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