Prosthetic Reconstruction of Superior Vena Cava System for Thymic Tumor: A Retrospective Analysis of 22 Cases

Abstract

Objective This study aimed to report our experience in superior vena cava (SVC) resection and reconstruction for 22 thymic tumor patients and to make comparisons with previous related reports. Methods A retrospective study on 22 patients (15 thymomas, 7 thymic cancers) who underwent tumor resection with concomitant SVC reconstruction. All the patients underwent vascular conduit reconstruction by the cross-clamping technique. The corresponding data were reviewed, including clinical presentation, operation management (surgery procedure, selection of suitable graft, strategies against SVC syndrome, etc.), postoperative cares (antithrombotic agent application, treatments on brain edema, etc.), and follow-up information. Result Two patients were myasthenic, well controlled by oral pyridostigmine. All resections were radical (R0). Ten patients received induction treatment. All the 15 thymoma patients were Masaoka stage III (type B1–B3). As for thymic cancer, six patients were Masaoka stage III and one was stage IVa. Wedge pulmonary resection was performed in three patients (two right upper lobe, one both upper lobe). Procedures included were single graft replacement in 12 patients, bilateral grafts in 9, and Y-shaped graft in 1 patient. Anticoagulation and dehydration agents were routinely applied after operation. No perioperative mortalities were observed. Major complication rate was 9.1%. The median survival time was 44.2 months (range, 4–92 months). Three- and 5-year overall survival rates were 80.8 and 44.0%, respectively. As for conduit patency, two grafts (9.1%) demonstrated evidence of occlusion during long-term follow-up, but no additional interventions were required due to no complications related. Conclusion Our study, confirming data from existing literature, showed that the prosthetic reconstruction of the SVC system is a feasible additional procedure during resection of thymic tumor infiltrating the venous mediastinal axis, minimally increasing postoperative complications in experienced hands.

Thymic en-bloc resection with veins: case demonstrations and review of the literature

“…The operative approach used should be individualized, should maximize exposure of the critical structures, and should be familiar to the surgeon. The vast majority of these cases are done via a sternotomy, although a hemi-clamshell or a cervico-sternotomy are reasonable options ( 2 , 3 , 5 - 7 ).…”

“…There is some debate regarding the maximum involvement of the SVC that will permit a partial resection. Some surgeons advocate for no more than 30% involvement, stating increased risk of kinking, thrombosis and occlusion ( 5 - 7 ), while other surgeons advocate for less than 50% ( 2 - 4 ). When performing a partial resection, a partial occlusion clamp can be utilized and the SVC can be resected en bloc with the tumor.…”

“…Alternatively, we ligate the left innominate vein and place the graft from the right innominate vein to the SVC or the right atrium. Some authors routinely conduct bilateral reconstruction ( 7 , 14 ), citing improved drainage with decreased risk of brain edema. This is also our preferred method.…”

“…Complete R0 resection ranges from 80% to 100% ( 5 , 7 , 18 ). The postoperative morbidity rate has been reported between 31% and 52% ( 5 - 7 ) and a mortality rate around 8%, although these studies have been more focused on thymic resection with SVC resection ( 5 , 6 ).…”

“…The Masaoka-Koga classification is used to stage thymic malignancies. Select patients with stage III (macroscopic invasion into neighboring organs such as pericardium and great vessels) and stage IV disease (pleural, pericardial or lymph node metastasis) should be considered for thymectomy with en - bloc resection of the involved venous structures ( 5 - 7 ).…”