From 3-Dimensional Printing to 5-Dimensional Printing: Enhancing Thoracic Surgical Planning and Resection of Complex Tumors Erin A. Gillaspie, MD, Jane.

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From 3-Dimensional Printing to 5-Dimensional Printing: Enhancing Thoracic Surgical Planning and Resection of Complex Tumors Erin A. Gillaspie, MD, Jane S. Matsumoto, MD, Natalie E. Morris, Robert J. Downey, MD, K. Robert Shen, MD, Mark S. Allen, MD, Shanda H. Blackmon, MD The Annals of Thoracic Surgery Volume 101, Issue 5, Pages 1958-1962 (May 2016) DOI: 10.1016/j.athoracsur.2015.12.075 Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Computed tomography scans are used to segment the image, which is then converted into a 3-dimensional anatomic model. The bottom right image represents the final segmentation. The Annals of Thoracic Surgery 2016 101, 1958-1962DOI: (10.1016/j.athoracsur.2015.12.075) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 The printer is in the process of printing the model, laying down material in a thin layer and then exposing it to ultraviolet light to harden before the next layer is applied. The Annals of Thoracic Surgery 2016 101, 1958-1962DOI: (10.1016/j.athoracsur.2015.12.075) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (A) Anterior view of 5-dimensional model demonstrating fused pre- and posttreatment superior sulcus lung cancer and level 5 lymph nodes with clear representation of the relationship of the tumor to surrounding structures. (B) Lateral view with the second rib removed for ease of viewing. A difference in the size of the tumor after treatment and complete pathologic response in the aortopulmonary lymph node is noticeable. The Annals of Thoracic Surgery 2016 101, 1958-1962DOI: (10.1016/j.athoracsur.2015.12.075) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) The pretreatment computed tomography (CT) scan demonstrates a superior sulcus lung tumor invading the mediastinum, abutting T2, and the first and second rib, without evidence of destruction. The left subclavian artery is encased and displaced at and just distal to the origin of the vertebral artery. (B) The posttreatment CT scan demonstrates superior sulcus tumor invading the mediastinum and abutting T2 to T3. The mass has decreased in size, and the degree of encasement and displacement of the left subclavian artery is also reduced. The Annals of Thoracic Surgery 2016 101, 1958-1962DOI: (10.1016/j.athoracsur.2015.12.075) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Posterior approach for division of the lateral aspect of the vertebral bodies, transections of the nerve roots, and separation of the posterior elements of the tumor. Orientation markers include left (L) and right (R). The Annals of Thoracic Surgery 2016 101, 1958-1962DOI: (10.1016/j.athoracsur.2015.12.075) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Second stage of the procedure was performed through a trap door anterior approach (head [H] to the left side of the photograph). The left lung is retracted laterally. The mediastinal structures were skeletonized, the thoracic duct was ligated, and the phrenic and vagus nerves were carefully preserved. The innominate (I) and tributaries were dissected, along with the underlying left carotid artery and proximal left subclavian artery (ligated the thyrocervical trunk and vertebral artery). A carotid subclavian bypass (yellow *) was performed with an 8-mm Hemagard (Atrium Medical Corp, Hudson, NH) Dacron (DuPont, Wilmington, DE) graft. The reimplantation of the subclavian vein (SCV) is identified by the white*. The subclavian artery (sca) can be seen posterior to the vein as it is attached to the carotid–subclavian bypass. The markers include left and lateral (L) and medial (M). The Annals of Thoracic Surgery 2016 101, 1958-1962DOI: (10.1016/j.athoracsur.2015.12.075) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 The en bloc resection of the tumor with the left upper lobe of the lung is seen on a roentgenogram. The Annals of Thoracic Surgery 2016 101, 1958-1962DOI: (10.1016/j.athoracsur.2015.12.075) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions