Extended pulmonary resections of advanced thoracic malignancies with support of cardiopulmonary bypass

Wiebe, Karsten; Baraki, Hassina; Macchiarini, Paolo; Haverich, Axel

doi:10.1016/j.ejcts.2005.10.041

“…Furthermore, utilizing an aggressive approach to resect all metastases present (irrespective of the number of metastases and including repeat resections for all recurrences), resulted in a 5-year survival ranging from 19 to 52% [56]. Advanced tumors with invasion into the mediastinum affecting the heart and greater vessels have also been resected, and despite requiring cardiopulmonary bypass, favorable outcomes have been reported which are surprisingly superior to those obtained with extended resections for non-small cell lung cancer (Figure 2) [57]. …”

Section: Complex Managementmentioning

confidence: 99%

Management of Sarcoma Metastases to the Lung

Digesu

¹

,

Wiesel

²

,

Vaporciyan

³

et al. 2016

Surgical Oncology Clinics of North America

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Synopsis Pulmonary metastases are a common manifestation of sarcoma that requires special attention. For decades, surgical resection of pulmonary metastases has been performed, and despite limited randomized data, surgery is increasingly accepted as an integral part in the management of metastatic disease. Although sarcoma is heterogeneous, common prognostic factors have been identified to guide surgeons prior to pulmonary metastasectomy including long disease-free interval, ability to obtain a complete resection, and extra-pulmonary disease control. Patients with adequate pulmonary reserve may undergo resection via thoracotomy or in select cases video-assisted thoracoscopic surgery (VATS). Long-term results indicate resection is potentially curative with significantly improved survival following complete resection. Recurrence, however, is not uncommon with many patients undergoing repeat resection. With advancing surgical technique and adjuvant therapies, patients with high or recurrent tumor burden are increasingly afforded disease control and potential cure. In this review, the prognostic characteristics of pulmonary metastases from sarcoma, pre-operative evaluation, operative technique, long-term outcomes, and management of complex patients are highlighted.

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“…For T4 N0 disease, aggressive surgical treatment within a multimodality therapy has been advocated and is strongly recommended by us, even when the application of cardiopulmonary bypass is required. As indicated by the small number of NSCLC patients included in the retrospective study, we were restrictive in performing radical surgical procedures in T4 NSCLC [4]. Our results underline this strategy.…”

mentioning

confidence: 76%

“…Clearly, advanced sarcomas profit from a radical surgical approach with cardiopulmonary bypass. The importance of patient selection for a successful outcome in case of NSCLC disease has been stressed in the editorial comment for the discussed paper [4]. With increasing reports on surgical treatments of T4 NSCLC tumors, we hope that the indication for radical surgical therapy in the future may be defined more precisely, allowing replacement of the unspecific description 'in carefully selected patients'.…”

mentioning

confidence: 99%

Reply to Zielinski and Kuzdzal

Wiebe

¹

2006

European Journal of Cardio-Thoracic Surgery

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We read with much interest the article 'Extended pulmonary resections of advanced thoracic malignancies with support of cardiopulmonary bypass' by Wiebe et al. [1]. The authors presented in an exciting way their experience with extremely difficult surgical treatment of the pulmonary malignancies infiltrating the heart or great vessels. Such kind of surgery obviously deserves the highest level of expertise. The authors are especially congratulated for the results of treatment of sarcomas which are known for the resistance for chemotherapy and radiotherapy, the radical operation being the only curative solution in these patients. The 5-year survival of 62.5% in this group may indicate the way that kind of tumor should be managed more often in the future.Our concern, however, is the management of patients with advanced non-small cell lung cancer. There were three patients in the presented group, all of them T4, according to Table 2. In such group the rate of N2 involvement is very high, so the need for the thorough mediastinal staging is generally agreed upon. The authors state that all patients with NSCLC underwent cervical mediastinoscopy. This is surprising that the tracheal infiltration by pT2 nodes, which ought to have been easily discovered during mediastinoscopy, was unexpectedly found during the operation. As the authors wrote that one-third patients underwent neoadjuvant chemotherapy and radiotherapy, it would be very interesting to know what was the method of restaging in this patient. It would also be interesting to know if N2 disease was excluded during mediastinoscopy in the other two patients.The indications for use of CPB in three patients with NSCLC were emergent in one patient and unexpected in two patients. In these patients there was an infiltration of the main pulmonary trunk (patient 2), left atrium (patient 4) and the pulmonary trunk and descending aorta (patient 13). Therefore, this extensive infiltration was not correctly estimated preoperatively. Such diagnostic inaccuracies may of course happen, despite the availability of advanced diagnostic modalities, however the patients with sarcomas operated on by the authors, with similarly advanced tumors were diagnosed much more accurately and operated on in the planned way. There is no mention about intraoperative staging being currently regarded as a standard of radical surgery in lung cancer. Again, it would be interesting to know if the authors performed any kind of lymphadenectomy or nodal sampling and if they found any N2 or N3 nodes intraoperatively. Contrary to the excellent results achieved in sarcomas, the results in NSCLC are quite discouraging with no 3-year survivals. There was no mention if any kind of adjuvant treatment was considered in these patients. In our opinion, the conclusions of the study strongly support further attempts of extended resections in sarcomas with use of CPB; however, such method of treatment of NSCLC remains highly controversial. References[1] Wiebe K, Baraki H, Macchiarini P, Haverich A. Extended pulmonary re...

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“…

We read with much interest the article 'Extended pulmonary resections of advanced thoracic malignancies with support of cardiopulmonary bypass' by Wiebe et al [1]. The authors presented in an exciting way their experience with extremely difficult surgical treatment of the pulmonary malignancies infiltrating the heart or great vessels.

…”

mentioning

confidence: 96%

Pulmonary resections for T4 non-small cell lung cancer with support of cardiopulmonary bypass

Zieliński¹,

Kużdżał²

2006

European Journal of Cardio-Thoracic Surgery

1

0

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We read with much interest the article 'Extended pulmonary resections of advanced thoracic malignancies with support of cardiopulmonary bypass' by Wiebe et al. [1]. The authors presented in an exciting way their experience with extremely difficult surgical treatment of the pulmonary malignancies infiltrating the heart or great vessels. Such kind of surgery obviously deserves the highest level of expertise. The authors are especially congratulated for the results of treatment of sarcomas which are known for the resistance for chemotherapy and radiotherapy, the radical operation being the only curative solution in these patients. The 5-year survival of 62.5% in this group may indicate the way that kind of tumor should be managed more often in the future.Our concern, however, is the management of patients with advanced non-small cell lung cancer. There were three patients in the presented group, all of them T4, according to Table 2. In such group the rate of N2 involvement is very high, so the need for the thorough mediastinal staging is generally agreed upon. The authors state that all patients with NSCLC underwent cervical mediastinoscopy. This is surprising that the tracheal infiltration by pT2 nodes, which ought to have been easily discovered during mediastinoscopy, was unexpectedly found during the operation. As the authors wrote that one-third patients underwent neoadjuvant chemotherapy and radiotherapy, it would be very interesting to know what was the method of restaging in this patient. It would also be interesting to know if N2 disease was excluded during mediastinoscopy in the other two patients.The indications for use of CPB in three patients with NSCLC were emergent in one patient and unexpected in two patients. In these patients there was an infiltration of the main pulmonary trunk (patient 2), left atrium (patient 4) and the pulmonary trunk and descending aorta (patient 13). Therefore, this extensive infiltration was not correctly estimated preoperatively. Such diagnostic inaccuracies may of course happen, despite the availability of advanced diagnostic modalities, however the patients with sarcomas operated on by the authors, with similarly advanced tumors were diagnosed much more accurately and operated on in the planned way. There is no mention about intraoperative staging being currently regarded as a standard of radical surgery in lung cancer. Again, it would be interesting to know if the authors performed any kind of lymphadenectomy or nodal sampling and if they found any N2 or N3 nodes intraoperatively. Contrary to the excellent results achieved in sarcomas, the results in NSCLC are quite discouraging with no 3-year survivals. There was no mention if any kind of adjuvant treatment was considered in these patients. In our opinion, the conclusions of the study strongly support further attempts of extended resections in sarcomas with use of CPB; however, such method of treatment of NSCLC remains highly controversial. References[1] Wiebe K, Baraki H, Macchiarini P, Haverich A. Extended pulmonary re...

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Extended pulmonary resections of advanced thoracic malignancies with support of cardiopulmonary bypass

Cited by 56 publications

References 25 publications

Management of Sarcoma Metastases to the Lung

Management of Sarcoma Metastases to the Lung

Reply to Zielinski and Kuzdzal

Pulmonary resections for T4 non-small cell lung cancer with support of cardiopulmonary bypass

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