Elsevier

Lung Cancer

Volume 45, Issue 3, September 2004, Pages 357-363
Lung Cancer

15 years single center experience with surgical resection of the superior vena cava for non-small cell lung cancer

https://doi.org/10.1016/j.lungcan.2004.02.009Get rights and content

Abstract

Objectives: To examine our results with surgery for locally advanced non-small cell lung cancer (NSCLC) invading the superior vena cava (SVC). Methods: A retrospective analysis of patients who underwent resection between 1988 and 2003 was performed. Postoperative morbidity, long-term survival, including risk factors for overall and disease-free survival were examined. Results: Median age of the 15 operated patients was 60 years (28–78). All had direct SVC invasion by tumor. All underwent mediastinoscopy. Seven patients with N2 disease, and one with a bulky right upper lobe tumor received induction therapy. Eight underwent lobectomy (three sleeve), and seven had pneumonectomy (two carinal). The SVC was replaced by interposition graft in nine patients, whereas six had partial resection. There were two postoperative deaths (14%) and three major morbidities (23%). There was one late graft thrombosis. Mean follow-up was 25 months (3–132, median 11). Overall 1 and 3-year survival was 68 and 57% and disease-free survival was 55 and 27%, respectively. All late deaths were due to recurrence. Survival of patients with N2 disease was not significantly worse than those with localized (N0/N1) nodal disease. There was a trend towards later recurrence in patients who had induction therapy (median disease-free interval of 29 months versus 5 months in the untreated group, P=0.3), but there was no significant effect on overall survival. The extent of lung resection and type of SVC procedure did not influence long-term survival. Conclusions: Carefully selected patients with NSCLC and SVC involvement can be operated upon with acceptable postoperative morbidity and mortality. Induction therapy appears to delay recurrence.

Introduction

Locally advanced non-small cell lung carcinoma (NSCLSC), with invasion of the superior vena cava (SVC), defined as Stage IIIb (TNM classification), is generally considered a contraindication for surgery. Early reports demonstrated no long-term survivors among T4 patients who underwent surgical resection [1]. Yet, over the last 15 years, several reports regarding surgical resection for selected T4 tumors have shown better results, with acceptable peri-operative morbidity, and 5-year survival of up to 30% [2], [3], [4], [5].

It has also been suggested, that among patients with T4 tumors, those with SVC invasion may have a better prognosis, when the tumor is surgically resected, as compared to those with tumors invading the esophagus, myocardium or aorta [3], [6].

The purpose of this study was to review our experience in this selected group of patients. We retrospectively analyzed our results with patients who underwent resection for NSCLC with direct SVC involvement by the tumor, emphasizing immediate and long-term survival, and defining factors that might influence survival.

Section snippets

Patients and methods

From February 1988 through August 2003, 23 patients underwent SVC resection for thoracic malignancies with direct SVC involvement by tumor. Patient with SVC invaded by mediastinal lymph nodes (and not by the tumor itself), as well as patients with evidence of distal metastases were not included in this study. Hospital charts, operative notes and pathology reports were reviewed after approval by the University Health Network Research Ethics Board. Follow-up was obtained through Thoracic Surgery

Results

There were nine males and six females. The median age was 60 years, ranging from 28 to 78 (Table 1). Follow-up was complete in all but one patient. This patient was alive and free of disease more than 11 years after right pneumonectomy for T4N2 disease, but was lost to follow-up thereafter. Mean follow-up time was 25 months, ranging from 3 to 132 months (median 11 months). All patients had proven NSCLC prior to any treatment.

There were seven patients with squamous cell carcinoma, five with

Comment

Surgical resection of locally advanced (T4) NSC lung cancer has traditionally been considered a surgical contraindication, as this group of patients had previously experienced an overall 5-year survival of 6–8% [7]. Initial reports regarding patients with NSCLC and direct SVC invasion revealed only anecdotal long-term survivors, and were usually published as case reports [8], [9]. The Memorial Sloan–Kettering Cancer Center group was among the first to report experience with a series of

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