報告人 : R4 莊冠華

1. Superior Vena Cava Resection for Lung and Mediastinal Malignancies: A Single-CenterExperience With 70 Cases Lorenzo Spaggiari, MD, PhD, Francesco Leo, MD, PhD, Giulia Veronesi, MD,Piergiorgio Solli, MD, Domenico Galetta, MD, Brunilda Tatani, MD, Francesco Petrella, MD, and Davide Radice, PhD Divisions of Thoracic Surgery and Epidemiology and Biostatistics, European Institute of Oncology, and University of Milan Schoolof Medicine, Milan, Italy 報告人: R4 莊冠華

2. Background • Superior vena cava (SVC) system invasion by lung and mediastinal malignancies has long been considered a contraindication for surgical resection. • The 1970s and 1980s, experimental animal research and clinical case reports suggested such an extended surgery resulting in long-term survival in some instances. • We have reviewed our experience in the treatment of locally advanced lung and mediastinal tumor invading the SVC system, analyzing postoperative outcome and long-term oncologic results.

3. In the last 15 years, several series of SVC resections have been published, confirming feasibility and reporting long-term survival data (Table 1)

4. Material and Methods • A specific database was designed for patients undergoing SVC resection and comprised four sections: • Demographics (age, sex, history,FEV1, DLCO) • Oncologic data (TMN, induction treatment, PET scan report ) • Intraoperative data • Postoperative and follow-up data

5. Intraoperative Management • Lung tumors --- standard muscle-sparing lateral thoracotomy • mediastinal tumor --- sternotomy or the hemiclamshell approach were used • The type of SVC resection performed depended on the degree of venous involvement.

6. When vessel involvement was limited (less than 50%), resection and direct repair was preferred • When the defect was too large, it was repaired by the use of a pericardial patch (Fig 1).

7. When the SVC was not extensively infiltrated close to one of the BCV trunks (left or right), the entire venous trunk was removed without subsequent reconstruction, unless both BCV were infiltrated or the patient had a previously resected or ligated contralateral internal jugular vein; in that case, the BCV was reconstructed by prosthetic replacement

8. When SVC infiltration involved more than 50% of the circumference of the SVC, prosthetic replacement by cross-clamping technique was preferred (Fig 3).

9. On an exceptional basis, when SVC infiltration involved the right side of the heart, the use of extracorporeal circulation was planned (Fig 4).

10. 1998 to 2002, SVC prosthetic replacement was performed by a polytetra-fluoroethylene (PTFE) graft (Fig 3). Since 2003, using a biological, custom-made bovine pericardial tube (Shelhigh No- React Pericardial Patch [10 15]; Shelhigh, Millburn, New Jersey [Fig 5]).

11. Follow-Up • Patients with SVC resection were followed up at 1 month and every 4 months afterward. Statistical Analysis • Postoperative mortality was defined as any death occurring during hospitalization or within 30 days after surgery. • Student’s t test • Survival curves were obtained by the Kaplan-Meier method,

12. Results • From November 1998 to May 2004, 70 patients underwent SVC system resection for either lung or mediastinal malignancies. • Clinical characteristics of the population are reported in Table 2.

14. Fifty-two patients (42 male patients, median age • 62,7 years) had SVC resection for nonsmall-cell lung • Twenty-one patients (40%) underwent mediastinal investigation by mediastinoscopy before SVC surgery, • 40 (77%) received preoperative induction treatment (chemotherapy, n=33; chemoradiation therapy, n=7). • In 18 patients, resection was performed for mediastinal malignancies

15. Superior Vena Cava Reconstruction • In 25 cases (35.7%), extent of SVC infiltration required a prosthetic replacement. • In the group of 13 patients who received SVC replacementfor lung cancer, replacement was performed by a PTFE graft in 8 patients (median size, 14; range, 10 to 16); and since 2003 by a biological, custom-made bovine pericardial tube in 5 patients (size no. 20)

16. Morbidity and Mortality • No intraoperative death was observed. • Lung cancer group --- major postoperative complications --23% (n=12, 7 was pulmonary ). --- mortality was 7.7% (n=4). • Mediastinal tumor group --- major postoperative complications --- 50% (n=9), The mortality was 5.5% (n=1, ARDS)

17. Morbidity and Mortality • The demographic and intraoperative variables --- no a significant impact on morbidity and mortality. • postoperative morbidity and mortality --- no affected by preoperative chemotherapy in either group (Fisher’s exact test, p =0.11).

18. Early and Late Thrombosis • Median follow-up of 32 months, 6 prosthetic thromboses were recorded (overall thrombosis rate 8.5%, prosthetic thrombosis rate 24% ). • Four thromboses occurred within 1 months after operation (early thrombosis) --- One was complete SVC prosthetic replacement, three were both left BCV and partial SVC resection with PTFE graft. • Two late thromboses (more than 1 month after surgery) • Not significantly related to any of the demographic and intraoperative variables • Nevertheless, in 4 of 6 cases (66.6%), a BCV reconstruction was associated.

19. Long-Term Survival • Median survival was 16.2 months • with a 5-year probability of survival of 31% Mediastinal lymph nodes involvement affected survival, 5-year survival • N0–N1 ---56% • N2 --- 21% , N3 --- 0% (P=0.056) • No difference between patients who received preoperative chemotherapy and those who did not (log-rank test, p =0.68). • The mediastinal tumours group was 49 months, with a 5-year probability of survival of 45%.

20. Comment Two questions regarding SVC surgery remain unaswered: • what are the defining characteristics of an optimum candidate for SVC resection? • which SVC reconstruction technique provides the best results?

21. Comment First question: • Never be considered in the case of urgent treatment of acute SVC syndrome. • The best results in terms of survival are obtained in mediastinal tumors • Mediastinal nodal status.

22. Comment • The role of neoadjuvant chemotherapy (Four reasons) • No difference between patients who received preoperative chemotherapy and those who did not (log-rank test, p =0.68). • It is true that a percentage of patients classed as clinical T4 are “false T4” (about 40%)

23. Comment Second question: • It depends on the degree of SVC infiltration • Direct repair, autologous pericardial Patch--- not require long-term anticoagulation. • Circumferential SVC resection---gold standard of SVC prosthetic replacement was PTFE--- require long-term anticoagulation and further increases the risk of trombosis. • Bovine pericardium---lower risk of thrombosis and reduce inflammatory response

24. Conclusion • SVC resection may achieve permanent cure • In the case of mediastinal tumors, SVC resection alone should not be considered a contraindication for surgery when prosthetic replacement is feasible • In the case of lung tumors, infiltration of SVC can achieve satisfactory long-term results after neoadjuvant chemotherapy, but only when pathologic N2 disease is excluded by preoperative mediastinoscopy.

25. Thanks for your attention !