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© 2002 European Association of Cardio-Thoracic Surgery
Simultaneous operation for cardiac disease and lung cancerCardiac Surgery Department, ‘San Giovanni Battista’ Hospital, C.so Bramante 88, Turin, Italy
* Corresponding author. Tel.: +39-11-633-5511; fax: +39-11-633-6130 Received March 18, 2002; received in revised form August 19, 2002; accepted August 23, 2002
Concomitant lesions of the heart and lung have been increasing and the issue of performing simultaneous pulmonary resection and cardiac surgery remains controversial. We report a retrospective study of 11 patients (ten male, one female) who underwent simultaneous lung resection and cardiac operation. In all cases the lung resection was performed before heparinization and cardiopulmonary bypass. All patients were discharged in 10 days. We did not have postoperative complications. Follow up mean was 41.2 months/patients. A combined procedure, when possible, avoids other thoracic procedure, permits to improve outcomes and provides economic benefit.
Key Words: Lung cancer; Cardiac surgery; Simultaneous surgery
We reported our experience in simultaneous cardiac surgery with pulmonary resections of 11 patients between January 1991 and December 1999. Ten patients were male, one was female. Mean age was 56.8±11.2 years (range 36–71). In all patients the lung lesions were accidentally found on preoperative chest X-ray during evaluation for cardiac surgery. Tumor preoperative stage (primary lung cancer) was stage I in nine, stage II in two, no other tumors were present. Left ventricular ejection fraction was greater than 0.60 in seven patients, 0.40–0.59 in four cases. The pulmonary resection, performed before the institution of cardiopulmonary bypass (CPB), was the lobectomy with a radical systematic mediastinal lymphadenectomy that was made without particular problems even if in all case surgical procedures were performed with a median sternotomy. Six patients underwent coronary artery bypass grafting (CABG, we used LIMA in five cases), two aortic valve replacement, one mitral, one aortic and mitral, and one resection of mixoma (Table 1). The pathologist confirmed the diagnosis in postoperative period. None received adjuvant chemotherapy or radiotherapy after lung resection. Follow-up was completed for all patients and ranged from 12 to 108 months (mean 41.2, SD 32.5).
There was no perioperative death. In all cases the pulmonary resection consisted of lobectomy and it was performed before the institution of CPB. We removed bronchopulmonary and hilar nodes in all cases, without particular problems even if all surgical procedures were performed with a median sternotomy, for the postoperative stage. The median aortic cross-clamp time was 37±35 min (range 9–92 min) and CPB time was 58±40 min (range 22–130 min). Blood loss mean was 660 ml (range 340–920 ml) and there was not any re-exploration for excessive bleeding. Blood transfusion was necessary in seven patients. No prolonged ventilator support was necessary (more than 24 h), mean ventilator time was 11 h. Patients were discharged in 36 h from ICU. None had prolonged air leaks, pleural space infections or wound infections. Pathologic examination revealed a malignant lesion in nine patients (of these seven had squamous cell carcinoma, two patients an adenocarcinoma), a benign disease was found in two patients (hamartoma). Patients were discharged in 10 days from hospital. Follow-up mean was 41.2 months/patient, three patients died from metastatic carcinoma at 15, 16 and 18 months and there was one no-cancer related death (re-CABG patient) at 20 months.
Concomitant lesions of heart and lung are uncommon and the natural history of patients with both treatable heart disease and lung cancer is unclear. Smokers are at increased risk for both coronary artery disease and lung cancer, but this fact was only present in 54% (6/11) of our patients. In patients with lung cancer at stages I or II, resection offers the best hope for cure. Following resection of stage I non-small cell lung cancer 5-year survival rates of 65–92% have been achieved [1]. In patients with coexisting cardiac disease the operative mortality following lung resection is significantly increased [2], performing the myocardial revascularization before the pulmonary resection, in a staged procedure, reduces the postoperative morbidity and mortality [3,4], although operative mortality in patients with coexisting lung disease undergoing CABG is significantly increased [5]. In addition, a two-stage procedure has the disadvantage of two anesthetics, two incisions, and a longer overall hospital stay. A single combined procedure may be preferred, with potential economic benefit. Pulmonary resection through a median sternotomy has been shown to result in excellent outcomes [6,7]; left lower lobectomy is the most difficult pulmonary resection through a median sternotomy and we performed it only in one patient in this series with no complications. Cardiopulmonary bypass has been shown to produce several systemic side effects [8,9]. CPB affects neutrophilis, platelets and gives complements activation; patients who undergo heart surgery with CPB are at substantial risk of postoperative bleeding. In our series we did not have re-explorations for bleeding, but we were very careful in haemostasis, and in heparin neutralization with prothamine. Several authors demonstrated that in patients undergoing combined surgery long-term survival is improved if the lung cancer is resected prior to CPB compared with during CPB [10,11]. Immunological alterations following CPB include depression of cell mediated immunity with decrease T-cell subsets [12], reduction in natural killer cell activity [13] and depressed granulocyte chemotaxis [14]. Although the effects of CPB on tumor growth and dissemination in patients with coexisting malignant disease remains unknown, a transient preoperative depression of immune function may determine malignant growth and dissemination in patients with coexisting disease. By performing simultaneous procedure and resecting the tumor prior the institution of CPB can minimize these effects. A report by Ulicny and associates demonstrated that the 5-year survival was higher in patients who underwent lung resection before CPB (55%) versus those who underwent lung resection after CPB (20%) [15]. The predicted survival following lung resection is in part determined by the nodal status of tumor. A radical systematic mediastinal lymphadenectomy confers survival advantage compared with that of a lesser dissection of the lymphnodes is less clear. Furthermore a radical dissection prolongs to the operating time and increases the morbidity [16].
Simultaneous cardiac surgery and lung resection, in this small number of patients, was safely and not associated with increased early or late morbidity or mortality. In this personal experience, as in literature, the long term survival is determined by tumor stage, and free survival in patients with stages I or II is satisfactory. A combined procedure, when possible, avoids the need for a second thoracic procedure and may improve outcomes and provides economic benefit. CPB was not associated with increased bleeding and early or late mortality, but we think, when possible, the better option is to avoid it in CABG patients.
ICVTS on-line discussion Author: Prof. Joachim Hasse, Thoracic Surgery, University Hospital of Freiburg, Hugstetter Str. 55, Freiburg, Germany Date: 09-Sep-2002 21:25 Message: In the presentation of the materials and methods the authors are referring to 11 cases of primary lung cancer. How many were confirmed preoperatively histologically and what were the criteria of stage II in two of them? Which tools were routinely used for specific oncologic diagnosis preoperatively? Radical mediastinal lymphadenectomy is claimed. What was the average number of lymphnodes that were dissected in the respective positions and, in particular in position 9 on the left-hand side. How were the subcarinal and pretracheal positions (3 and 7) approached? Were frozen section proofs of complete resection obtained? According to the results, in two patients benign hamartomas were found. Usually for such lesions that can, with differential diagnosis, be anticipated from CT patterns, eventually smoking history and intraoperative findings lesser resection or even enucleation are sufficient. Which lobes were affected? The overtreatment should be discussed. The postoperative staging (pTNM) is not reported but is essential for the judgement of both the methods and the results. Although survival calculations are of limited meaning in a small series of nine patients they should be added. So far one can conclude a real mortality of 33% at 18 months. Did the fourth death at 20 months occur in a cancer patient? The conclusion of satisfactory outcome is weak without the knowledge of pTNM and other details as mentioned before. Author: Dr. Hermann Aebert, Thoracic and Cardiovascular Surgery, Eberhard Karls University, 72076 Tuebingen, Germany Date: 09-Oct-2002 16:48 Message: Simultaneous operation may be an attractive option in some patients. However, I found it difficult to perform the usual radical lymphadenectomy through a median sternotomy, particularly for left sided tumors. How many lymph nodes from which locations were removed? How was the approach to the lymph nodes at the tracheal bifurcation, were they exposed by opening of the dorsal pericardium? Regarding the left lower lobe, lobectomy before ECC appears extremely difficult.The cases I have done via sternotomy were performed on ECC which may even be required for some steps of upper lobectomy and lymphadenectomy if large and deep patients do not tolerate some extent of cardiac compression. However, in my experience a much more comfortable way to perform CABG and resection of left sided tumors and particularly of the lower lobe is via lateral thoracotomy. The ascending aorta and the main pulmonary artery are cannulated after the lung resection and radical lymphadenectomy. Harvesting of the mammary artery poses no problems. PII: S1569929302000348
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Abstract
1. Materials and methods