Abstract
T4 non-small cell lung carcinomas (NSCLC) were deemed unresectable. Advances in surgery have challenged this dogma. We describe technical aspects and result on superior vena cava (SVC), carinal, thoracic inlet tumor surgeries, and resection under cardiopulmonary bypass (CPB). SVC reconstruction requires hemodynamic control to reverse SVC clamping cerebral effects and excellent cephalic venous bed patency. Among 50 SVC resections, including 25 carinal pneumonectomies, post-operative mortality rate was 8%. In the N0–N1 group, 5- and 10-year survival rates were 46.6 and 37.7%, respectively. Right carinal pneumonectomy was performed through right thoracotomy. Sternotomy was favored for left carinal pneumonectomy or carinal resection alone. Among 138 carinal resections, including eight right upper lobectomies, 123 right pneumonectomies, four left pneumonectomies, and three isolated carinal resections, the post-operative mortality rate was 9.4%. In the N0–N1 patients, 5-year survival rate was 47%. 191 patients underwent resections of thoracic inlet tumors through a transclavicular cervicothoracic anterior approach combined in 63 patients with a posterior midline incision for limited spine invasion. In N0–N1 group, 5- and 10-year survival rates were 41.5 and 29.7%, respectively. CPB allowed resection of tumors invading the heart or great vessels in 13 patients. R0 resection and post-operative mortality rate were 94.4 and 5.5%, respectively. In this series of 388 T4 NSCLC, the post-operative mortality rate was 4%. In the R0 and N0–N1 groups, the 5-year survival rates were 44 and 41%, respectively. Surgical resection of T4 locally advanced NSCLC is worth being performed in selected N0–N1 patients, provided that a radical resection is expected.
Similar content being viewed by others
Abbreviations
- NSCLC:
-
Non-small cell lung carcinoma
- SVC:
-
Superior vena cava
- PTFE:
-
Polytetrafluoroethylene
- PA:
-
Pulmonary artery
- ARDS:
-
Acute respiratory distress syndrome
- MOF:
-
Multi-organ failure
- CPB:
-
Cardiopulmonary bypass
- ECMO:
-
Extracorporeal membrane oxygenation
References
Parker SL, Long T, Bolden S, et al. Cancer statistics, 1997. CA Cancer J Clin. 1997;47:5–27.
Dartevelle P, Marzelle J, Chapelier A, Loc’h F. Extended operations for T3–T4 primary lung cancers. Indications and results. Chest. 1989;96(1Suppl):51S–53S.
Macchiarini P, Chapelier AR, Monnet I, Vannetzel JM, Rebischung JL, Cerrina J, Parquin F, Ladurie FL, Lenot B, Dartevelle PG. Extended operations after induction therapy for stage IIIb (T4) non-small cell lung cancer. Ann Thorac Surg. 1994;57(4):966–73.
McCormack PM. Extended pulmonary resections. In: Pearson FG, Deslauriers J, Ginsberg RJ, editors. Surgery thoracic. New York: Churchill Livingstone; 1995. pp. 897–908.
Macchiarini P, Dartevelle P. Extended resections for lung cancer. In: Roth JA, Cox J, Hong WK, editors. Lung cancer. 2nd ed. London: Blackwell Science, 1998. pp. 135–161.
Rusch VW, Azzoli CG, Rosenzweig KE. Therapeutic options for the treatment of advanced lung cancer: introduction. Semin Thorac Cardiovasc Surg. 2008;20(3):183.
Grunenwald DH, Andre F, Le Pechoux C, et al. Benefit of surgery after chemoradiotherapy in stage IIIB (T4 and/or N3) non–small cell lung cancer. J Thorac Cardiovasc Surg. 2001;122:796–802.
Yildizeli B, Dartevelle PG, Fadel E, Mussot S, Chapelier A. 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. 2008;86(4):1065–75. doi:10.1016/j.athoracsur.2008.07.004.
Dartevelle P, Macchiarini P, Chapelier A. Superior vena cava resection and reconstruction. In: Faber LP, editor. Techniques of pulmonary resection. Philadelphia: WB Saunders; 1995.
Spaggiari L, Regnard JF, Magdeleinat P, et al. Extended resections for bronchogenic carcinoma invading the superior vena cava system. Ann Thorac Surg. 2000;69:233–6.
Dartevelle PG, Chapelier AR, Pastorino U, et al. Long-term follow-up after prosthetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumors. J Thorac Cardiovasc Surg. 1991;102:259–65.
Spaggiari L, Thomas P, Magdeleinat P, et al. Superior vena cava resection with prosthetic replacement for non–small cell lung cancer: long-term results of a multicentric study. Eur J Cardiothorac Surg. 2002;21:1080–6.
Shargall Y, de Perrot M, Keshavjee S, et al. 15 year s single center experience with surgical resection of the superior vena cava for non-small cell lung cancer. Lung Cancer. 2004;45:357–63.
Spaggiari L, Magdeleinat P, Kondo H, et al. Results of superior vena cava resection for lung cancer. Analysis of prognostic factors. Lung Cancer. 2004 Jun;44(3):339–46.
Lee DS, Flores RM. Superior vena caval resection in lung cancer. Thorac Surg Clin. 2014;24(4):441–7. doi:10.1016/j.thorsurg.2014.07.009. (Epub 2014 Sep 11).
Lei J, Su K, Li XF, Zhou YA, Han Y, Huang LJ, Wang XP. ECMO-assisted carinal resection and reconstruction after left pneumonectomy. J Cardiothorac Surg. 2010;5:89. doi:10.1186/1749-8090-5-89.
de Perrot M, Fadel E, Mercier O, Mussot S, Chapelier A, Dartevelle P. Long-term results after carinal resection for carcinoma: does the benefit warrant the risk? J Thorac Cardiovasc Surg. 2006;131(1):81–9. (Epub 2005 Dec 5).
Tsuchiya R, Goya T, Naruke T, Suemasu K. Resection of tracheal carina for lung cancer. Procedure, complications, and mortality. J Thorac Cardiovasc Surg. 1990;99(5):779–87.
Martin J, Ginsberg RJ, Abolhoda A, et al. Morbidity and mortality after neoadjuvant therapy for lung cancer: the risks of right pneumonectomy. Ann Thorac Surg. 2001;72:1149–54.
Tapias LF, Ott HC, Mathisen DJ. Complications following carinal resections, sleeve resections. Thorac Surg Clin. 2015;25(4):435–47. doi:10.1016/j.thorsurg.2015.07.003. (Epub 2015 Sep 8. Review).
Dartevelle P, Macchiarini P. Carinal resection for bronchogenic cancer. Semin Thorac Cardiovasc Surg. 1996;8(4):414–25.
Grillo HC, Bendixen HH, Gephardt T. Resection of the carina and lower trachea. Ann Surg. 1963;158:889–93.
Shin S, Park JS, Shim YM, Kim HJ, Kim J. Carinal resection and reconstruction in thoracic malignancies. J Surg Oncol. 2014;110(3):239–44. doi:10.1002/jso.23643.
Weder W, Inci I. Carinal resection and sleeve pneumonectomy. Thorac Surg Clin. 2014;24(1):77–83. doi:10.1016/j.thorsurg.2013.10.004. (Review).
Detterbeck FC. Changes in the treatment of Pancoast tumors. Ann Thorac Surg. 2003;75(6):1990–7.
Shaw RR, Paulson DL, Kee JL Jr. Treatment of superior sulcus tumors by irradiation followed by resection. Ann Surg. 1961;154:29–40.
Okubo K, et al. Treatment of Pancoast tumors. Combined irradiation and radical resection. Thorac Cardiovasc Surg. 1995;43:84.
Wright CD, Menard MT, Wain JC, et al. Induction chemoradiation compared with induction radiation for lung cancer involving the superior sulcus. Ann Thorac Surg. 2002;73:1541–4.
Kunitoh H, Kato H, Tsuboi M, et al. A phase II trial of pre-operative chemoradiotherapy followed by surgical resection in Pancoast tumors: initial report of Japan Clinical Oncology Group trial (JCOG 9806). Proc Am Soc Clin Oncol. 2003;22:2549.
Collaud S, Fadel E, Schirren J, Yokomise H, Bolukbas S, Dartevelle P, Keshavjee S, Waddell TK, de Perrot M. En bloc resection of pulmonary sulcus non-small cell lung cancer invading the spine: a systematic literature review and pooled data analysis. Ann Surg. 2015;262(1):184–8.
Fadel E, Chapelier A, Bacha E, Leroy-Ladurie F, Cerrina J, Macchiarini P, Dartevelle P. Subclavian artery resection and reconstruction for thoracic inlet cancers. J Vasc Surg. 1999;29(4):581–8.
Fadel E, Missenard G, Chapelier A, Mussot S, Leroy-Ladurie F, Cerrina J, Dartevelle P. En bloc resection of non-small cell lung cancer invading the thoracic inlet and intervertebral foramina. J Thorac Cardiovasc Surg. 2002;123(4):676–85.
Fadel E, Missenard G, Court C, Mercier O, Mussot S, Fabre D, Dartevelle P. Long-term outcomes of en bloc resection of non-small cell lung cancer invading the thoracic inlet and spine. Ann Thorac Surg. 2011;92(3):1024–30. discussion 1030.
Dartevelle PG, Chapelier AR, Macchiarini P, Lenot B, Cerrina J, Ladurie FL, Parquin FJ, Lafont D. Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet. J Thorac Cardiovasc Surg. 1993;105(6):1025–34.
de Perrot M, Fadel E, Mussot S, de Palma A, Chapelier A, Dartevelle P. Resection of locally advanced (T4) non-small cell lung cancer with cardiopulmonary bypass. Ann Thorac Surg. 2005;79(5):1691–6. (discussion 1697).
Langer NB, Mercier O, Fabre D, Lawton J, Mussot S, Dartevelle P, Fadel E. Outcomes after resection of T4 non-small cell lung cancer using cardiopulmonary bypass. Ann Thorac Surg. 2016;102(3):902–10. doi:10.1016/j.athoracsur.2016.03.044.
Fukuse T, Wada H, Hitomi S. Extended operations for non-small cell lung cancers invading great vessels and left atrium. Eur J Cardiothorac Surg. 1997;11:664–9.
Ohta M, Hirabayasi H, Shiono H, et al. Surgical resection for lung cancer with infiltration of the thoracic aorta. J Thorac Cardiovasc Surg. 2005;129:804–8.
S, Waddell TK, Yasufuku K, Oreopoulos G, Rampersaud R, Rubin B, Roche-Nagle G, Keshavjee S, de Perrot M. Thoracic aortic endografting facilitates the resection of tumors infiltrating the aorta. J Thorac Cardiovasc Surg. 2014 Apr;147(4):1178–82. doi:10.1016/j.jtcvs.2013.12.020. (discussion 1182).
Bobbio A, Carbognani P, Grapeggia M, et al. Surgical outcome of combined pulmonary and atrial resection for lung cancer. Thorac Cardiovasc Surg. 2004;52:180–2.
Shirakusa T, Kimura M. Partial atrial resection in advanced lung carcinoma with and without cardiopulmonary bypass. Thorax. 1991;46:484–7.
Tsuchiya R, Asamura H, Kondo H, Goya T, Naruke T. Extended resection of the left atrium, great vessels, or both for lung cancer. Ann Thorac Surg. 1994;57:960–5.
Ratto GB, Costa R, Vassallo G, et al. Twelve-year experience with left atrial resection in the treatment of non-small cell lung cancer. Ann Thorac Surg. 2004 Jul;78(1):234–7.
Bobbio A, Carbognani P, Grapeggia M, et al. Surgical outcome of combined pulmonary and atrial resection for lung cancer. Thorac Cardiovasc Surg. 2004 Jun;52(3):180–2.
Ricci C, Rendina E, Venuta f, et al. Reconstruction of the pulmonary artery in patients with lung cancer. Ann Thorac. 1994;57:627–33.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Dartevelle, P.G., Mitilian, D. & Fadel, E. Extended surgery for T4 lung cancer: a 30 years’ experience. Gen Thorac Cardiovasc Surg 65, 321–328 (2017). https://doi.org/10.1007/s11748-017-0752-6
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11748-017-0752-6