Resection of Lung Cancer Invading the Mediastinum Philippe G. Dartevelle MARIE-LANNELONGUE HOSPITAL GUSTAVE ROUSSY INSTITUTE INSTITUTE OF THORACIC ONCOLOGY PARIS SUD UNIVERSITY
Mediastinal Invasion Superior vena cava Tracheal bifurcation Pulmonary artery Aorta and supra-aortic trunks Heart Esophagus
SVC Replacement
Concerns about SVC reconstruction Graft material (PTFE or pericardium) Effects of SVC clamping Fluid administration Heparin No bypass Long term patency (anticoagulation 6 mo)
SVC Replacement S u r v i v a l 1.8.6.4.2 0 45% 20% 10 N2 15 N1, N0 p=0.2 0 12 24 36 48 60 72 months
Carinal Pneumonectomy
1 2 3 4
Right upper lobectomy and carinal resection
Carinal resection for carcinoma Survival according to nodal status Survival (%) 100 75 50 25 53% 15% N0/N1 N2/N3 14 yrs after carinal pneumonectomy and SVC replacement 0 0 60 120 180 240 Months after surgery Patients at risk N0/N1 N2/N3 74 26 26 4 9 2 4
Pulmonary artery resection and reconstruction
Invasion of the PA _ Median sternotomy _ CPB between venae cavae and ascending aorta _ Normothermia and beating heart _ Pericardial or PTFE patch
Extension to the left atrium
Supra-aortic trunks
Aortic invasion
Cannulation for partial CPB through left thoracotomy
Marie Lannelongue experience of lung cancer surgery under CPB 2003 2013 n = 17 Thoracic aorta 5 Left atrium 4 Carina 3 Pulmonary artery 3 SVC and right atrium 2
Survival after resection under 1,8,6,4,2 0 CPB Mortality : 1 / 17 (6%) R0 R1 0 12 24 36 48 60 mo
Low grade sarcoma of the lung
Airway and esophagus reconstruction
And 3 years after surgery 1 year after
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
Two Years Later
30 months after with her baby «Filippo»
Esophageal Reconstruction
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
R0/R1 1,8,6,4,2 0 P=0,133 62% R0 R1 0 12 24 36 48 60 mois Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013
100 80 Mean Arterial Pressure Mean brachiocephalic Venous Pressure Brain Arterial-Venous Gradient mm Hg 60 40 20 0 Basal Clamping Alone During SVC Clamping With Intraluminal Shunt Volume Expansion & Vasoconstrictive Agents
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
Patients' Profile (n=25) Mean age: 58 years (range: 39-79 yrs) Gender: 22 M / 3 F Squamous vs nonsquamous: 20 / 5
Nodal status 12 10 8 6 10 12 4 2 0 N2 N1 N0 1
SVC Replacement APPROACH: Thoracotomy vs. sternotomy 24 / 1 RESECTION: Intrapericardial Pneumonectomy 11 Carinal Pneumonectomy 11 Right Upper Lobectomy 3
SVC Reconstruction TYPE SVC REPLACEMENT: Truncular 23 Left brachiocephalic vein - RA 2 CLAMPING TIME : 28.6 min (15-50)
Complications Bronchopleural fistula Pneumonia # Deaths 3 2 1 Extrapericardial cardiac herniation Mortality 8% 1
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 25 11 8 7 6 5 4 Systemic 12 Resp insuf. 2 0 12 24 36 48 60 72 months
SVC Replacement S u r v i v a l 1.8.6.4.2 0 11 Carinal resection 14 Noncarinal resection 38% 25% p=0.24 0 12 24 36 48 60 72 months
Reimplantation of the intermediate bronchus into the trachea
Azygos arch resection and reimplantation into the right atrium n = 1
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%
End to end trachea- left main bronchus anastomosis and implantation of the intermediate bronchus into the left main bronchus through a right thoracotomy
PTFE graft's Patency n=25 p a t e n c y 1.8.6.4.2 0 96% 0 24 48 72 96 120 months
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
Tumors invading the subclavian vessels n = 35
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 / 64 35 22 16/2
Overall Survival S u r v i v a l 1.8.6.4.2 0 37% 7% n = 94 N0 (n=73) N1-3 (n=21) p = 0.01 0 20 40 60 80 100 120 Time (months)
Subclavian Artery Invasion 1 Survival.8.6.4.2 SA invaded n=35 SA not invaded n=59 p=ns 0 0 12 24 36 48 60 72 84 96 108 120 months
Envahissemment de l OG Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013
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
Aortic arch resection and reconstruction under CPB n = 2
Main pulmonary artery bifurcation resection under CPB in Lung Cancer
Série du CCML Sexe: H/F 12/5 Age : 56 ans (44 71 ans) 2003 2013 N=17 Induction: oui 8/ non 9 Planifié 9 non 8 Histologie Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013
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
Envahissemment de l aorte Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013
Envahissemment de l aorte Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013
Envahissemment de l aorte Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013
Envahissemment de l aorte Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013
Envaissemment du Tc de l artère pulmonaire Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013
Envaissemment de VCS + stent OD Congrès de Chirurgie Thoracique et Cardio-Vasculaire - Marseille 12/15 juin 2013
Left atrium invasion
14 years after carinal pneumonectomy combined with SVC replacement
Rationale Prognosis of T4 NSCLC (N0-N1) Curative intent (R0) Demanding surgery Extracorporeal circulation Benefit vs risk
Right upper lobectomy and carinal resection
Aortic resection under CPB
Maximal Airway Resection in Right Carinal Pneumonectomy Extension of the tumor should not be - > 2-3 cm, or - 3-4 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