Extended resection for lung cancer invading mediastinal organs

Atrial resection for T4 non-small cell lung cancer with left atrium involvement: a systematic review and meta-analysis of survival

PURPOSE

Extended resection for non-small cell lung cancer (NSCLC) with T4 left atrium involvement is controversial. We performed a systematic review and meta-analysis to evaluate the short- and long-term outcomes of this treatment strategy.

METHODS

We searched the PubMed database for studies on atrial resection in NSCLC patients. The primary investigated outcome was the effectiveness of the surgery represented by survival data and the secondary outcomes were postoperative morbidity, mortality, and recurrence.

RESULTS

Our search identified 18 eligible studies including a total of 483 patients. Eleven studies reported median overall survival and 17 studies reported overall survival rates. The estimated pooled 1, 3, 5-year overall survival rates were 69.1% (95% CI 61.7-76.0%), 21.5% (95% CI 12.3-32.3%), and 19.9% (95% CI 13.9-26.6%), respectively. The median overall survival was 24 months (95% CI 17.7-27 months). Most studies reported significant associations between better survival and N0/1 status, complete resection status, and neoadjuvant therapy.

CONCLUSION

Extended lung resection, including the left atrium, for NSCLC is feasible with acceptable morbidity and mortality when complete resection is achieved. Lymph node N0/1 status coupled with the use of neoadjuvant therapies is associated with better outcomes.

Atrial Resection without Cardiopulmonary Bypass for Lung Cancer

BACKGROUND

Results of resection of lung cancer invading left atrium (T4atrium) without cardiopulmonary bypass (CPB) remain controversial. We reviewed our experience analyzing surgical results and postoperative outcomes.

METHODS

Patients who underwent extended lung resection for T4atrium without CPB between 1998 and 2018 were retrospectively reviewed using a prospective database.

RESULTS

The study included 44 patients (34 males and 10 females; median age: 63 years). Twenty-five patients underwent preoperative mediastinal staging and 27 received induction treatment (IT). Surgery included 40 (90.9%) pneumonectomies, 3 (6.8%) lobectomies, and 1 bilobectomy (2.3%). Pathological nodal status was N0 in 10 patients (22.7%), N1 in 18 (40.9%), and N2 in 16 (36.4%). Four patients receiving IT had a complete pathological response (9.1%). Eight (18.2%) patients had microscopic tumor evidence on atrial resected margins. Mortality was nil. The major complication rate was 11.4%, including one bronchopleural fistula, one cardiac herniation, and three hemothoraces, all requiring reintervention. The minor complication rate was 25.5%. After a median survival of 37 months (range: 1-144 months), 20 (45.4%) patients were alive. Five-year survival rate and disease-free interval were 39 and 45.8%, respectively. Patients with N0 and R0 disease had a best prognosis (log-rank test: p = 0.03 and p = 0.01, respectively). IT neither influenced survival nor postoperative complications. On multivariate analysis, pN0 (p = 0.04 [95% confidence interval [CI]: 0.65-9.66] and negative atrial margins (p = 0.02 [95% CI: 0.96-8.35]) were positive independent prognostic factors.

CONCLUSIONS

T4atrium is technically feasible without mortality and acceptable morbidity. Patients with N2 cancers should not be operated. T4atrium should not be systematically considered as a definitive contraindication to surgery.

[pT4 non-small cell lung cancer: Surgical characteristics in present practice]

INTRODUCTION

pT4 is a group of miscellaneous tumors: our goal was to revisit their surgical reality.

METHODS

The different characteristics and prognostic factors of lung pT4 (n=403) were analysed according to three subgroups: G1 - by direct extension; G2 - by nodule in other ipsilateral lobe; G3 - because of both.

RESULTS

There were 332 males and 71 females mean aged 61.5 years. Surgery [exploratory: 89 (22.1 %), lobectomy: 149 (37 %), pneumonectomy: 169 (41.9 %)] was followed by 26 postoperative deaths (6.5 %), 82 complications (20.3 %) and concerned few pN0 (47.6 %). G1 (n=196) and G3 (n=53) were not different. By comparison with them, G2 (n=53) were mainly females (24\13 %), with less explorative thoracotomy (2.6\34 %), more complete R0 resections (77\29 %), less pneumonectomy (31\47 %), more small sized tumors (mean: 37\57 mm), more adenocarcinoma (67\32 %), more N0 tumors (48\31.7 %) and stages IIIA disease (46.7\56 %). G2 5-year survival rates were higher (G2: 22 %; G1: 13 %; G3: 15 %); G1 rates depended of the invaded structure (20.9 % for the vertebra down to 0 % for the esophagus and carina). pN2 rates were not very high but not different between groups (G1: 13.6 %; G2: 15.6 %; G3: 14.3 %; P=0.52). Multivariate analysis demonstrated completeness and type of resection, stage and age as independent factors of prognosis.

CONCLUSION

Surgery for pT4 is justified provided rigorous selection of extension forms. However, assimilating extension and ipsilateral lobe nodule in a same group does not obey to surgical reality.

Surgical management of lung cancer invading the aorta or the superior vena cava

OBJECTIVE

Invasion of mediastinal structures (T4) is considered as an absolute contraindication to surgical management of non-small cell lung cancer (NSCLC). The authors studied the role of surgical treatment in case of direct aortic and superior venous caval involvement.

PATIENTS

From 1995 to 2000, 13 patients with left lung NSCLC invading descending aorta and 9 patients with right upper lobe NSCLC and superior vena cava (SVC) invasion were subjected to thoracotomy for lung resection. Surgery was indicated in case of absence of intraluminal extension. All patients were cN2 negative. The pathology results and 5-year survival were recorded and analyzed.

RESULTS

In three cases (23%) the tumor was adhered to the parietal pleura overlying descending aorta, which was resected en block with tumor-associated lung parenchyma. Aortic adventitia invasion by tumor led to local resection of adventitia (<1cm(2)) in nine patients (69%). Invasion deeper than adventitia was encountered in one case (8%), which was managed with aortic partial occlusion, resection of aortic wall and repair of the defect with Gore graft patch. In three patients (33%) the SVC wall was involved by the tumor 1-3cm in length and 2-4mm of the circumference. The defect was repaired with direct suturing. In five patients (56%) the area of SVC wall that was invaded was 3cmx2cm. The defect was repaired with Dacron patch. In 1 patient (11%) an arterial 14 graft was end-to-end interposed. All resections were radical (R0). Neither associated postoperative complications nor operative mortality was recorded. Five-year survival was 30.7% for the cases with aortic invasion and 11% for the ones with SVC involvement.

CONCLUSIONS

Radical surgical resection of lung tumors with localized aortic invasion can be considered after exclusion of N2 involvement.

Primary lung cancer involving mediastinum and mimicking left atrial myxoma: a case report and review of literature

We report a case of primary large cell carcinoma of the lung invading the heart and mimicking a left atrial myxoma. This case highlights the problems we face in diagnosis and management of a very unusual presentation of poorly differentiated primary large ('non-small') cell lung cancer with extension into the left atrium. It is important to have a high index of suspicion for a primary lung malignancy in chronic heavy smokers with none to minimal respiratory symptoms for early diagnosis and full staging procedures, as some of these tumours may be suitable for lung resection.

Resection of lung carcinomas invading the mediastinum, including the superior vena cava

Extended resection of lung carcinomas invading the superior vena cava was demonstrated to be feasible by several authors. This article describes these technically demanding procedures, with their short- and long-term results. In addition, current controversies are discussed concerning technical aspects, indications, outcomes, and classification of these locally advanced non-small cell lung cancers.

Surgery for locally advanced non-small cell lung cancer

Advanced stage non-small lung cancers are currently considered unresectable. However numerous series on patients with locally advanced disease treated by surgery have been published. Surgery alone or induction treatments followed by surgery achieve long-term outcomes in an encouraging proportion of selected patients with T4 disease, despite the high rate of morbidity associated with technically demanding procedures.

Is lung cancer surgery justified in patients with direct mediastinal invasion?

OBJECTIVE

To assess the results of the surgical treatment of patients with stage IIIB non-small cell lung carcinoma (NSCLC) invading the mediastinum (T4).

METHODS

Twenty-nine patients were operated on from 1986 to 1999. Histology was squamous cell carcinoma in 17 patients, adenocarcinoma in eight, large cell carcinoma in two and neuroendocrinal carcinoma in two. Three patients received a preoperative chemotherapy (n = 2) or radiochemotherapy (n = 1). The lung resection consisted of a pneumonectomy in 25 patients and a lobectomy in four. The procedure was extended to one of the following structures: superior vena cava (SVC) (n = 17), aorta (n = 1), left atrium (n = 5) and carina (n = 6). Seventeen patients had a postoperative regimen including radiochemotherapy (n = 12), radiotherapy (n = 4), or chemotherapy (n = 1).

RESULTS

Complete R0 resection was achieved in 25 patients, whereas four patients had a microscopically (n = 1) or macroscopically (n = 3) residual disease. The operative mortality rate was 7% (n = 2). Non-fatal major complications occurred in eight patients (28%). Overall 5-year survival rate was 28% (median 11 months), including the operative mortality. The median survival of the 18 patients with an N0 or N1 disease was 16 months whereas the median survival of the 11 patients with an N2 disease was 9 months. At completion of the study, 22 patients have died, two postoperatively and 10 from pulmonary causes without evidence of cancer.

CONCLUSIONS

Surgical management of T4 NSC lung cancer invading the mediastinum should be considered, in the absence of N2 disease, when a complete resection is achievable.