Resection of the left atrium in lung cancer

An analysis of results of surgical treatment of 28 patients with lung cancer who underwent resection of the left atrium has shown that squamous cell cancer was diagnosed in 18 patients (64%), adenocarcinoma--in 5 (18%), dimorphous cancer--in 2 (7%), mucoepidermoid cancer in 2 (7%), atypical carcinoid--in 1 patient (4%). The degree of regional lymphogenic spread of the tumor NO took place in 11 patients (39%), N1--in 6 patients (22%), N2--in 11(39%). True invasion of the tumor to the left atrium myocardium took place in 20 patients (71%), involvement of the pulmonary vein orifices in the tumor process--in 8 (29%). Resection of the atrium was made using mechanical suturing apparatuses. The right side resections were fulfilled in 16 patients (57%), left side resections in 12 patients (43%). Pneumonectomy was fulfilled in 26 patients (93%), lobectomy--in 2 patients (7%). The operative interventions in five cases (18%) were estimated as microscopically non-radical (R1). The average time in the intensive care unit after operation was 3 days (from 1 till 12), in the surgical thoracal department--18 days (from 13 till 37). In the early postoperative period one patient died (4%), complications were noted in 5 patients (18%). The total one year survival was 69%, three year survival--39%, 5 year survival--17%. The survival median was 23 months. Resection of the left atrium in the selected lung cancer patients was not followed by growing operative lethality and the acceptable long term results were obtained.     

Resection for lung cancer in the elderly patient

Age is sometimes used as an excuse not to resect lung cancer. Nugent et al [10] noted that, although only 6% of patients younger than 45 years had stage I or II disease, 33% underwent surgical resection. In contrast, of the 33% of elderly patients who had stage I or II disease, only 6% underwent surgical resection. The elderly patients who are carefully selected for lung resection are undoubtedly stronger physiologically than others their same age. Patients with adequate predicted postoperative lung function, no contraindications from other medical problems, good performance status, and social support should be offered standard resection for early-stage NSCLC. Lung cancer resection in elderly patients is justified and has decreasing morbidity and mortality rates. Careful patient selection and operative planning are necessary, however. It is wise to have a diagnosis and staging done before the patient arrives in the operating suite. The surgeon should avoid extended resections when possible. In addition, elderly patients should be ambulated as soon as possible and adequate pain control should be ensured. Finally, the stage of the cancer and occurrence of cardiopulmonary complications are the main determinants of outcome.     

肺癌累及上腔静脉的外科治疗

目的分析探讨肺癌累及上腔静脉行手术切除的可行性及价值。方法回顾性分析1988年3月—2005年4月的31例肺癌累及上腔静脉手术治疗患者的临床资料,其中鳞癌17例、腺癌8例、小细胞未分化癌6例;N0．1期12例,N2期19例;T4期22例,T2．3期9例。采用上腔静脉切除人工血管置换（18例）,侧壁切除自体心包片修补（8例）、直接缝合（5例）的方法处理切除后的上腔静脉,统计围手术期并发症及长期生存率,分析生存及预后情况。结果18例上腔静脉置换者中,上腔静脉阻断者17例,阻断时间8～35min;13例上腔静脉部分切除修补者,9例阻断上腔静脉,阻断时间3～15min。无手术死亡,术后并发症发生率为48％（15／31）。术后随访28例,时间3～130个月,总的中位生存期为31个月,1,3和5年生存率分别为61％,33％和21％,其中N1．1期、N2期患者的中位生存期分别为42和13个月（x^2=14．3,P=0．000）;病理类型及手术方式对预后无影响;术前及术中化学治疗（化疗）的患者预后好于术前及术中未化疗者,中位生存期分别为39和14个月（x^2=5．0,P=0．025）。结论肺癌累及上腔静脉进行手术治疗可行,无纵隔淋巴结转移者预后较好,应尽可能手术治疗;术前或术中化疗值得推荐。     

Resection and aorta replacement in extended and combined operations for lung cancer

In spite of the progress in thoracic surgery and oncology, great lethality in lung cancer patient still persists, and so the questions of not only the early diagnostics but also the development of new techniques of surgical treatment remain actual which allow radical ablation of extended tumors. In the Russian Scientific Center of Surgery named after academician B.V. Petrovsky of the Russian Academy of Medical Sciences three patients were subjected to extended combined operations of pneumonectomy with a simultaneous resection and replacement of the thoracic part of the aorta for local dissemination of lung cancer. Extracorporeal circulation was used in one patient and in two patients resection and replacement of the aorta were fulfilled on the cross-clapmed aorta under conditions of ischemia of organs and tissues below the left subclavian artery. There were no ischemic injuries of organs after operation. All the patients were directed to chemio-radiation therapy.     

Resection of chest wall invasion in patients with non-small cell lung cancer

Objective: The treatment of patients with non-small cell lung cancer invading the parietal pleura or chest wall is still debated. It is unsolved whether the depth of chest wall involvement or the type of resection (extrapleural or en bloc) affects long-term survival. Methods: design, retrospective analysis; setting, Hyogo Medical Center for Adults, patients: the 97 patients who underwent surgical resection for non-small cell lung cancer involving the parietal pleura or chest wall between 1985 and 1997 were reviewed. Results: Of the 97 patients, 76 had apparently complete resection, 21 had incomplete resection. The overall 5-year survival of completely resected patients was 34.2%, and that of incompletely resected patients was 14.3% (P=0.0489). In complete resection cases, the chest wall involvement was limited to the parietal pleura in 40, extended into the subpleural soft tissues in 10, and extended into the ribs in 26. The 5-year survivals were 32.5, 30.0 and 38.5%, respectively (no significant difference). The 5-year survival of completely resected patients with T3 N0 M0 disease was 44.2%, T3 N1 M0 disease 40.0%, and T3N2 M0 disease 6.2% (P=0.0019). The 5-year survival of completely resected patients with extrapleural resections was 30.0%, that of en bloc resections 38.9% (no significant difference). Conclusions: Survival of patients with lung cancer invading the chest wall or parietal pleura after resection is highly dependent on the completeness of resection and the extent of nodal involvement, but not so much on the depth of chest wall invasion or type of resection.     

Resection of stage III non-small cell lung cancer following induction therapy

Approximately 25%–30% of all patients with non-small cell lung cancer (NSCLC) present with stage III tumors. Except for specific subsets, these tumors are not usually amenable to complete surgical resection and are associated with a 5-year survival of 10% or less. Because patients with stage III NSCLC die of distant metastases, recent efforts to improve the prognosis of these tumors have focused on neoadjuvant therapy using chemotherapy or chemoradiotherapy as induction treatment and subsequent surgical resection for local control. Many trials have now shown the feasibility of neoadjuvant therapy and suggest that overall survival is approximately double that seen after surgical resection or radiation alone. Future clinical trials will define whether surgical resection after induction therapy provides better local control and survival than chemotherapy and high-dose radiation alone.

---

Resumen Aproximadamente 25–30% de la totalidad de los pacientes con cáncer pulmonar de células no pequeñas se presentan con tumores en estado III. A excepción de algunos subgrupos específicos, tales tumores usualmente no son susceptibles de resección quirúrgica completa y se asocian con una tasa de sobrevida de 5 años de 10% o menos. Debido a que los pacientes en estado III mueren por metástasis distantes, los esfuerzos recientes encaminados a mejorar el pronóstico se han concentrado en la terapia neoadyuvante utilizando quimioterapia o quimioradioterapia como tratamiento de inducción y resección quirúrgica subsiguiente para el control local de la enfermedad. Muchos ensayos clínicos han demostrado la factibilidad de la terapia neoadyuvante y sugieren que la tasa global de sobrevida es aproximadamente el doble de la que se ve en pacientes sometidos a resección quirúrgica o a irradiación solamente. Los futuros ensayos clínicos deben definir si la resección quirúrgica luego de la terapia de inducción resulta en mejor control local y mejor sobrevida que con la quimioterapia o la irradiación solamente.

---

Résumé Environ 25–30% de tous les patients ayant un cancer autre qu'à petites cellules du poumon (non-small cell lung cancer ou «NSCLC») se présentent au stade III de leur maladie. Exceptés des sous-groupes spécifiques, ces tumeurs ne sont généralement pas traitables par la résection chirurgical complète et leur survie à 5 ans est de 10% ou moins. Parce que les patients des stades III des NSCLC meurent habituellement des métastases à distance, des efforts récents pour améliorer le pronostic se sont centrés sur la chimiothérapie néoadjuvante, c'est-à-dire par la chimiothérapie ou la chimioradiothérapie en induction suivie de résection locale. Beaucoup d'essais ont démontré la faisabilité de la thérapie néoadjuvante, et suggèrent que la survie globale est environ la double de celle après résection chirurgicale ou radiothérapie seule. Des essais cliniques futurs sont seuls capables de démontrer si la résection après l'induction thérapeutique par la chimiothérapie adjuvante peut contrôler la maladie et améliorer le pronostic par rapport à la chimiothérapie et la radiothérapie seules.

     

Resection of lung metastases of colorectal cancer. Indications and indication limits

From 1970 through 1986, a total of 62 patients underwent thoracotomy for colorectal metastases to the lungs. Four had exploration only, whereas in 13 a nonradical, and in 45 a "curative" resection was performed. There was one postoperative death. Cumulative 5-year survival following radical resection was 44%. Conversely, all other patients succumbed within 3 years. Extrapulmonary disease has not yet been associated with 5-year survival and may usually contraindicate resection. The impacts of multiple metastases exceeding 3 nodules or bilateral pulmonary involvement on prognosis can not been determined from our series, since the procedure in respective patients was not radical in the majority of cases. In turn, localisation and venous drainage of the primary tumor did not significantly influence long term survival.     

Resection and radical lymphadenectomy for lung cancer: prognostic significance of lymphatic metastases

From 1979 to 1987, 1103 thoracotomies were performed in patients with lung cancer: 824 (74.7%) radical resections, 141 (12.7%) palliative resections and 138 (12.5%) exploratory thoracotomies. Among the 965 patients who underwent resection, 539 patients were N0, 190 patients N1 and 236 patients N2. Among patients with N1 disease we observed more frequent hilar metastases in the more advanced tumors (p less than 0.05). In 84 out of the 232 N2 patients (36.2%; 13.4% of all patients) a skipping of all pulmonary sites was observed. The most commonly invaded mediastinal levels were the paratracheal nodes on the right and the aortic nodes on the left, followed by the subcarinal nodes. The greater the neoplastic involvement of pulmonary nodal sites, the higher the percentage of patients with N2 disease and the number of mediastinal levels with tumor cells (p less than 0.05). The 5-year survival rate is 60% for N0, 46% for N1 and 23% for N2 disease. There is no significant difference in survival between N2 and N1 + N2 patients. Metastatic involvement of both upper and lower mediastinal levels carries a poorer prognosis compared to involvement of one compartment only (p less than 0.02). Patients with findings of mediastinal metastatic involvement should be selected: studies on lymphatic metastases are useful to better establish surgical indications for N2 patients.     

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.     

Resection of multifocal non-small cell lung cancer when the bronchioloalveolar subtype is involved

OBJECTIVE: Bronchioloalveolar lung cancer is commonly multifocal and can also present with other non-small cell types. The staging and treatment of multifocal non-small cell cancer are controversial. We evaluated the current staging of multifocal bronchioloalveolar carcinoma and the therapeutic effectiveness of resection when this tumor type is involved. METHODS: We reviewed our experience between 1992 and 2000 with complete pulmonary resections for bronchioloalveolar carcinoma. Kaplan-Meier survival curves were calculated from the dates of pulmonary resection. RESULTS: Among 73 patients with bronchioloalveolar carcinoma, 14 patients, 7 male and 7 female with a mean age of 65 years (51-87 years), had multifocal lesions without lymph node metastases. Follow-up was 100% for a median of 5 years (range 2.6-8.5 years). Tumor distribution was unilateral in 9 patients and bilateral in 5 patients. The multifocal nature of the disease was discovered intraoperatively in 4 patients. Nine patients had 2 lesions, 4 patients had 3 lesions, and 1 patient had innumerable discrete foci in a single lobe. Operative mortality was 0. Postoperatively, 10 patients were staged pIIIB or pIV on the basis of multiple foci of similar morphology; 4 patients had some differences in histology (implying multiple stage 1 primaries). The median survival time to death from cancer was 14 months (141 days-5.6 years). The overall 5-year survival after resection of multifocal bronchioloalveolar carcinoma was 64%. Unilateral or bilateral distribution had no impact on survival. CONCLUSIONS: The current staging system is not prognostic for multifocal bronchioloalveolar carcinoma without lymph node metastases. Complete resection of multifocal non-small cell lung cancer when bronchioloalveolar carcinoma is a component may achieve survivals similar to that of stage I and II unifocal non-small cell lung cancer. When bronchioloalveolar carcinoma is believed to be one of the cell types in multifocal disease without lymph node metastases, consideration should be given to surgical resection.     

Resection of adrenal metastases from non-small cell lung cancer: a multicenter study

BACKGROUND: In recent case reports and limited series, adrenalectomy was recommended for an isolated adrenal metastasis from non-small cell lung cancer (NSCLC). METHODS: We retrospectively studied patients with a solitary adrenal metastasis from NSCLC who had undergone potentially curative resection in eight centers. RESULTS: Forty-three patients were included. Their adrenal gland metastasis was discovered synchronously with NSCLC in 32 patients, and metachronously in 11. It was homolateral to the NSCLC in 31 patients and contralateral in 12 (p < 0.01). Median survival was 11 months, and 3 patients survived more than 5 years. There was no difference between the synchronous and metachronous groups regarding recurrence rate or survival. Survival was not affected by the homolateral location of the metastasis, the histology of the NSCLC, TNM stage, any adjuvant and neoadjuvant treatment, or, in the metachronous group, a disease-free interval exceeding 6 months. CONCLUSIONS: We confirm the possibility of long-term survival after resection of isolated adrenal metastasis from NSCLC, but no clinical or pathologic criteria were detected to identify patients amenable to potential cure.