Twelve-year experience with left atrial resection in the treatment of non-small cell lung cancer

Background

We retrospectively reviewed our 12-year experience in the surgical treatment of non-small cell lung cancer invading the left atrium. End points of the study were overall survival and factors potentially affecting survival.

Methods

Nineteen consecutive patients with lung cancer invading the left atrium underwent surgery. Three patients with N2 disease underwent induction chemotherapy. Patients with either incomplete resections or pN2 disease received postoperative chemoradiotherapy.

Results

Five-year survival was 14%, and the median survival time was 25 months. These figures refer to a very homogeneous group of patients with respect to the extent of atrial infiltration. Patients with N2 disease tended to have a worse outcome than patients with N0 or N1 disease (p = 0.06). The 3 patients with N2 disease who underwent induction chemotherapy were alive and disease-free at 30, 15, and 11 months from surgery. Survival was not affected by histology, type of surgery, or completeness of resection. Three patients with residual cancer in the atrial resection margin underwent postoperative chemoradiotherapy and are alive at 25, 17, and 15 months after surgery.

Conclusions

In spite of the poor survival rates we report, the present experience suggests that more-favorable results could be expected by the routine preoperative use of positron emission tomographic scan staging, a more-extensive assessment of atrial invasion, the application of induction chemotherapy in patients with N2 disease, and postoperative chemoradiotherapy in patients with tumors abutting the atrial resection margin.     

Bilateral Trans-Septal Approach to Right Lung Cancer Invading the Left Atrium

We describe a 69-year-old woman with primary lung cancer in the right lower lobe invasive to the left atrium (LA) via the pulmonary vein (PV). The tumor in the LA measured 30 × 26 mm, and to avoid critical embolism preoperative induction therapy was not performed. The patient underwent right thoracotomy under cardiopulmonary bypass (CPB), and the atrial septum was incised via the right atrium. The tumor was placed out of the LA, followed by lobectomy. For right lung tumors invading the LA, the bilateral trans-septal approach is useful for confirming the surgical margin.     

Left upper lobectomy with combined resection of the distal arch aorta after chemoradiotherapy for locally advanced lung cancer

We report a case of complete resection of lung cancer involving the thoracic aorta, after induction chemoradiotherapy in a 55-year-old man. The chemoradiotherapy, which consisted of two courses of platinum-based chemotherapy with concurrent radiation to a total of 40 Gy, resulted in a partial response. Left upper lobectomy with combined resection and reconstruction of the distal arch aorta and left subclavian artery was performed under cardiopulmonary bypass. The patient was given two courses of platinum-based adjuvant chemotherapy, and there has been no sign of recurrence in the 34 months since his operation.     

肺切除加左心房部分切除术治疗局部晚期肺癌

目的 为寻求晚期肺癌患者的外科治疗方法，提高手术疗效，总结34例局部晚期肺癌患者行肺切除加左心房部分切除术的经验。方法 对34例局部晚期肺癌患者施行了肺切除加左心房部分切除术。左肺下叶切除术19例，左全肺切除术4例，右肺中下叶切除术6例，右肺下叶切除术2例，右全肺切除术3例。肿瘤侵及肺静脉根部与心房交界处近心端25例，明显侵犯左心房9例，其中2例同时侵及靠近肺动脉分叉处，常规无法处理肺动脉，在体外循环下切除全肺并同时切除部分左心房。结果 本组无手术死亡，术后发生并发症11例，其中心律失常8例次，肺炎5例次，心功能不全1例次。1年、3年生存率分别为79．4％、44.1％，6例生存＞5年。结论 肺癌累及左心房或肺静脉根部时应切除部分左心房以达到根治性切除，从而延长患者寿命，提高生存质量。     

Ex-situ-Manschettenresektion mit Autotransplantation des linken Lungenunterlappens nach erweiterter Pneumonektomie

A 69-year-old patient with reduced pulmonary function was diagnosed as suffering from non-small cell lung cancer of the left lung invading the main bronchus, pulmonary artery and left atrium. Staging examinations were negative. Using cardiopulmonary bypass, an extended pneumonectomy with partial resection of the left atrium was performed. The cardiac defect was closed with a pericardial patch. The lower lobe was divided ex situ from the upper lobe and reimplanted with anastomosis of the lower pulmonary vein to the left auricle. After a totally uneventful course the patient is in good condition and free of tumor recurrence 2.5 years postoperatively.     

Use of percutaneous cardiopulmonary support (PCPS) for extended surgery in patients with T4 tumor

Since 1991, we have performed operations for tumors invading the upper airway, left atrium or main pulmonary artery with percutaneous cardiopulmonary support (PCPS) stand by support available. Of 15 cases with PCPS stand by, 6 patients actually underwent operation using PCPS. There were three esophageal cancers invading the carina, two lung neoplasms with left atrial invasion and one neoplasm extending to the main pulmonary artery. One of three patients with esophageal cancer had massive bleeding in the trachea resulting in airway obstruction. For this patient, emergency PCPS was carried out followed by the total removal of the thoracic esophagus and combined resection of membranous portion of the carina. As a result, a substantial amount of time (6 hours) was required. The two patients with reconstruction of the carina due to esophageal cancer were also successfully treated by using PCPS. Two patients with malignant pulmonary neoplasms invading the left atrium underwent combined resection of the lung and left atrium using a combination of PCPS and ventricular fibrillation under normothermia. In conclusion, PCPS should be accepted as a standard technique for patients with advanced thoracic malignancies in whom cardiac arrest or ventilation support is thought to be necessary for the complete removal of the tumor.     

Novel use of endoluminal repair as prophylaxis of aortic rupture secondary to radiotherapy for lung cancer

Non-small-cell lung cancer (NSCLC) invading the aorta is staged as T(4). Only 9% of T(4) tumors are resected; the alternative is chemoradiotherapy, but for peri-aortic NSCLC, radiation damage to the aortic wall can induce fatal rupture. We report the case of a 76 year-old man with a 3-cm left lower lobe NSCLC clearly invading the aortic wall. A thoracic stent graft was inserted prophylactically to prevent aortic rupture. He then received 64 Gy radiotherapy in 32 fractions, resulting in tumor shrinkage. Prophylactic aortic endografting, a less invasive treatment than open surgery, may enable high dose irradiation of the aortic wall.     

Transmanubrial osteomuscular sparing approach for lung cancer invading the anterior part of the thoracic inlet

Standard treatment for lung cancer presenting as a superior sulcus tumor is induction chemoradiotherapy followed by surgery, which yields rates of about 70% complete resection and 50% 5-year survival rate. However, the surgical technique to achieve complete resection for superior sulcus tumor invading major anatomical sites including the subclavian artery is challenging. The anterior transcervical thoracic approach applied by Dartevelle and colleagues provides excellent exposure of the subclavian vessels. Grunenwald and associates have improved on this approach to preserve the clavicle and sternoclavicular joint. We applied the transmanubrial osteomuscular-sparing approach in two patients. In both cases, exposure of the subclavian vessels was excellent. In one case, the subclavian artery was resected and reconstructed with a polytetrafl uoroethylene graft. This patient has continued to show recurrence-free survival for more than 5 years. We outline our experience and review the literature on the surgical approach for superior sulcus tumor invading the anterior part of the thoracic inlet.     

Successful treatment for lung cancer associated with pulmonary sequestration

We encountered a 69-year-old man with lung adenocarcinoma and pulmonary sequestration. The cancer lesion was located in the left upper lobe, with sequestration of the left lower lobe. Left upper lobectomy was performed after induction chemoradiotherapy, but the sequestered lung lobe was preserved because the preoperative respiratory function was poor. Preservation of the sequestered lung during surgery for lung cancer should be considered in patients who have poor respiratory function and no signs of respiratory infection.     

Takotsubo cardiomyopathy associated with pulmonary resections after induction chemoradiotherapy for non-small cell lung cancer

Takotsubo cardiomyopathy (TTC), also known as transient left ventricular (LV) apical ballooning syndrome, is characterized by transient LV dysfunction. We present the case of a 72-year-old man who was diagnosed as having TTC after surgery for two lung tumors. The patient was treated with induction chemoradiotherapy (CRT) followed by pulmonary resections for double primary non-small cell lung cancers (NSCLC): cT4N1M0 disease in the right lung and cT2N0M0 in the left lung. Induction CRT was performed. A right upper lobectomy was initially performed, and a left upper divisionectomy was subsequently performed. At 3?days after the second surgery, he developed dyspnea and general fatigue accompanied by a T-wave inversion on electrocardiography (ECG). An echocardiogram revealed akinesis at the apex with a 30?% ejection fraction. He was diagnosed as having TTC and recovered with supportive care. This case is the first report of TTC occurring after tri-modality therapy for NSCLC.     

Advanced esophageal cancer with an esophago-bronchial fistula successfully treated by chemoradiotherapy following esophageal bypass surgery: report of a case

Esophageal bypass surgery using a gastric tube prior to definitive chemoradiotherapy in preparation for the formation of esophago-tracheal or bronchial fistula is a possible strategy for esophageal cancer invading the airway. This report presents the case of a patient with esophageal cancer involving the left main bronchus who underwent esophageal bypass followed by definitive chemoradiotherapy and who has achieved long-term survival without deterioration of his quality of life, in spite of the development of a malignant esophago-bronchial fistula.     

Surgical Treatment of Lung Cancer Invading the Left Atrium or Base of the Pulmonary Vein

Background  The purpose of the present study was to explore the efficacy of an extended operation for locally advanced non-small cell lung cancer invading the left atrium and intrapericardial pulmonary vein. Methods  From January 2000 to January 2006, lobectomy or pneumonectomy combined with extended resection of the left atrium was carried out in 46 patients. The operations included left lower lobectomy in 6 cases, left pneumonectomy in 14 cases, right middle and lower lobectomy in 8 cases, right lower lobectomy in 2 cases, and right pneumonectomy in 16 cases; these cases accounted for 4.9% of the lung cancer patients who underwent surgical treatment in the Changzheng Hospital, Second Military Medical University, during the study period. Results  There were no surgery-related deaths, and the overall 1-, 3-, and 5-year survival rates were 71.77%, 37.79%, and 22.04%, respectively; the 1-, 3-, and 5-year survival rates of patients with no lymph node involvement (N0) were 77.16%, 43.40%, and 28.94%, respectively; the 1-, 3-, and 5-year survival rates of N1 patients were 75.94%, 41.88%, and 27.92%, respectively; the 1- and 3-year survival rates of N2 patients were 53.85% and 17.95%, respectively. Conclusions  Surgical treatment of T4 lung cancer invading the left atrium or the base of the pulmonary vein is feasible, particularly in N0 and N1 patients with a ≤3 cm maximum diameter of primary lung cancer. It can improve the quality of life and increase long-term survival. Surgical management should be considered in selected lung cancer patients.     

Aortic resection for lung cancer with use of biomedicus centrifugal pump--a case report

A 56-year-old woman with lung cancer that is invading the descending aorta, a part of the left atrial wall, and the esophagus was treated. The treatment included a pneumonectomy, resections of the descending aorta, resections of part of the left atrial wall and resections of the thoracic esophagus. For the resection of aorta and for its reconstruction, partial left heart bypass from the left atrium to the femoral artery by a Bio pump was used. The Bio pump proved to be simple, safe and effective, and capable of protecting the peripheral viscera from ischemia during the descending aortic cross clamping.     

Surgical resection of T3 and T4 lung cancer

Lung cancer invading neighboring anatomical structures such as the chest wall, pericardium, diaphragm, and left atrium are categorized as T3 or T4, which is regarded as locally advanced lung cancer. The purpose of this study was to evaluate results of surgical treatment of T3-4N0-2M0 non-small cell lung cancer according to involved organs. From 1981 to April 2005, 148 patients with lung cancer invading neighboring organs were surgically treated in our hospital. The 5-year survival was 41.4% in all cases. According to 5-year survival of clinical characteristics, the chest wall (parietal pleura) group (45.5%) had a significantly better prognosis compared with the left atrium (0%, p = 0.03) and diaphragm (0%, p = 0.04) groups. T3N0 (50.3%), IIB (55.4%), IIIA (44.6%), and complete resection groups (49.0%) showed a significantly better prognosis compared with T3N2 (27.9%, p = 0.01), III B (0%, p < 0.0001), and incomplete resection groups (13.9%, p < 0.0001), respectively. These results indicate that the prognosis of patients with N2 disease or incomplete resection remains poor in regardless with the type of involved organs.     

A case of pulmonary metastasis of malignant fibrous histiocytoma with left atrial infiltration via the pulmonary vein

We report a case of a woman who at age 58 had an operation on the right femur for malignant fibrous histiocytoma (MFH). At age 63, a chest X-ray examination disclosed a tumor shadow, for which we suspected metastasis from the MFH. Chest computed tomography showed that the tumor had infiltrated to the left atrium via the pulmonary vein. We operated on the patient, first dividing the arterial supply to the lower lobe, and then opening the pericardium. We blocked the lower pulmonary vein and left atrium with a Cooley-Dera clamp and resected the tumor. The tumor was polypoid and had invaded the left atrium. Fifteen months after this lung surgery, the patient was diagnosed with a brain tumor, which was resected. Invasive primary lung cancer to the left atrium via the pulmonary vein is common, but metastasis from a sarcoma such as MFH to the left atrium via the pulmonary vein is extremely rare.     

Radical resections for T4 lung cancer

T4 lung cancers are a heterogeneous group of locally advanced lung cancers. Treatment is palliative for the majority of patients, ranging from supportive care to chemoradiotherapy. In certain patients, however, surgery is beneficial and may be curative. Patients with T4N0M0 cancers invading the distal trachea, carina, left atrium, aorta, superior vena cava, or vertebral bodies may be surgical candidates. Radical resections of these T4 lung cancers have potential for cure if no mediastinal lymph node metastases (N2 or N3) occur and if resection is complete. Increased postoperative mortality exists and extends beyond 30 days, as evidenced by a 30-day mortality of 8% and a 90-day mortality of 18%. Improved palliation (median survival of 19 months) and cure (31% five-year survival) are possible in patients who meet the criteria, who undergo radical resection, and who are followed by physicians in facilities with special interests in extended resections. The use of induction therapy and surgery in T4 patients may further increase survival and the number of T4 patients in whom radical resection is possible. Radical resections are contraindicated in patients with T4 lung cancers associated with malignant pleural effusions. Unfortunately, these patients have the worst prognosis. If surgical palliation is an option, only pulmonary resection with pleurectomy and not pleuropneumonectomy should be considered. In contrast, lung cancers with the best prognosis are those T4 tumors diagnosed because of a satellite tumor nodule within the same lobe. Because radical resections are usually not required, operative mortality is not increased. Five-year survival in patients with satellite intralobar tumor nodules without mediastinal nodal metastases is comparable to survival of highly selected T4N0M0 patients who undergo radical resection. These two extremes of T4 lung cancers, malignant pleural effusion and satellite intralobar tumor nodules, generally are not considered for or do not require radical resections. It is debatable that the definition of T4 should include these entities.     

Successful resection of giant hemangiopericytoma originating from the left atrium

We report a case of a giant hemangiopericytoma in the left atrium showing severe dyspnea. Preoperative echocardiogram showed the giant tumor herniating into the left ventricle during cardiac diastole. Emergency surgery was performed due to failure of hemodynamics. The tumor was identified to originate from the posterior wall of the left atrium and was successfully excised with the left atrial wall. Histological investigations revealed existence of malignant hemangiopericytoma.     

Completely resected superior sulcus tumor and vascular reconstruction of vertebral and subclavian arteries

A 62-year-old man was pointed out the superior sulcus tumor of the left lung invading to the subclavian artery and the vertebral artery. Bronchoscopic brushing cytology of the tumor showed Class V large cell carcinoma. The patient was diagnosed as clinical stage IIIA(cT4N0M0). After concurrent chemoradiotherapy, we performed left-upper lobectomy and reconstructions of left subclavian and vertebral arteries through modified transmanubrial approach. Surgeons of three different departments took part in the operation. Cooperative works were the key for the complete resection of such an advanced superior sulcus tumor.     

En Bloc Resection with the Assistance of Video‐Assisted Thoracoscopy for Left Lower Lung Cancer Invading Thoracic Vertebrae and Rib: A Case Report

Lung cancer invading the spine was previously considered unresectable and fatal and, consequently, there are few reports focusing on tumors located in the lower lung lobe and invading the spine. With the development of spinal instrumentation and surgical techniques, and wider acceptance of spondylectomy by surgeons, radical surgical resection has become feasible. Here, we present a case of a male patient with a left lower lung cancer invading thoracic vertebrae who underwent complete resection with sagittal en bloc hemivertebrectomy with video‐assisted thoracoscopy. A 60‐year‐old man complained of left chest pain for 3 months. Chest computed tomography and thoracic vertebrae magnetic resonance image revealed that a tumor in the left lower lung lobe had invaded the seventh and eighth thoracic vertebrae and the eighth rib. As no lymph node or distant metastasis was detected by positron emission tomography‐computed tomography, the patient was diagnosed with left lower lung cancer directly invading the seventh and eighth thoracic vertebrae and the eighth rib (T4N0M0, stage IIIA) instead of metastasizing to the thoracic vertebrae. An en bloc resection of the lung tumor and the involved vertebrae was performed by a thoracic surgeon and orthopaedic surgeon with video‐assisted thoracoscopy. Six months after the operation, there was no evidence of local recurrence, and the patient had recovered well. En Bloc resection with video‐assisted thoracoscopy for lung cancer invading thoracic vertebrae is a safe and feasible surgical method. This method can significantly improve the safety and convenience of this type of surgery.     

Primary embryonal carcinoma of heart with SVC syndrome

We present a case report of a 25-year-old man with embryonal carcinoma of right atrium and multiple lung metastases featuring SVC syndrome. We resected the cardiac tumor which occupied the right atrium and performed left upper lobectomy. No tumor mass or vestige was detected in the testes. Cis-platinum based combination chemotherapy was performed for residual lung tumors, which leads to the complete remission.