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© 2003 European Association of Cardio-Thoracic Surgery
The use of cardiopulmonary bypass during extended resection of non-small cell lung cancerDepartment of Thoracic Surgery, Kyoto University, 53 Shogoin, Kyoto 606-8507, Japan
* Corresponding author. Tel.: +81-75-751-4975; fax: +81-75-751-4974 Received May 15, 2003; received in revised form August 7, 2003; accepted August 26, 2003
We undertook a retrospective study in order to assess the risks and benefits of the use of cardiopulmonary bypass (CPB) during operative resection of non-small cell lung cancer (NSCLC). Eleven patients (nine male and two female with a median age of 62 years, range 28–76 years) underwent extended resection of locally advanced NSCLC using CPB. The indication for the use of CPB was resection of the left atrium (  ), the aorta ( ), the pulmonary artery (), or for respiratory support ( ). No deaths occurred during the first 30 days postoperatively. With exception of one hospital death due to MRSA mediastinitis and local recurrence, all the patients were discharged and returned to their social activities. Two patients are alive with recurrent disease at follow-up 37 and 41 months post-surgery, respectively. Eight patients died due to recurrence and the median postoperative survival time was 269 days (range: 112–1132 days). One patient who had no evidence of recurrence died of aspiration pneumonia 10 months after surgery. CPB is a safe and effective tool for use during extended resection of locally advanced NSCLC. However, careful consideration for the risk/benefit ratio should be required when assessing the indication for surgical intervention.
Key Words: Cardiopulmonary bypass; Non-small cell lung cancer; Postoperative complication
The use of cardiopulmonary bypass (CPB) during resection of thoracic malignancy has been controversial. Following the report by Neville et al. in 1965 of high morbidity and mortality in such cases [1], most thoracic surgeons have considered such operations to be contraindicated. However, with advances in medical technology, CPB has become safer and less expensive. In view of this, the risk/benefit ratio of using CPB may have changed significantly [2–5].
2.1. Patient selection (Table 1) Evaluation for operability of patients with non-small cell lung cancer (NSCLC) was performed using CT scanning, MRI and MR-angiography, 67Ga scintigraphy, fluoro-deoxygenate-glucose positron emission tomography (FDG-PET), bone scintigraphy and fiber optic bronchoscopy. Mediastinal lymphadenopathy was evaluated basically with CT scan and a larger than 10-mm short-axis diameter was considered as nodal positivity. Mediastinoscopy was performed in a case with equivocal lymph node enlargement.
Patients were fully informed about the risk/benefit of operation and other therapeutic modalities. Consideration for surgical resection was given when a case met the following criteria: cT4N0-1M0 or single level cN2 disease, fair performance status, no other surgical contraindication, and written informed consent. The final decision for surgical resection was made as a consensus of radiologists, pulmonologists and thoracic surgeons. Between January 1991 and December 2001, 11 patients with non-small cell lung cancer (NSCLC) underwent extended resection using CPB in Kyoto University Hospital. The demographic data of the patients are shown in Table 1. The preoperative performance status was fair in all patients. The pathological diagnosis was squamous cell carcinoma in six cases, adenocarcinoma in three cases, adenoid cystic carcinoma in one case and epidermoid carcinoma in the remaining one case. In four cases the clinical stage was T4N0M0, in three cases it was T4N1M0 and in the remaining four cases the clinical stage was T4N2M0. Three patients, two at stage cT4N0M0 and one at stage cT4N1M0, underwent surgery without prior induction therapy. The remaining eight patients were operated after induction therapy. This consisted of chemotherapy in three patients, radiotherapy in three and both therapies in two.
(Table 2) Operation was performed through postro- or anterolateral thoracotomy in five cases, median sternotomy in three, and both in three. Pneumonectomy was performed in nine patients, and the remaining two underwent lobectomy.
In all cases, decision of using CPB was made during operation when efforts to avoid its use were unsuccessful and it was found that the tumor was otherwise unresectable. The indication for using CPB was resection of parts of the heart or great vessels in 10 cases. The resected areas were the left atrium ( ), the aorta (), and the pulmonary artery (). CPB was used for respiratory support because of severe hypoxia during hilar manipulation in the remaining one case. Types of CPB are shown in Table 2. In patient 4, a selective cerebral perfusion was required because of tumor invasion to the aortic arch [6]. Complete resection was undertaken in nine cases. In two of these cases there was microscopic residual disease: in patient 11 there was possible residual tumor in the aortic wall; and in patient 9, tracheal stump was diagnosed as cancer-positive, although it was diagnosed as negative at the intraoperative frozen section (Table 4).
The median blood transfusion was two units (range: 0–24 units, one unit being equivalent to 200 ml of whole blood).
(Tables 3 and 4) In all cases, the pathological stage of lung cancer was identical to the clinical stage found on preoperative clinical assessment.
The median duration of postoperative intubation was 1 day (range: 0–6 days). However, re-intubation was required in two cases. Patient 7 was extubated on POD 1, but re-intubated on POD 13 because of mucus retention. This patient was re-extubated on POD 24, and was discharged. Patient 3 was extubated on POD 2, but was re-intubated at the time of operation for sternal wound infection on POD 28. The patient was not extubated until his death. Re-thoracotomy was performed only in the above case. Infectious complication after surgery was noted in two cases. Patient 3 developed fatal MRSA mediastinitis after sternal wound dehiscense. In patient 11, MRSA was detected from sputum culture on POD 7 without symptom of pneumonia. This patient developed aseptic sternal wound dehiscense, but recovered with irrigation. Minor cerebrovascular complication was seen in one patient who manifested mild drowsiness with small cerebral infarction on POD 1, but required no further therapy. Postoperative cardiovascular complication was noted in four patients, and they were successfully treated with anti-arrhythmic agents or catecholamines. Recurrent nerve palsy due to surgical manipulation was seen in two patients. Postoperative chemo- or radiotherapy was performed in eight patients. Postoperative treatment was not given due to medical reasons in patients 3 and 11, or unknown reason in patient 2. There were no deaths within 30 days of the operation, but one hospital death on POD 346 due to MRSA mediastinitis with local recurrence was noted. The remaining 10 patients were discharged from hospital and returned to their social activities. During the follow-up period, eight patients died due to recurrence with a median survival of 254 days (range: 112–1132 days). Four of these deaths were due to a local recurrence and the remaining four were secondary to a distant metastasis. One additional patient died of aspiration pneumonia on POD 295 with no evidence of recurrent disease. Two patients are alive but have recurrent disease (mediastinal lymph nodes) at follow-up 37 and 41 months after surgery.
The use of CPB in the resection of lung cancer has two advantages. First, it enables a combined resection of otherwise unresectable tumors involving the heart and the great vessels. Second, the use of CPB sometimes improves the surgeon's field of vision that is limited by secure airways. However, the use of CPB also has some disadvantages, such as hemorrhage, the possibility of hematogenous dissemination of the tumor cells, and high cost. The use of CPB in the resection of thoracic malignancy has been controversial. The biggest issue has been the safety of CPB and this has been of concern since the report by Neville in 1965 of high morbidity and mortality in such cases [1]. However, with progress in medical technology since 1965, CPB has become much safer. Klepetko has reported favorable morbidity and mortality rates in seven cases where there was combined resection of T4 lung tumors invading the aorta [5]. In addition, Gillinov has concluded that CPB can be a valuable adjunct in surgical treatment of neoplasia where the great vessels are involved in malignant lesions [4]. A possible CPB-related additional risk is hematogenous dissemination of tumor cells. There have only been a few reports that have documented bypass-related spread of tumor cells in cases where an extracorporeal bypass technique was used in thoracic or abdominal surgery for neoplastic lesions. However, it is possible that this paucity of reporting may be partly due to the difficulty of proving that the bypass technique caused the tumor dissemination. Since we experienced such a case [7], and we now no longer re-use suctioned blood. On balance, even though there are some problems with its use, CPB may well be a safe and important tool in thoracic oncologic surgery. Another important issue to consider is whether NSCLCs should be resected where they are invading adjacent components even if they are potentially resectable using CPB. The criteria for such cases varies in different institutions. Doddoli [8] and Fukuse [9] have reported that they only operate on N0-1 tumors, while Klepetko performs single-level N2 NSCLC resections [5]. Tsuchiya reports that even bulky N2 NSCLC is resectable [3]. We believe that the safety profile of CPB is so good that this need not affect the decision on whether to treat these lesions surgically. Our current policy is that cN0-1 NSCLC is resectable after preoperative chemotherapy or radiotherapy or both, and that the decision on surgical treatment of cN2 NSCLC is taken on a case by case basis. In conclusion, CPB is a safe and effective tool for use during extended resection of locally-advanced NSCLC. However, curability of such operation is still very low. Careful consideration for the risk/benefit ratio should be required when assessing the indication for surgical intervention. doi:10.1016/S1569-9293(03)00194-4
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Abstract
1. Introduction