Extended Operations for the Treatment of Lung Cancer

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Extended Operations for the Treatment of Lung Cancer Philippe G. Dartevelle, MD The Annals of Thoracic Surgery Volume 63, Issue 1, Pages 12-19 (January 1997) DOI: 10.1016/S0003-4975(96)01084-3

Fig. 1 (A) Doctor Max Merlier and (B) Dr Henri Le Brigand. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 2 Centre Chirurgical Marie Lannelongue. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 3 Survival of 60 patients who underwent carinal pneumonectomy for bronchogenic carcinoma. With a median follow-up of 4.3 years, the overall 5- and 10-year survival rates, including postoperative deaths, were 42.3% and 29%, respectively. Overall median survival was 2.9 years. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 4 Hemodynamic repercussions during cross-clamping of a patent superior vena cava (SVC). Clampage of the SVC without any protection results in a low arterial–venous gradient in the cerebral vascular bed. The use of a shunt reestablishes a normal gradient but enhances the potential for a thrombosis and interferes with the operative field, making the performance of the vascular procedure difficult. It is easier to maintain a normal gradient in the cerebral vascular bed by increasing the intravascular fluid load to compensate for the clamping-induced hypovolemia and arterial systemic pressure by vascoconstrictive agents. (Reprinted with permission from Dartevelle P, Macchiarini P, Chapelier A. Technique of superior vena cava resection and reconstruction. Chest Surg Clin North Am 1995;5:345–58.) The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 5 (A) Clamping and division of the superior vena cava beyond each side of the tumor. (B) This maneuver facilitates the exposure and stapling of the retrocaval pulmonary artery. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 6 (A) Computed tomographic scan of a 56-year-old man with a squamous tumor originating from the ventral segment of the right upper lobe and invading the tracheobronchial bifurcation and the posterior border of the superior vena cava (SVC). (B) Pulmonary angiography shows the amputation of the right mediastinal artery (arrow). The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 7 Anatomy of the thoracic inlet. The first encountered structure is the subclavian vein, which drains with the internal jugular vein into the brachiocephalic vein. The posterior jugular and vertebral veins with the thoracic duct drain into the posterior surface of this confluence. Behind, we find the plane of the subclavian artery, which is separated from the venous plane by the anterior scalene muscle and phrenic nerve. Several primary branches of the subclavian artery often vascularize the tumor. The last plane is made up of the brachial plexus. C8 is well above the first rib, whereas T1 arises between the first and second thoracic vertebrae and is usually included in the tumor. (Reprinted from Testut L, Jacob O. Anatomie topographique. Lyon: Renaux Valentin, 1909.) The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 8 (A) Computed tomographic scan showing an apical bronchogenic tumor invading the anterior path of the left thoracic inlet. (B) On preoperative arteriography, the left subclavian artery is included by the tumor (arrow) beyond the origin of the left vertebral artery. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 9 Computed tomogram showing an apical bronchogenic tumor invading the posterior path of the left thoracic inlet. At operation, the subclavian artery was massively invaded. Note the absence of tumor at the level of the costotransverse foramen. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 10 Computed tomogram showing a left apical bronchogenic tumor invading the intervertebral foramen (arrow) between T1 and T2. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 11 (A) Right tumor invading the first thoracic intervertebral foramen. (B) The lesion is usually approached through transcervical (anterior) and middle (posterior) incisions for apical malignant tumors invading the first two thoracic intervertebral foramina. During the cervical step, the anterolateral aspects of the vertebral bodies of C7 throughout T2 are safely and perfectly exposed and a median slice (arrow) on the prevertebral planes can greatly facilitate the section of the invaded vertebral bodies during the posterior step of the operation. Usually, tumors invade two intervertebral foramina, necessitating resection of at least hemivertebrectomy (line of transection) above and below the invaded one. (C) The hemivertebrae need to be fixed thereafter. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 12 Chest roentgenogram of the postsurgical specimen shows the tumor resected en bloc with the first three ribs and hemivertebrae. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 13 Chest roentgenogram showing the bilateral spinal fixation with metal rods interposed. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 14 Preoperative arteriogram demonstrating a long, ascending and descending (arrow) spinal artery arising from the left fourth intercostal artery and entering the spinal canal between the second and third intervertebral foramina in a patient with left apical tumor invading the T2-T3 intervertebral foramen. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)

Fig. 15 Overall survival of 55 patients operated on for an apical tumor invading the thoracic inlet. The Annals of Thoracic Surgery 1997 63, 12-19DOI: (10.1016/S0003-4975(96)01084-3)