Combined Pulmonary Artery Sleeve Resection / Left Upper Lobectomy and Extended Resection of the Thoracic Aorta After TEVAR for T4 Lung Cancer

Originally presented as a STSA/CTSNet Surgical Motion Picture at the 2016 STSA Annual Meeting. 

Objectives: The therapeutic approach for advanced stage lung cancer is controversial, specifically in the surgical management of tumors invading the great vessels and mediastinum. The authors present a case in which they performed a left upper lobectomy and sleeve resection of the left pulmonary artery and extended resection of the thoracic aortic wall after the placement of an endoluminal prosthesis (TEVAR).

Methods: The 77-year-old patient underwent a CT scan of the chest for routine surveillance due to 30-pack year smoking history. The CT scan revealed a spiculated mass in the medial left upper lobe (3.6 X 2.7), abutting the aortic arch. A PET CT showed the mass was FDG avid (SUV 14.2), clinical stage IIIA (T4NoMo). The mass was inseparable from the aortic arch and the left main pulmonary artery. Induction chemotherapy was initiated in anticipation of subsequent operative resection. To facilitate a safe resection of the aortic arch, the authors performed preoperative thoracic endovascular aortic repair (TEVAR) one week prior to the planned operative resection.

Results: The patient underwent mediastinoscopy and left thoracotomy, with left upper lobectomy incorporating pulmonary artery sleeve resection. The adventitia of the thoracic aorta was completely dissected free of the invasive tumor, followed by mediastinal and hilar lymphadenectomy. An intercostal muscle flap was positioned between the left pulmonary artery and bronchial staple line. Post-operative course was uneventful.

Conclusion: The use of induction therapy and extended resection of the pulmonary artery and aorta for advanced T4 tumors may be performed safely, and may be aided by the use of prophylactic TEVAR. Tumors that invade the great vessels and mediastinum may be approached after careful preoperative planning, and extended resection should be considered for carefully selected patients.

Copyright 2016, used with permission from the Southern Thoracic Surgical Association. All rights reserved.