Extending operability in lung cancer involving the heart and great vessels

Phase II study of S‐1 plus cisplatin with concurrent radiotherapy for locally advanced thymic carcinoma: Results of the LOGIK1605 / JART ‐1501 study

Background

Combination chemotherapy is used to treat advanced thymic carcinoma; however, the effects are insufficient.

Methods

Previously untreated patients with unresectable locally advanced thymic carcinoma received two cycles of 80 mg/m²/day S‐1 orally on days 1–14 plus 60 mg/m²/day cisplatin intravenously on day 1, and concurrent radiotherapy (60 Gy).

Results

Three patients were enrolled into the study. Toxicity and survival were assessable in all patients, but the treatment response was only assessable in one patient. The study was terminated because of poor case recruitment. The patients' characteristics were as follows: male/female = 2/1; PS 0/1 = 2/1; median age (range) = 59 (55–72); and stage III/IV = 2/1. The patient in which the treatment response was assessed exhibited SD (response rate: 0%). In both nonevaluable cases, the second course of chemotherapy was judged to be post‐protocol treatment because it was delayed by ≥14 days, but a CR and PR were achieved after the end of the study, respectively. G4 leukopenia/neutropenia and G3 febrile neutropenia occurred in one patient each (33%). The median time to tumor progression was 17.6 months, and the 1‐, 2‐, 3‐, and 4‐year survival rates were 67, 33, 33, and 33%, respectively. The median overall survival time was not reached, and the 1‐, 2‐, 3‐, and 4‐year survival rates were 100, 67, 67, and 67%, respectively.

Conclusions

Although it was difficult to recruit patients, there was a long‐term survivor >4 years who appeared to have achieved a CR, indicating that such chemoradiotherapy may be effective against locally advanced thymic carcinoma.

Largest known malignant solitary fibrous tumour of the pleura-extended resection warranting cardiopulmonary bypass support

This case reports the largest known malignant solitary fibrous tumour of the pleura treated with en bloc surgical resection warranting the use of cardiopulmonary bypass support. A 60-year-old male presented with dyspnoea and a dry cough. Following extensive investigations, a radiological and histologic diagnosis of malignant solitary fibrous tumour of the pleura was made. This 4.3 kg tumour occupied the entire left hemithorax, involved the left lung and infiltrated into the pericardial cavity. Although the postoperative course was uneventful with a 12-day length of stay, the patient opted not to undergo adjuvant radiotherapy to a single positive margin site and died 6 months later due to local recurrence.

Extended resections of non-small cell lung cancers invading the aorta, pulmonary artery, left atrium, or esophagus: can they be justified?

T4 tumors that invade the heart, great vessels, or esophagus comprise a heterogenous group of locally invasive lung cancers. Prognosis depends on nodal status; this relationship has been consistently demonstrated in many of the small series of extended resection. Current National Comprehensive Cancer Network guidelines do not recommend surgery for T4 extension with N2-3 disease (stage IIIB). However, biopsy-proven T4 N0-1 (stage IIIA) may be operable. Localized tumors with invasion of the aorta, pulmonary artery, left atrium, or esophagus represent a small subset of T4 disease. Acquiring sufficient randomized data to provide statistical proof of a survival advantage for patients undergoing extended resections for these neoplasms will likely never be possible.Therefore, we are left to critically analyze current documented experience to make clinical decisions on a case-by-case basis.It is clear that the operative morbidity and mortality of extended resections for locally advanced T4 tumors have significantly improved over time,yet the risks are still high. The indications for such procedures and the anticipated outcomes should be clearly weighed in terms of potential perioperative complications and expertise of the surgical team. Patients with T4 N0-1 have the best prognosis and with complete resection may have the potential for cure. The use of induction therapy and surgery for advanced T4 tumors may improve survival. Current data suggest that for tumors that invade the aorta, pulmonary artery,left atrium, or esophagus, resection should be considered in relation to multidisciplinary care.For properly selected patients receiving treatment at high volume, experienced centers, extended resections may be warranted.

Surgical treatment of stage III non-small cell lung cancer

The resectability of NSCLC is determined by its stage. The surgical treatment in stage I and II NSCLC remains a golden standard. Stage IIIA NSCLC constitutes a non-homogenous group, and many patients are potentially non-resectable. The patients in stage IIIA NSCLC also constitute a non-homogenous group. The patients in stage T3N1 usually undergo surgical resection, but many patients with N2 disease are disqualified from surgical treatment due to the negative prognostic factors. The negative prognostic factors comprise: (1) metastases to upper paratracheal (no 2), anterior paratracheal (no 3), and subcarinal (no 7) lymph nodes; (2) metastases to multiple mediastinal lymph nodes; (3) occurrence of the so called 'bulky disease'; (4) capsular lymph node invasion. The occurrence of one of these negative prognostic factors disqualifies the patient with N2 disease from radical surgical treatment. In more advanced cases, i.e. stage IIIB, and stage IV NSCLC, patients are rarely operated. It regards the patients in stage T4 N1, and in M1 disease with a single metastasis (mainly to CNS) accompanied by the stage I, or II, of the primary focus. In these cases N2 disease always constitutes the contraindication to the surgical treatment. Multidisciplinary approach in the treatment of NSCLC is supposed to improve the results of the treatment of NSCLC.

Preoperative and intraoperative ultrasonographic examination as an aid in lung cancer operations

To assess the extent of tumor invasion in lung cancer, my colleagues and I routinely use preoperative transesophageal ultrasonic endoscopy and intraoperative ultrasonography in addition to preoperative roentgenography, computed tomographic scanning, and other standard procedures. Both transesophageal ultrasonic endoscopy and intraoperative ultrasonography allow for a real-time assessment of the extent to which the lung cancer has invaded adjacent organs and are useful in determining the operability and safety margin of the involved organ or organs. We found intraoperative ultrasonography to be more accurate than transesophageal ultrasonic endoscopy, because intraoperative ultrasonography can be done at any time during the operation, as needed, and the probe can be directly applied to the desired location from a variety of angles. In contrast, when transesophageal ultrasonic endoscopy is used, the presence of air in the lung tissue can interfere with an accurate evaluation of some aspects of the tumor. Our results indicate that the sensitivity of transesophageal ultrasonic endoscopy and intraoperative ultrasonography is 68.4% and 100%, respectively, and the specificity is 81.3% for transesophageal ultrasonic endoscopy and 95.5% for intraoperative ultrasonography.

Partial atrial resection in advanced lung carcinoma with and without cardiopulmonary bypass

Combined pneumonectomy and partial resection of the left atrium was performed in 12 patients with advanced lung carcinoma (T3 and T4 in the new UICC classification). In the eight patients with a T3 lung carcinoma intrapericardial atrial resection with vascular clamping was carried out; four of the patients died within a year. The remaining four patients had a T4 tumour and underwent removal of the right lung and part of the left atrium under total cardiopulmonary bypass. One patient died shortly after the operation from cerebral and cerebellar infarction, and one died 11 months later from brain metastases. Two are alive and well. Complete resection appears to offer a chance for longer survival in patients with advanced lung carcinoma that extends directly into the intrapericardial pulmonary vessels or atrium.

Dumbbell metastatic cystosarcoma phyllodes of the heart and lung

Cystosarcoma phyllodes is an uncommon breast tumor that rarely metastasizes. A case of dumbbell cystosarcoma phyllodes metastatic to the heart and lung diagnosed antemortem is described. The roles of diagnostic echocardiography and surgical excision are discussed. Atrial extension of a lung malignancy through a pulmonary vein is not an absolute contraindication to operation, but careful patient selection and operative planning are required.

Results of surgical treatment of patients with T3 non-small cell lung cancer

Sixty-one patients with T3 non-small cell lung cancer were surgically treated in our department from February, 1974, through April, 1986. The overall 5-year survival, excluding patients with pleurisy, was 23%, and the 5-year survival for patients undergoing complete resection and incomplete resection was 42% and 10%, respectively (p less than 0.01). Survival in patients with T3 N0 and T3 N1 or N2 disease was 33% and 0 at 5 years, respectively. The prognosis for patients with pleurisy was poor, and all died within 3 years. Therefore, complete lung resection should be done in patients with T3 N0 non-small cell lung cancer if complete resection is expected. Long-term survival is less likely for patients with lymph node metastases if complete resection cannot be performed.

Surgical implications in malignant cardiac disease

Despite the rarity of primary malignant tumors of the heart (0.0017 to 0.03% of large postmortem series) and the infrequency of clinical signs and symptoms (0 to 50%) of the more common metastatic cardiac tumors, many cardiothoracic surgeons at some time will encounter a patient with one of these two conditions. A review of the medical literature yielded 28 cases of primary cardiac tumors, 10 of secondary tumors, and 12 of carcinoid heart disease treated surgically and followed sufficiently for retrospective evaluation. We summarized those cases and made the following conclusions. Primary malignant tumors of the heart are occasionally resectable, although cure is unlikely; survival may be enhanced by postoperative irradiation but probably not by postoperative chemotherapy. For patients with secondary malignant tumors of the heart, surgical intervention is rarely of benefit except for establishing a tissue diagnosis, effecting artificial cardiac pacing, decompressing symptomatic pericardial effusions, or reducing an obstructive tumor mass. Patients with carcinoid heart disease affecting the valves may derive benefit from valve replacement or repair. Thus, in selected patients with malignant cardiac disease, surgical intervention may be feasible and should always be among the therapeutic options considered.