated on in a single center, it is difficult to randomize an adequate number of patients to demonstrate a statistically significant difference. It is also difficult to prove the hypothesis that chemotherapy may be effective in stages II and IIIA but completely ineffective in stage IIIB. Moreover, in our experience of extended resection for T4 lesions, almost all patients with recurrent disease present systemic rather than local recurrence, suggesting that a multimodal preventive approach is essential.

Because these patients may not tolerate adjuvant chemotherapy after such extended procedures, I would rather propose neoadjuvant chemotherapy. In addition, induction chemotherapy by three cycles of a platinum-based regimen may help improve patient selection, thereby excluding rapidly spreading disease not amenable to effective surgical treatment.

N2 disease is another important issue. First, SVC invasion by bulky N2 disease is a formal contraindication to surgical resection because of the poor prognosis of these patients. By contrast, the indication for resection in clinical (not bulky) N2 disease should be addressed in relation to the patient's clinical situation. N2 multilevel disease (mediastinoscopy-proven R4, R2 stations) should be considered an absolute contraindication and treated by chemoradiation therapy. However, single-station N2 disease (7 or R4 stations strictly adherent to the primary tumor) should be considered oncologically as N1 disease and eligible for resection after induction chemotherapy.

In conclusion, we currently use the following guidelines in the treatment of SVC for lung neoplasm:

• mediastinoscopy in all patients to exclude multilevel lymph node disease after whole-body computed tomography (CT) and positron-emission tomography (PET) scan;

• three or four cycles of induction chemotherapy with a cisplatin-based regimen, and restaging by CT and PET scan;

• SVC resection by lateral muscle-sparing thoracotomy in the fourth intercostal space in the presence of tracheobronchial invasion; otherwise, a hemi-clamshell approach should be preferred;

• resection without cardiopulmonary support;

• reconstruction with a biologic pericardial prosthesis;

• no anticoagulation therapy at discharge, but only antiaggregant therapy;

• adjuvant radiotherapy in R1 patients; and

• evaluation for biologic treatment if biologic determinants are present.

	References

Top References

 

1. Lanuti M, De Delva PE, Gaissert HA, et al. Review of superior vena cava resection in the management of benign disease and pulmonary or mediastinal malignancies Ann Thorac Surg 2009;88:392-398.[Abstract/Free Full Text]
2. Spaggiari L, Leo F, Veronesi G, et al. Superior vena cava resection for lung and mediastinal malignancies: a single-center experience with 70 cases Ann Thorac Surg 2007;83:223-230.[Abstract/Free Full Text]
3. Spaggiari L. Invited commentary Ann Thorac Surg 2008;86:375.[Free Full Text]

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 Author home page(s): Lorenzo Spaggiari Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Spaggiari, L. Search for Related Content PubMed PubMed Citation Articles by Spaggiari, L. Related Collections Lung - cancer Mediastinum Related Article