Resection and reconstruction of the great vessels for lung cancer and mediastinal tumor

Between January 1994 and December 1997, 17 patients with lung cancer and 5 patients with mediastinal tumor underwent extensive resection and reconstruction of the great vessels. In patients with lung cancer, the aorta was resected under cardiopulmonary bypass in 4 patients, the superior vena cava in 12, and the left main pulmonary artery with combined resection of the left atrium in 1 and the aorta in 1. In five patients who underwent resection of the superior vena cava, subcarinal resection and reconstruction were also performed. Three patients died within 30 days after surgery. Six patients died of cancer between 3 months and 2 years after surgery. Two patients who underwent aortic resection for node negative lung cancer have survived more than 3 years after surgery. Six patients have survived between 6 months and 2 years after surgery. The histologic type of mediastinal tumor was thymic cancer in 3 patients, invasive thymoma in 1 and malignant lymphoma in 1. In patients who underwent resection of the superior vena cava for mediastinal tumor, bilateral brachiocephalic vein reconstruction was performed in 4 patients and the left brachiocephalic vein reconstruction in 1. One patient underwent resection of the right atrium. The patient with invasive thymoma has survived for more than 3 years. Two of 3 patients with thymic cancer died within 2 years. When complete resection is achieved with combined resection of the great vessels, survival may be anticipated in patients with N0 lung cancer or in those with invasive thymoma.     

A case of thymoma protruding into the superior vena cava through the thymic vein

We describe an unusual case of an invasive thymoma protruding into the superior vena cava and left brachiocephalic vein through the thymic veins in a 64-year-old patient. The tumor was resected with a bypass of the right brachiocephalic vein and right atrium. Although this type of growth form is rare for an invasive thymoma, this case suggests that in surgical procedures for thymomas, meticulous examination of the thymic veins is necessary to avoid leaving residual tumor.     

血管重建在原发性纵隔肿瘤中的临床应用

目的总结血管重建在原发性纵隔肿瘤中的应用经验和疗效。方法经外科手术治疗并血管重建的原发性纵隔肿瘤76例,22例（28.9%）单纯侵及上腔静脉;16例（21.1%）侵及单纯左或右无名静脉;34例（44.7%）侵及上腔静脉和左或右无名静脉;有4例（5.3%）单纯侵及主动脉外膜。行完整切除70例,部分切除6例;行血管置换46例,血管成形30例。结果全组病人无一例围术期死亡。上腔静脉阻断时间为（10-30）min,平均（18.0±5.3）min。左或右无名静脉单侧阻断时间为（11-25）min,平均（16.5±4.2）min。全组病人均获随访,时间为12-26个月,术后生活质量满意。结论纵隔肿瘤侵及上腔静脉及其属支大血管的病人,如全身无系统功能严重受损应积极手术治疗,可选用血管置换或血管成形术。     

Malignant thymoma in children: a 20-year review

Malignant thymomas are extremely rare in children, with only 27 cases reported thus far in the pediatric surgical literature. We report four additional cases diagnosed at this institution over the past 20 years (ages 3 to 14 years). Clinical presentations included superior vena cava syndrome, cough, dyspnea, cyanosis, enlarging mediastinal mass, spontaneous pneumothorax, and pleuropericardial effusion. Three patients underwent incomplete resection of the mass or biopsy because of "unresectability" and were treated with radiotherapy and adjunctive chemotherapy. One patient underwent near complete macroscopic resection as well as radiotherapy and chemotherapy. All patients died at intervals ranging from 6 months to 2 1/2 years after diagnosis. Three patients were found to have metastatic disease prior to death or at autopsy. In one case, the initial pathological diagnosis was lymphocytic thymoma. After ultrastructural studies were performed, the diagnosis was changed to thymic T-cell lymphoma. This patient subsequently developed acute lymphoblastic leukemia 3 months after surgical resection followed by radiotherapy. Malignant thymomas are highly aggressive tumors in children. A radical surgical approach with complete excision of the tumor and contiguous structures in continuity, with adjunctive radiotherapy and chemotherapy remains the only hope for survival in children with these rare lesions.     

Transcaval invasion of right atrium by thymoma: resection via transient cava-pulmonary shunt

Transcaval extension of the thymoma to the right atrium has very rarely been reported, and cardiopulmonary bypass is recommended for successful resection. An invasive thymoma with intravascular invasion of the superior vena cava, and the left innominate vein extending into the right atrium was presented. Intra-atrial extension was resected through a transient external shunt from the inferior vena cava to the main pulmonary artery. We discussed the feasibility of this surgical technique and possible advantages of cardiopulmonary bypass avoidance.     

Technical points of venous reconstruction for disorders of the superior vena cava

In recent years, the number of patients with disorders of the superior vena cava due to mediastinal tumors such as malignant thymoma, teratoma and hilus type of lung cancer is now increasing in Japan. For those patients, we have tried to do venous reconstruction for the disorders of the superior vena cava (SVC) due to malignant mediastinal tumors. By these combined surgical procedures such as resection of malignant tumor and SVC reconstruction, curability and longevity of the life were apparently recognized. However, it is very important to select patients of which resection of tumor and venous reconstruction can be carried out by several kinds of examinations such as computed tomography (CT), magnetic resonance angiography (MRA) and venography. There are 3 kinds of reconstruction such as direct suture and patch grafting, as well as bypass grafting with ringed e-PTFE (expanded-polytetrafluoloethylene) prosthetic graft except for endovascular interventions of which number of patients is still few. On the other hand, bypass grafting is also effective for high intracranial pressure with syncope for the patients whose tumors could not be resected, because of huge tumor and diffuse invasion.     

Surgical Treatment of Complex Malignant Anterior Mediastinal Tumors Invading the Superior Vena Cava

Determining the appropriate surgery-based treatment for complicated anterior mediastinal malignancies (CAMM), especially those invading the superior vena cava (SVC) and its branches, remains a challenge for general thoracic surgeons. In this report, we summarize our experience and lessons regarding this issue in order to discuss a reasonable strategy for diagnosis and treatment of CAMM. Between January 2001 and April 2003, 15 patients with CAMM invading the SVC and/or its branches with or without invasion of other neighboring organs were surgically treated in our institution by a single surgeon team. We collected clinical data from the medical charts and from surgeons’ specific notes for complicated cases, and performed a comprehensive analysis. There were 9 patients with malignant thymoma. Thymic carcinoma, teratoma, embryonal carcinoma, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, and mixed teratoma with thymoma were diagnosed in 1 patient each. All procedures were performed via median sternotomy. Some angioplasty techniques were successfully used to resect and reconstruct the SVC. Ten of the 15 patients also underwent pulmonary resection due to involvement of pulmonary parenchyma. Four of the patients underwent perioperative chemotherapy. There were no perioperative deaths. Two patients suffered prolonged ventilation after surgery, and there were no other severe complications related to surgery. One patient died 10 months after surgery. The remaining 14 patients were still living and their progress is still monitored. As of August 2004, the median follow-up duration for all patients was 35 months, and the disease-free survival duration was 10–43 months. CAMM can be safely and completely resected via a median sternotomy, even if it has invaded other mediastinal structures. CAMM should be pathologically identified before initial treatment. A good outcome for patients with CAMM is possible if a suitable strategy combining accurate diagnosis and appropriate treatment, especially surgical resection, is established. Ke-Neng Chen and Shao-Fa Xu contributed equally to this work.     

Intraatrial extension of thyroid cancer: technique and results of a radical surgical approach

An occlusion of the superior vena cava by a tumor thrombus extending into the right atrium was diagnosed in three patients with a follicular thyroid cancer. All patients showed the typical clinical picture of the superior vena cava syndrome. A right parasternal thoracotomy was performed for preparation of the major vessels. The superior vena cava was opened and the entire intravascular tumor thrombus was removed. The cavotomy was closed directly in two patients. In the third patient the left brachiocephalic trunk was resected and reconstructed with a vascular (polytetrafluoroethylene) graft. This patient had bone and brain metastases and an occlusion of the graft 3 months after surgery after anticoagulation was stopped. The other two patients were clinically symptom free without local recurrence 13 and 50 months after surgery. An aggressive surgical approach is justified in grossly invasive thyroid cancer to decrease local recurrence and death rates, to correct the disturbing clinical symptoms of superior vena caval occlusion, and to prevent tumor embolism and the development of distant metastases. By reducing tumor mass, an even better basis for radioiodine treatment can be prepared.     

Major vascular resection as part of pancreaticoduodenectomy for cancer: Radiologic, intraoperative, and pathologic analysis

Intraoperative assessment is inaccurate in defining the relationship of a pancreatic head neoplasm to adjacent vascular structures. We evaluated the ability of preoperative contrast-enhanced CT to predict the need for vascular resection during pancreaticoduodenectomy and examined the resected vessels for histologic evidence of tumor invasion. During a 7-year period, 63 patients underwent pancreaticoduodenectomy with en bloc resection of adjacent vascular structures for a presumed pancreatic head malignancy. Clinical, radiologie, operative, and pathologic data were reviewed and analyzed. Fifty-six patients underwent resection of the superior mesenteric-portal vein confluence, three patients required inferior vena cava resection, and the hepatic artery was resected and reconstructed in eight patients. The operative mortality rate was 1.6%, and the overall complication rate was 22%. CT predicted the need for resection of the superior mesenteric or portal veins in 84% of patients. Pathologic analysis revealed tumor invasion of the vein wall in 71% of resected specimens. Tumor invasion of vascular structures adjacent to the pancreas can be predicted with preoperative CT and should alert the surgeon that vascular resection may be required. Histologic evidence of tumor cell infiltration of vessel walls was present in the majority of the resected specimens. Supported by the Various Donors Fund for Pancreatic Cancer Research at M.D. Anderson Cancer Center. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998.     

Surgical treatment of the malignant mediastinal tumors--with special reference to prosthetic reconstruction of superior vena cava

Sixteen patients with the malignant mediastinal tumors compromising the superior vena cava (SVC) and brachiocephalic veins (BCV) were treated from April 1974 to March 1987. SVC reconstruction by prosthesis combined with or without tumor resection were performed in 6 cases and removal of the tumor with partial resection of SVC and right BCV in one case. Two patients died within one month and two patients survived over 5 years postoperatively. Tumor resection, removal of the right lung and SVC wall, and patch angioplasty were performed in one patient who died three and one half months postoperatively. Resection of the tumor and left BCV were performed in 4 patients. Segmentally resected left BCV was reconstructed with interposed graft in two, prosthesis was implanted between left BCV and right atrium in one and no venous reconstruction was attempted in one. Three patients are alive and one patient died six and one half years after operation. Exploratory mediastinotomy was carried out in 3 cases and radiation therapy alone in one case. All but one patients died within one year after diagnosis. Though the long term results of the surgical treatment for malignant mediastinal tumor was not satisfactory, extensive resection of the tumor was worth attempting, as the patency rate of the prosthetic venous reconstruction was improved.     

Thymic carcinoma with tumor thrombus into the superior vena cava

Tumor thrombus into the vena cava have been reported in cases with renal cell carcinoma, thyroid tumor and in those with thymoma. These tumors are frequently invasive and continuous from the main tumor that shows direct vessel wall invasion. Here, we report a case of thymic carcinoma with superior vena cava syndrome, which was caused by a tumor thrombus in the superior vena cava without vessel wall invasion. The main mediastinal tumor did not show innominate vein invasion, and the superior vena cava syndrome was a result of separate tumor thrombus that was free of vessel wall invasion. The tumor thrombus could be removed through a simple venotomy. To prevent stenosis in the superior vena cava and the left innominate vein, we used a pericardial patch to close the venotomy site.     

Gore-Tex grafts for replacement of the superior vena cava in 10 patients with intrathoracic malignant tumors

Ten patients with lung cancer and mediastinal tumor invading the mediastinal structures underwent replacement of superior vena cava (SVC) with ringed Gore-Tex to resect malignant tumors. In patients with lung cancer sleeve pneumonectomy (3 patients), sleeve lobectomy (1 patients) and tracheal resection (one patient) were performed simultaneously. By resection of the VCS system, invasive thymomas were able to be resected completely in 2 of 3 patients. In 2 patients with mediastinal tumors, one with metastatic testicular chorio carcinoma and one with malignant lymphoma of non-Hodgkin type, aggressive chemotherapy was followed by resection of the residual tumors including VCS. Except for one patient, there was no sign showing disturbance of the venous return in the VCS system in the 5 to 43 months' postoperative follow up period. We conclude that ringed Gore-Tex graft permits the extended operation for intrathoracic malignancies invading the mediastinal structures.     

冠状窦顶重建治疗无顶综合征合并心内膜垫缺损和永存左上腔静脉

目的 总结冠状静脉窦顶重建在无顶冠状静脉窦综合征合并心内膜垫缺损和永存左上腔静脉的外科治疗经验.方法 2000年1月至2008年1月共753例心内膜垫缺损病人行畸形矫治手术,15例(2%)同时合并永存左上腔静脉和无顶冠状静脉窦综合征,包括部分型心内膜垫缺损12例,完全型心内膜垫缺损3例.均在行心内膜垫缺损矫治术同期重建冠状静脉窦顶,1例直接结扎左上腔静脉,14例将左上腔静脉隔入右房,其中10例用自体心包补片,4例通过折叠左房后壁完成冠状静脉窦顶的重建,最后在重建的冠状静脉窦开口的左侧缝合修补房间隔缺损.结果 术后早期1例死于严重肺部感染.术后随访3个月～6年,无远期死亡病例.14例术后均未见腔静脉、肺静脉回流梗阻和心房水平残余分流.1例行左房后壁折叠分隔左上腔静脉者术后早期超声心动图提示左上腔静脉入左房顶处血流速度偏快.结论 合并心内膜垫缺损和永存左上腔静脉的无顶冠状静脉窦综合征外科治疗有难度,冠状窦顶重建技术能够取得良好的治疗效果.     

The difficult approach to neoplastic superior vena cava syndrome: surgical option

AIM: Superior vena cava syndrome is a dramatic event that can be cured in specialized centers. METHODS: Between 1989 and 1995 6 patients with superior vena cava syndrome underwent surgical treatment for thoracic tumors. In all cases the vena was restricted by a neoplastic sleeve. A median sternotomy was performed in all cases. Two patients received an associated right anterolateral thoracotomy to obtain good surgical exposure for tumor resection and grafting. A 12 mm diameter polytetrafluoroethylene graft was inserted in all cases. The tumor resection was radical in 4 cases (2 thymic carcinomas, 2 malignant germ cell tumors) and palliative in 2 (1 non-small cell lung cancer and 1 mediastinal fibrosis). RESULTS: We had no in-hospital mortality. All patients had immediate relief of obstruction after by-pass. Three patients were alive without disease at the end of follow-up (40-96 mo), one patient died of postoperative complications after 4 mo, 2 patients died of disease after 4 and 12 mo. CONCLUSION: PTFE by-pass graft for treatment of the obstructed SVC relieves SVC syndrome and has good medium term patency.     

En bloc (non-chest wall) resection for bronchogenic carcinoma with parietal fixation. Factors affecting survival

Seventy-three patients (57 men and 16 women) underwent en bloc resection of lung and attached parietes between 1970 and 1982. All patients had documented malignant pleural invasion. Chest wall parietal pleura was invaded in 33 patients, pericardium in 14, phrenic or vagus nerve in nine, left atrium in five, superior vena cava in four, esophagus in two, diaphragm in one, and multiple structures in five. No patient underwent chest wall resection. Parietal pleurectomy was performed in all patients with involvement of the chest wall parietal pleura; 37 lobectomies and 36 pneumonectomies were performed. Operative mortality was 12.3%. The actuarial overall 5 year survival rate (Kaplan-Meier method) was 39.7%. We conclude that en bloc resection for primary bronchogenic carcinoma with invasion of adjacent intrathoracic structures, although associated with a significant mortality, can be performed with a reasonable likelihood of long-term survival.     

原发心脏雪旺细胞瘤

目的 探讨原发心脏雪旺细胞瘤临床特征、诊断及外科治疗。方法 报告1例原发恶性心脏雪旺细胞瘤的诊断及手术经过，并收集到世界文献报道18例资料，对其临床表现、诊断及外科治疗进行讨论。结果 19例中，恶性17例，良性2例，其中施行手术切除11例，良性肿瘤术后效果好，恶性肿瘤远期生存率低。结论 原发心脏雪旺细胞瘤极其罕见，诊断依靠临床表现、心脏超声、核磁共振检查、组织形态及免疫组化特征。良性心脏雪旺细胞瘤切除彻底可获得良好效果，恶性心脏雪旺细胞瘤由于局部伸长、浸润和远处转移不能彻底切除，预后不良。心脏移植治疗早期原发心脏恶性雪旺细胞瘤可望得到较好效果。     

Superior vena cava reconstruction combined with resection of mediastinal-pulmonary malignant tumors

From 1988 to 1997, we experienced 5 cases of the superior vena cava (SVC) replacement with expanded polytetrafluoroethylene (ePTFE) grafts combined with resection of mediastinal or pulmonary malignant tumors. Two patients had lung cancer and three had invasive thymoma. Resection and reconstruction of the superior vena cava (SVC) were performed by application of a bypass graft between the innominate vein and the right atrium in two cases and a temporary bypass using a heparin-coated tube in three cases. Except in one patient who died of acute respiratory failure, no complication or occlusive symptom were observed postoperatively. Two patients remain healthy for 5 years 4 months and 2 years 7 months after operation. Three died 9 years, 5 months, and 110 days after operation respectively. In conclusion, ePTFE graft replacement or patch angioplasty of the SVC should be part of planning and execution of radical excision with curative intent of mediastinal or pulmonary malignant tumors.     

Leiomyosarcoma of the inferior vena cava

Leiomyosarcoma of the inferior vena cava is a rare tumor of mesenchymal origin most commonly found in women. Clinical signs are non-specific. Imagery with ultrasound, CT, or MRI may strongly suggest the diagnosis, but it can only be confirmed by histologic examination of tissue obtained pre or intra-operatively. The tumor is slow growing but nonetheless carries a bad prognosis; it may grow to a large size before directly invading adjacent structures. Systemic spread is a late occurrence. Radical surgical resection is the only treatment which offers any hope for prolonged survival. Standard vascular surgical techniques are usually sufficient. Progress in the techniques of hepatectomy and liver transplantation have allowed the experienced surgeon to undertake the removal of retrohepatic lesions once considered unresectable. High-lying lesions adjacent to the hepatic veins or with thrombus extending into the proximal vena cava may require extracorporeal circulation with or without profound hypothermic circulatory arrest. The efficacy of chemotherapy, whether pre-operative for inaccessible tumors or post-operative for incompletely resected or recurrent tumor, is poorly defined and very limited.     

Management of superior vena cava syndrome by internal jugular to femoral vein bypass

We report a 30-year-old man with superior vena cava syndrome due to fibrosis from a previously irradiated malignant thymoma. The patient presented 4 years after the initial treatment, after having been lost to follow-up. Investigations revealed total obstruction of the superior vena cava, and right subclavian and right internal jugular vein. The patient underwent an extra-anatomic bypass (ringed polytetrafluoroethylene graft 10-mm diameter) between the left internal jugular vein and the left femoral vein brought in a subcutaneous tunnel over the anterior chest and abdominal wall. Entry to the thoracic cavity was avoided due to extensive fibrotic changes visualized in the computed tomographic chest scan. Follow-up Doppler at 2 months, 6 months, 1 year, and 3 years showed a patent graft. An internal jugular vein to the femoral vein bypass is a simple method for palliation of superior vena cava syndrome.     

永久性下腔静脉滤器在下肢深静脉血栓治疗中的中长期疗效及应用价值

目的 总结永久性下腔静脉滤器在下肢深静脉血栓治疗中的中长期疗效并评估其应用价值.方法 回顾性分析上海交通大学医学院附属仁济医院血管外科2010年1月-2015年10月置入永久性下腔静脉滤器的86例下肢深静脉血栓的病例资料,其中男性41例,女性45例,年龄50 ～ 94岁,平均年龄71.8岁.深静脉血栓位于左下肢51例,右下肢25例,双下肢10例,合并肺栓塞6例.滤器置入后,无溶栓禁忌者行导管溶栓,必要时行髂股静脉球囊扩张及支架置入.术后除抗凝禁忌者外,均采用抗凝治疗.结果 所有患者均一次性放置滤器成功.置入贝朗Vena Tech LP滤器76例,强生TrapEase滤器10例.单纯滤器置入65例,滤器置入+导管溶栓7例,滤器置入+导管溶栓+球囊扩张/支架置入14例.随访12～81个月,平均51个月,死亡27例,均非滤器相关性,其中恶性肿瘤17例,其他死因10例.深静脉血栓复发3例,支架狭窄伴血栓形成2例.滤器倾斜6例,倾斜角度＜15°,滤器下方血栓形成3例,滤器明显移位2例,无滤器断裂、下腔静脉穿孔及出血等发生,无症状性肺栓塞新发或者复发.结论 永久性滤器可以有效预防下肢深静脉血栓导致的肺栓塞,但长期留置可能导致相关并发症,对于高龄或者合并晚期肿瘤等、预期寿命有限的患者,永久性滤器仍是不错的选择.