Salvage resection of advanced mediastinal tumors

Abstract

The surgical treatment of locally advanced mediastinal tumors invading the great vessels and other nearby structures still represent a tricky question, principally due to the technical complexity of the resective phase, the contingent need to carry out viable vascular reconstructions and, therefore, the proper management of pathophysiologic issues. Published large-number series providing oncologic outcomes of patients who have undergone extended radical surgery for invasive mediastinal masses are just a few. Furthermore, the wide variety of different histologies included in some of these studies, as well as the heterogeneity of chemo and radiation therapies employed, did not allow for the development of clear oncologic guidelines. Usually in the past, surgical resections of large masses along with the neighbouring structures were not offered to patients because of related morbidity and mortality and limited information available on the prognostic advantage for long term. However, in the last decades, advances in surgical technique and perioperative management, as well as increased oncologic experience in this field, have allowed radical exeresis in selected patients with invasive tumors requiring resections extended to the surrounding structures and complex vascular reconstructions. Such aggressive surgical treatment has been proposed in association or not with adjuvant chemo-or radiotherapy regimens, achieving encouraging oncologic results with limited morbidity and mortality in experienced institutions. Congestive heart failure or impending cardiovascular collapse due to the compression by the large mass are the most frequent immediately lifethreatening problems that some of these patients can experience. In this setting, medical palliation is usually ineffective and an aggressive salvage surgical treatment may remain the only therapeutic option.

Surgical feasibility and long‐term outcome of superior vena cava replacement for advanced thymoma in patients undergoing preoperative chemotherapy or chemoradiotherapy

“…Some studies have shown that patients with advanced thymoma, in whom preoperative examination confirms that resection of their tumor is not achievable, should be treated with induction chemoradiotherapy to improve the feasibility of complete surgical resection 7,9,14,18,20 . However, studies on the therapeutic effect of preoperative induction chemoradiotherapy for patients with advanced thymoma invading the SVC is still limited, 3,6,21,23 and whether preoperative induction therapy will affect the patency of vascular grafts is a concern for many clinicians 16,24–26 . Extensive resection of malignant thymic tumors combined with reconstruction of SVC and left innominate vein have been reported to be beneficial, 16,25–26 but there are few reports on induction chemoradiotherapy before thymoma resection and SVC replacement and reconstruction surgery.…”

“…Invasion to mediastinal structures is one of the clinical features of advanced thymic tumors. Because of its aggressive behavior, thymic tumors may invade adjacent organs or large vessels, such as the superior vena cava (SVC), innominate veins and pericardium, etc 3 . In recent years, several reports have described surgical resection with SVC reconstruction for the treatment of advanced thymic tumors 4,5 .…”

“…Radiotherapy is expected to prevent cancer cell microresidues at local sites, whereas chemotherapy has the potential to eliminate micrometastases, thus facilitating complete resection 12–14 . Therefore, salvage surgery after definitive chemoradiotherapy is sometimes performed to control local disease by experienced surgical institutions 3,15 . It is for this reason that surgical cases after neoadjuvant chemoradiotherapy treatment for advanced thymic tumors may not be rare 16–17 .…”