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Disclosures

Disclosures

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Disclosures

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  1. Disclosures • EES: teaching, speaking, consulting • Varian: advisory board, speaking

  2. Pulmonary arterioplasty and vena cava reconstruction as part of lung cancer resection Bryan F. Meyers MD MPH Patrick and Joy Williamson Professor of Surgery

  3. Definition:T4 • Tumor of any size characterized by one of the following: (1) invasion of the trachea, carina, heart, great vessels, vertebral body, esophagus, or mediastinum, (2) one or more satellite tumor nodules in the same lobe, or (3) malignant pleural effusion Rice & Blackstone, 2002

  4. SVC Involvement

  5. Barnard et al., Eur J Cardiothorac Surg 2001

  6. Barnard et al., Eur J Cardiothorac Surg 2001

  7. Synthesis of Studies T4 Resections Bernard et al., Eur J Cardiothor Surg, 2001

  8. SVC Involvement • Majority are unresectable • N2, distant mets, extensive mediastinal inv. • Issues • amount of circumferential involvement • need for clamping (how long is too long?) • increased ICP, brain damage • reduction in cardiac inflow • Operative mortality 5-7% • Median and 5 year survival modest

  9. Case Presentation • 70 y/o with HTN • CXR: right perihilar mass • CT : 4.5 cm central mass • SVC compressed • Tumor abutting aorta and PA • FNA revealed adenocarcinoma

  10. Case Presentation • Induction chemotherapy with response • repeat CT and PET scan • Mediastinoscopy negative • PET: FDG activity in right hilum • All metastatic work-up negative

  11. Case Presentation • Right pneumonectomy • Large mass anterior to right main PA • Involved pericardium, phrenic nerve, lateral border of SVC, superior pulmonary vein • Central involvement required amputation at SPV/atrial junction • SVC encircled, central line in RA, SVC amputated along lateral wall & patched

  12. Variable degrees of resection and reconstruction • Tangential resection and simple closure • Tangential resection and patch • Complete resection with interposition graft reconstruction

  13. Variable approaches • Thomas et al, 1994 • 11 lateral, 4 circumferential resections • 9 sutured, 2 patched, 4 tube grafted • Misthos et al, 2007 • 8 lateral and 1 circumferential • 3 sutured, 5 patched, 1 tube graft

  14. Example of Tangential Resection and Closure • Central right upper lobe tumor • Bronchus, PA and PV all transected with negative margins • Close abutment and possible invasion of SVC near azygous

  15. Considerations of Tangential Resection • Simple • Narrows the SVC- watch for central line or portocath • Judgement about how much to narrow before patching • Avoid staples on specimen- will hinder margin assessment

  16. Dartevelle 2009 • Results of Primary Surgery With T4 Non–Small Cell Lung Cancer During a 25-Year Period in a Single Center: The Benefit is Worth the Risk • BedrettinYıldızeli, MD, Philippe G. Dartevelle, MD, ElieFadel, MD, SachaMussot, MD, and AlainChapelier, MD • Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Paris-Sud University, • Le Plessis Robinson, France • Ann ThoracSurg 2008;86:1065–75

  17. Yildizelli and Dartevelle • 39 cases of SVC invasion • Resections included: • 32 right pneumonectomy • 5 right upper lobectomy • 2 wedge resection • Stages included: • 18 were N1, 16 were N2/3; 1 was M1 • Median surv 19 months, 5YS 29% Ann ThoracSurg 2008;86:1065–75

  18. SVC Resection: Factors Influencing Long-Term Survival • Survival • median survival 11 months • 1, 3, 5 year survival 49%, 25% and 21% • pneumonectomy vs lobe (death risk) • No other factor associated with survival • T status • N status Spaggiari et al., in press JTCVS 2002

  19. Survival T4 Lung Cancers - Tracheal, Carinal, Atrial, Aortic, SVC, Vertebral Body Involvement 19 mo Rice & Blackstone, 2002

  20. Conclusions • Radical resections for T4 NSCLC can be achieved with acceptable morbidity, mortality and survival • Best prognosis in SVC invasion with partial resection/closure/patch • Complete resection, in all series, key to any reasonable survival • Patient selection, induction/adjuvant therapy might impact outcome

  21. References SVC resection • Dartevelle PG, Chapelier AR, Pastorino U, et al. Long-term follow–up after prosthetic replacement of the superior vena cava combined with resection of mediastinal–pulmonary malignant tumors. J ThoracCardiovascSurg 1991;102:259–265. • Tsuchiya R, Asamura H, Kondo H, Goya T, Naruke T. Extended resection of the left atrium, great vessels, or both for lung cancer. Ann ThoracSurg 1994;57:960–965. • Gonzalez–Fajardo JA, Garcia–Yuste M, Florez S, Ramos G, Alvarez T, Coca JM. Hemodynamic and cerebral repercussions arising from surgical interruption of the superior vena cava. Experimental model. J ThoracCardiovascSurg 1994;107:1044–1049. • PiccioneJr,W, FaberLP, Warren WH. Superior vena caval reconstruction using autologous pericardium. Ann ThoracSurg 1990;50:417–419. • Solli P, Spaggiari L, Grasso F, Pastorino U. Double prosthetic replacement of pulmonary artery and superior vena cava and sleeve lobectomy for lung cancer. Eur J CardiothoracSurg 2001;20:1045–1048. • Dartevelle P, Macchiarini P, Chapelier A. Technique of superior vena cava resection and reconstruction. Chest SurgClin N Am 1995;5: 345–358. • Rendina EA, Venuta F, De Giacomo T, et al. Induction chemotherapy for T4 centrally located non-small cell lung cancer. J ThoracCardiovascSurg 1999;117:225–233. • Surgery of the Superior Vena Cava: Resection and Reconstructionhttp://www.ctsnet.org/sections/clinicalresources/thoracic/expert_tech-6.html. FedericoVenuta, MD , Erino A. Rendina, MD and Giorgio F. Coloni

  22. Pulmonary arterioplasty • Always upper lobe problem • Usually left upper lobe issue (70:30 in Venuta/Rendina series) • Similar concerns as for SVC invasion: • Complete resection important • Consideration of nodal and distant mets • Variable options to reconstruct based on extent of resection

  23. Case presentation 70 year old with dysphagia Swallow negative for good explanation Left hilar mass noted- CT scan obtained

  24. Case

  25. Case

  26. Issues • Pneumonectomy sparing options should be considered • Bronchial sleeve would be hampered by apparent PA involvement • Potential complete resection with sparing of LLL using double sleeve • More common presentation is more peripheral tumor abutting PA

  27. Technical options • Primary suture closure • Patch with various materials • Autologous pericardium • Autologous pulmonary vein • Bovine pericardium • Sleeve PA plasty without prosthetic • Conduit reconstruction

  28. References for pulmonary arterioplasty • Puma et al. Eur J Cardiothorac Surg (2011) 40 (3): e107-e111. doi: 10.1016/j.ejcts.2011.05.012 • Venuta, Rendina. J ThoracCardiovascSurg 2009;138:1185-1191