Resection of Lung Cancer Invading the Mediastinum

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1 Resection of Lung Cancer Invading the Mediastinum Philippe G. Dartevelle MARIE-LANNELONGUE HOSPITAL GUSTAVE ROUSSY INSTITUTE INSTITUTE OF THORACIC ONCOLOGY PARIS SUD UNIVERSITY

2 Mediastinal Invasion Superior vena cava Tracheal bifurcation Pulmonary artery Aorta and supra-aortic trunks Heart Esophagus

3 SVC Replacement

4 Concerns about SVC reconstruction Graft material (PTFE or pericardium) Effects of SVC clamping Fluid administration Heparin No bypass Long term patency (anticoagulation 6 mo)

5

6 SVC Replacement S u r v i v a l % 20% 10 N2 15 N1, N0 p= months

7 Carinal Pneumonectomy

8

9 Right upper lobectomy and carinal resection

10 Carinal resection for carcinoma Survival according to nodal status Survival (%) % 15% N0/N1 N2/N3 14 yrs after carinal pneumonectomy and SVC replacement Months after surgery Patients at risk N0/N1 N2/N

11 Pulmonary artery resection and reconstruction

12 Invasion of the PA _ Median sternotomy _ CPB between venae cavae and ascending aorta _ Normothermia and beating heart _ Pericardial or PTFE patch

13 Extension to the left atrium

14 Supra-aortic trunks

15 Aortic invasion

16 Cannulation for partial CPB through left thoracotomy

17 Marie Lannelongue experience of lung cancer surgery under CPB n = 17 Thoracic aorta 5 Left atrium 4 Carina 3 Pulmonary artery 3 SVC and right atrium 2

18 Survival after resection under 1,8,6,4,2 0 CPB Mortality : 1 / 17 (6%) R0 R mo

19 Low grade sarcoma of the lung

20 Airway and esophagus reconstruction

21 And 3 years after surgery 1 year after

22 Conclusion Demanding surgery Experience in many fields of cardiothoracic and vascular surgery and more Selection of patients T4 non N2-3 and expected R0 resection If applicable the benefit outweighs the risks

23 Two Years Later

24 30 months after with her baby «Filippo»

25 Esophageal Reconstruction

26 Complications Morbidité Mortalité Pneumopathie 6 1 Pyothorax 1 Pancréatite 1 Total (%) 8 (47%) 1 (6%) Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

27 R0/R1 1,8,6,4,2 0 P=0,133 62% R0 R mois Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

28

29 Mean Arterial Pressure Mean brachiocephalic Venous Pressure Brain Arterial-Venous Gradient mm Hg Basal Clamping Alone During SVC Clamping With Intraluminal Shunt Volume Expansion & Vasoconstrictive Agents

30 Preventing Clamping Effects Pharmacological agents - Fluid Load Shortening Clamping time Anticoagulation - Thereafter - 2 mg/kg/day Before clamping- 0.5 mg/kg iv Hospital discharge - Coumadin

31 Patients' Profile (n=25) Mean age: 58 years (range: yrs) Gender: 22 M / 3 F Squamous vs nonsquamous: 20 / 5

32 Nodal status N2 N1 N0 1

33 SVC Replacement APPROACH: Thoracotomy vs. sternotomy 24 / 1 RESECTION: Intrapericardial Pneumonectomy 11 Carinal Pneumonectomy 11 Right Upper Lobectomy 3

34

35

36

37 SVC Reconstruction TYPE SVC REPLACEMENT: Truncular 23 Left brachiocephalic vein - RA 2 CLAMPING TIME : 28.6 min (15-50)

38 Complications Bronchopleural fistula Pneumonia # Deaths Extrapericardial cardiac herniation Mortality 8% 1

39 SVC Replacement S u r v i v a l 1,8,6,4,2 0 MS n=25 Failure (n=14 pts) 1.8 yrs 32% Median Follow-up (5.0 yrs) Patients at risk Systemic 12 Resp insuf months

40 SVC Replacement S u r v i v a l Carinal resection 14 Noncarinal resection 38% 25% p= months

41 Reimplantation of the intermediate bronchus into the trachea

42 Azygos arch resection and reimplantation into the right atrium n = 1

43

44

45 Intraop. mortality N0-N1 5 y. surv. N2-N3 5 y. surv. Overall 5 y. surv. Inlet 1% 37% 7% 31% Carina 6,4 % 49.7% 6% 38% SVC 8 % 45% 20% 32%

46 End to end trachea- left main bronchus anastomosis and implantation of the intermediate bronchus into the left main bronchus through a right thoracotomy

47 PTFE graft's Patency n=25 p a t e n c y % months

48 Conclusion Prognosis of completely resected T4 NSCLC is essentially related to nodal status Radical surgery can be performed with an acceptable mortality rate (range 1 8 %) It results in a 5 year survival rate between 37 and 50% in non N2/3 lung cancer Surgery in T4 (non N2) NSCLC should be more frequently indicated and performed

49 Tumors invading the subclavian vessels n = 35

50

51

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54

55

56

57 Tumor extension Bone: First 2 vs. First 4 ribs 46 / 48 Intervertebral Foramen (T1-T2) 19 Nerves: Phrenic Nerve Nerve Roots C8 vs. T1 Vessels: Subclavian artery (17 PTFE; 18 EE) Subclavian Vein (21 ligation; 1 plasty) Vertebral/Carotid Artery 32 1 / /2

58 Overall Survival S u r v i v a l % 7% n = 94 N0 (n=73) N1-3 (n=21) p = Time (months)

59 Subclavian Artery Invasion 1 Survival SA invaded n=35 SA not invaded n=59 p=ns months

60

61

62

63

64 Envahissemment de l OG Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

65 CONCLUSION Thoracic Inlet Invasion Is a Surgically & Potentially Curable Disease Provided: a) An Adapted Approach is used b) Absence of N2-3 disease Invasion of the Subclavian Vessels Does Not Indicate Inoperability Extension of surgery to the intervertebral foramen may result in long term survival

66 Aortic arch resection and reconstruction under CPB n = 2

67

68

69

70

71

72

73 Main pulmonary artery bifurcation resection under CPB in Lung Cancer

74 Série du CCML Sexe: H/F 12/5 Age : 56 ans (44 71 ans) N=17 Induction: oui 8/ non 9 Planifié 9 non 8 Histologie Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

75 Aorte thoracique 5 Oreillette Gauche 4 Carêne 3 Tronc de l artère pulmonaire 3 VCS+OD 2 Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

76 Envahissemment de l aorte Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

77 Envahissemment de l aorte Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

78 Envahissemment de l aorte Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

79 Envahissemment de l aorte Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

80 Envaissemment du Tc de l artère pulmonaire Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

81 Envaissemment de VCS + stent OD Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013

82

83

84 Left atrium invasion

85 14 years after carinal pneumonectomy combined with SVC replacement

86 Rationale Prognosis of T4 NSCLC (N0-N1) Curative intent (R0) Demanding surgery Extracorporeal circulation Benefit vs risk

87 Right upper lobectomy and carinal resection

88 Aortic resection under CPB

89 Maximal Airway Resection in Right Carinal Pneumonectomy Extension of the tumor should not be - > 2-3 cm, or cartilaginous rings above the carina, or - beyond 1.5 cm in the contralateral bronchus The safe limit is 4 cm between the division line of the lower trachea and the section of contralateral main bronchus

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