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Dominique H Grunenwald

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    MTE 03 - Surgery for T4 Lung Cancer (Sign Up Required) (ID 552)

    • Event: WCLC 2017
    • Type: Meet the Expert
    • Track: Surgery
    • Presentations: 1
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      MTE 03.01 - Do Extended Resections Improve T4 Lung Cancer Outcomes? (ID 7776)

      07:00 - 08:00  |  Presenting Author(s): Dominique H Grunenwald

      • Abstract
      • Presentation
      • Slides

      T4 lung cancers invading neighboring structures comprise a heterogenous group of locally invasive tumors. In a small subset of these localized tumors whose extrapulmonary invasion preceded any lymphatic extension, an adequate excisional procedure can achieve surprising long term survivals. The indications for such procedures and the anticipated outcomes should be weighed on a case by case basis, in terms of potential perioperative complications and expertise of the surgical team. Advanced surgical techniques are now being applied for T4 lesions due to improvements in surgery and anesthesiology and progress in combined treatment modalities. In the present staging, T4 tumors without mediastinal nodal metastasis are now considered to be potentially curable if complete resection is possible. A summary of the literature, under the light of personal experience allows a critical point of view, knowing that a surgical procedure which would not be reproducible in other centers would never be recognized as an option for practice. Therefore among the published series it is important to distinguish the real progress given by innovative techniques or procedures that could be applied throughout the world, even only in selected centers, from the simple reports of individual performances or exploits. Proximal tumors from the lower lobe may involve the atrial wall of the heart. In some cases a left atrial resection can be performed, followed by direct closure, or replacement of the atrial wall. Fukuse reported a series of 42 patients, from which left atrium was resected in 14 patients, Mortality rate was low (2.4%), regarding complexity of the procedures [1]. Low stages in nodal status were associated with increased survival (p = 0.0013). More recently was reported a series of 19 patients who underwent extended lung resection involving the left atrium without cardiopulmonary bypass [2]. An interatrial septum dissection is performed, thus increasing the length of the atrial cuff. R0 resections were observed in 89% of the patients. Ninety-day mortality rate was 16%. Five-year survival rate is 44%, and 3 patients (16%) are alive more than 6 years after surgery. Other reports advocate the use of cardiopulmonary bypass in these occasional situations [3-5]. Invasion of the superior vena cava (SVC) by a T4 non small cell lung c ancer (NSCLC) led surgical teams to attempt lobectomies or pneumonectomies extended to the vena cava [6]. Actually direct extension to the vessel by the tumor mass itself is a rare situation. SVC involvement generally results from a bulky disease, in which the nodal disease is the greatest component. The rationale of resecting SVC in N2 disease remains questionable, in view of the high potential of metastatic spread and the poor prognosis. Nevertheless, different techniques were proposed, including lateral clamping of SVC, partial, or total reconstruction. These procedures are associated with high morbidity rates. A multicentric international review of prosthetic replacement after SVC resection for nsclc in 28 patients (N2 involvement in 50%) showed morbidity and mortality rates of 39% and 14%, respectively. Overall 5-year survival rate was 15% [7]. Despite some reports who claim better survival rates, close to 50% at five years, the latter seems more realistic, and this warrants a thorough evaluation with the aim to preclude these patients from surgery in case of N2 involvement. A bronchial carcinoma extended to the tracheal bifurcation can be resected in selected patients [8]. A high rate of post-operative morbidity (10 to 30%), including bronchial dehiscences, jeopardizes the outcome, but long-term survivals have been observed in 15 to 23% of the cases. A meticulous mediastinal assessment is mandatory to eliminate invasion of the airway by a bulky disease. Only patients with T-invasion will be offered surgical resection. NNSCLC invading the thoracic inlet can easily penetrate spinal structures because of their particular anatomic situation. The best local control for resectable tumors is achieved by surgical operation, provided the resection is complete and respecting oncologic principles. Direct invasion of the vertebral body became an option following the first report in 1996 of a successful en bloc total vertebrectomy for lung cancer invading the spine [9]. Reported experiences from Europe, North-America and Asia demonstrate feasability and encouraging results of these challenging procedures, . Recently a comprehensive literature search, on a total of 1,001 abstracts and 93 articles found overall 5-year survival rates ranging from 37% to 59% and the mortality rate ranged from 0% to 6.9% [10]. Undoubtly enbloc resection for lung cancer invading the spine is reaching the stage of current practice in expert centers. This is probably due to a particular biology of these tumors which are peripheral and whose noisy symptoms lead to a relatively early diagnosis, thus permitting a high rate of complete resections. Evidence suggests that triple modality therapy with complete resection of locally advanced Pancoast tumors with involvement of the spine offers an advantage over other therapeutic modalities. Despite the absence of such an evidence in other T4 lung cancers, recent advances in patient's care and surgical techniques allowed surgeons to become more aggressive, and to propose occasionally extended resections with encouraging long-term survival rates to patients suffering from tumors invading the tracheal bifurcation, the left atrium, or the great vessels. The 8[th] edition of TNM classifies,T4N0-1 tumors in a "surgical" category, stage IIIA. 1. Fukuse T, et al. Extended operation for nsclc invading great vessels and left atrium. Eur J Cardiothorac Surg 1997;11:664–9 2. Galvaing G, et al. Left atrial resection for T4 lung cancer without cardiopulmonary bypass: technical aspects and outcomes.Ann Thorac Surg 2014;97:1708-13 3. Klepetko W, et al. T4 lung tumors with infiltration of the thoracic aorta: is an operation reasonable? Ann Thorac Surg 1999;67:340–4 4. De Perrot M, et al. Resection of locally advanced (T4) nsclc with cardiopulmonary bypass. Ann Thorac Surg 2005; 79:1691–6 5. Langer NB, et al. Outcomes after resection of T4 nsclc using cardiopulmonary bypass. Ann Thorac Surg 2016;102:902-10 6. Grunenwald DH. Resection of lung carcinomas invading the mediastinum, including the superior vena cava. Thorac Surg Clin 2004;14:255–63 7. Spaggiari L, et al. Superior vena cava resection with prosthetic replacement for nsclc: long term results of a multicentric study. Eur J Cardiothorac Surg 2002;21:1080–6 8. Mathisen DJ, Grillo HC. Carinal resection for bronchogenic carcinoma. J Thorac Cardiovasc Surg 1991;102:16−23 9. Grunenwald D, et al. Total vertebrectomy for en bloc resection of lung cancer invading the spine. Ann Thorac Surg 1996;61:723–6 10. Setzer M, et al. Management of locally advanced pancoast (superior sulcus) tumors with spine involvement. Cancer Control 2014;21:158-67

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