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Ann Thorac Surg 2000;70:1172-1175
© 2000 The Society of Thoracic Surgeons

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Original articles: general thoracic

Combined tracheal sleeve and superior vena cava resections for non–small cell lung cancer

^a Department of Thoracic Surgery, European Institute of Oncology, Milan, Italy

Address reprint requests to Dr Spaggiari, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy
e-mail: lorenzo.spaggiari{at}ieo.it

	Abstract

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Background. Combined superior vena cava and tracheal sleeve resections are occasionally indicated in the treatment of non–small cell lung cancer. However, more effective induction therapy may potentially expand the benefit of locally extended resections.

Methods. From January 1998 to December 1999, 6 consecutive patients had combined tracheal sleeve and superior vena cava resections for non–small cell lung cancer after induction treatment. Surgical approach was muscle-sparing lateral thoracotomy in 4 patients and hemiclamshell approach in 2 patients. There were four tracheal sleeve pneumonectomies, one tracheal sleeve bilobectomy, and one tracheal sleeve lobectomy. Three patients (50%) had complete superior vena cava resection with graft replacement, whereas the other patients had partial superior vena cava resection using vascular staplers.

Results. There were no perioperative complications. Three patients (50%) had major postoperative complications, but there were no postoperative deaths. Four patients are still alive, 2 without evidence of disease. The median survival was 14.5 months (range, 3 to 17 months).

Conclusions. These combined resections are technically feasible with no postoperative mortality but high morbidity (50%). This aggressive surgery may be useful in highly selected patients where adequate local control can achieve long-term survival.

	Introduction

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Although the resection of the superior vena cava (SVC) for non–small cell lung cancer (NSCLC) is a topic of debate [1], two recent studies reported technical feasibility, low postoperative mortality rate, and noteworthy 5-year survival in patients with T4, N0-N1 disease [2, 3]. However, combined extended resections (tracheal sleeve and SVC resections) in advanced NSCLC have not been investigated yet.

In this report we present our preliminary experience with combined extended resection for NSCLC in patients with concomitant SVC and carinal involvement, analyzing technical feasibility and early and late postoperative outcomes.

	Material and methods

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From January 1998 to December 1999, 11 patients (9 men and 2 women, median age 62 years, range 45 to 77 years) had SVC resection for NSCLC. These patients comprise 4.4% (11 of 250) of all patients who had radical lung resection for NSCLC in that period.

Six of these patients had associated carinal resection and comprise 16.6% (6 of 36) of all tracheobronchial sleeve resections done in that period. During the same period there were 12 (4.8%) exploratory thoracotomies.

All patients in the present series had induction treatment (five cases of chemotherapy, one case of chemotherapy, associated with thrice-daily hyperfractionated radiotherapy). In five cases, the indication for both tracheal sleeve and SVC resections was the direct invasion (T4) by the tumor, whereas in the remaining case the resection was done for N2 involvement.

Patients with T4 involvement had the SVC resection as the first procedure, and in the patient with N2 involvement the tracheal sleeve resection was done first (Figs 1, 2, and 3).

View larger version (132K): [in this window] [in a new window]   Fig 1. Infiltration of the superior vena cava (SCV) by N2 non–small cell lung carcinoma after induction treatment. The SVC and right main pulmonary artery (PA) are isolated.

View larger version (127K): [in this window] [in a new window]   Fig 2. Same case as in Figure 1. The tracheal sleeve resection has been done, and the tracheal anastomosis is covered by a pericardial flap. A truncular substitution of the superior vena cava by a 12-mm ringed polytetrafluoroethylene graft is in progress. The distal anastomosis was done first.

View larger version (132K): [in this window] [in a new window]   Fig 3. Same case as in Figures 1 and 2. The proximal anastomosis is done, and the superior vena cava replacement is completed. (PTFE = polytetrafluoroethylene.)

Three patients had more than two thirds of the SVC circumference involved by the tumor (Fig 4), and they had SVC replacement with polytetrafluoroethylene (PTFE) graft. No patients had SVC syndrome from SVC occlusion before resection. Complete clamping of the SVC system was done after having widely opened the pericardium without positioning any venous shunts. An anticoagulation therapy of 0.5 mg/kg intravenous sodium heparin was given before clamping. The clamping time during graft replacement was short (27, 35, and 38 minutes), and this is the most important factor to avoid perioperative neurologic complications. The brain pressure gradient was maintained by moderate fluid implementation (10 mL/kg during clamping). No steroids or hyperventilation was used.

View larger version (102K): [in this window] [in a new window]   Fig 4. Prechemotherapy computed tomographic thoracic scan showing the degree of superior vena caval involvement requiring graft replacement.

When the distal anastomosis was done on the left brachiocephalic vein, a 10- or 12-mm ringed PTFE graft was preferred, whereas a 12- to 14-mm ringed PTFE graft replacement was used for truncular revascularization.

Three patients had partial resection of the SVC without complete clamping and tangential suture using a vascular stapler.

	Results

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Tables 1, 2, and 3 report the main data of the present series. There were no perioperative complications resulting from SVC clamping and no postoperative deaths.

Four patients are still alive, two without evidence of disease. One patient died without disease. The median survival was 14.5 months (range, 3 to 17 months).

	Comment

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Combined tracheal sleeve and SVC resections are technically demanding procedures in which major difficulties are associated with uncertain oncologic benefits.

These extended resections for NSCLC have been done only occasionally and rarely reported in the literature. To the best of our knowledge, and with the exception of some case reports, only three series with more than 4 patients are cited in the English-language literature with some 5-year survivors, including six cases by Dartevelle and colleagues [5] followed up over a 16-year period, 12 cases by Tsuchiya and associates [6], and 4 cases by Spaggiari and colleagues [3]. However, no data concerning postoperative morbidity, mortality, and outcome were reported.

Survival after SVC resection as well as tracheal sleeve pneumonectomy has been proved noteworthy mainly in patients without mediastinal lymph node involvement [2, 3]; however, patients with combined SVC and tracheal sleeve resection comprise a subgroup of patients in whom oncologic benefits of surgical resections are far from being proved. Furthermore, anesthesiologic and surgical feasibility and postoperative morbidity are still under investigation.

From an anesthesiologic point of view, combined extended resections for T4 NSCLC are a challenge; in fact, tracheal sleeve resection with mediastinectomy for radical lymph node dissection requires an accurate fluid balance in terms of fluid restriction. By contrast, complete SVC replacement without internal or external shunts requires fluid implementation during clamping to increase arterial pressure and to maintain a brain pressure gradient to avoid cerebral edema. However, such fluid implementation might facilitate postoperative pulmonary edema mainly in pneumonectomized patients. In our opinion, this serious complication might be avoided by reducing clamping time and then by performing SVC resection before lung resection. In this way, appropriate administration of diuretics could easily remove the surplus of fluids before pulmonary resection.

From a technical point of view, limited SVC involvement can be resected easily by tangentially clamping the vessels and by suturing the SVC using a vascular stapler or a running suture. Superior vena caval involvement exceeding one third of the circumference requires graft replacement. The choice of the site of proximal anastomosis depends on the degree of SVC involvement and the surgical approach used. When brachiocephalic vein confluence is involved, we prefer to revascularize the left brachiocephalic vein closing the right one. In this case, a 12-mm diameter ringed PTFE graft is sufficient; for truncular substitution a 12- or 14-mm-diameter ringed PTFE graft is the choice. In our series of SVC resections and graft replacement for lung and mediastinal neoplasm (nine cases) during the past two years, the median clamping time was 34 minutes (range, 24 to 38 minutes). In our experience, the PTFE graft has remained patent at long-term assessment (Fig 5) [1].

View larger version (118K): [in this window] [in a new window]   Fig 5. Spiral computed tomographic thoracic scan after injection of contrast dye during follow-up. Note the graft patency.

The use of a small-diameter, no-ringed prosthesis and the presence of a previous subclavian vein thrombosis might explain the early graft thrombosis that occurred in one patient of our series.

Concerning the use of anticoagulant agents, we maintained patients who had SVC resection with graft replacement on coumadin for at least for 6 months. However, the ideal anticoagulant regimen at discharge after SVC replacement is still not determined.

From a prognostic point of view, it has been suggested that only patients without mediastinal lymph node involvement should undergo SVC resection. However, that suggestion was based on data from surgical series in which most patients did not benefit from new chemotherapy regimens. All our patients underwent preoperative cisplatin-based chemotherapy and had a good response.

Although the curative potential of extended resection for locally advanced NSCLC has yet to be defined, in selected T4N0 patients with SVC involvement, a radical resection, with or without bronchoplastic procedures, can achieve excellent local control. However, in N2 disease, induction treatment is mandatory and the benefit of surgical resection versus radical radiotherapy has to be tested in prospective trials. In any case, pretreatment mediastinoscopy is an essential staging procedure to determine the optimal treatment of these highly selected patients.

	References

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1. Dartevelle P.G., Chapelier A., Pastorino U., et al. Long-term follow-up after prosthetic replacement of the superior vena cava combined with the resection of mediastinal-pulmonary malignant tumors. J Thorac Cardiovasc Surg 1991;102:259-265.[Abstract]
2. Thomas P., Magnan P.E., Moulin G., Giudicelli R., Fuentes P. Extended operation for lung cancer invading the superior vena cava. Eur J Cardiothorac Surg 1994;8:177-182.[Abstract]
3. Spaggiari L., Regnard J.F., Magdeleinat P., Jauffret B., Puyo P., Levasseur P. Extended resections for bronchogenic carcinoma invading the superior vena cava system. Ann Thorac Surg 2000;69:233-236.[Abstract/Free Full Text]
4. Mathey J. Tumeur benigne de leperon tracheal, resection et refection du carrefour tracheo-bronchique. Semin Hopital Paris 1951;27:2699-2703.
5. Dartevelle P.G. Extended operations for the treatment of lung cancer. Ann Thorac Surg 1997;63:12-19.[Abstract/Free Full Text]
6. Tsuchiya R., Asamura H., Kondo H., Goya T., Naruke T. Extended resection of the left atrium, great vessels, or both for lung cancer. Ann Thorac Surg 1994;57:960-965.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lorenzo Spaggiari Ugo Pastorino Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Spaggiari, L. Articles by Pastorino, U. Search for Related Content PubMed PubMed Citation Articles by Spaggiari, L. Articles by Pastorino, U.