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Pulmonary Arterioplasty and Vena Cava Reconstruction in Lung Cancer Resection

This article discusses the use of pulmonary arterioplasty and vena cava reconstruction as part of lung cancer resection in T4 stage tumors. It explores the benefits, risks, and outcomes of these procedures, highlighting the importance of complete resection for reasonable survival rates.

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Pulmonary Arterioplasty and Vena Cava Reconstruction in Lung Cancer Resection

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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

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