Surgical techniques and results of the pulmonary artery reconstruction for patients with central non-small cell lung cancer

Qianli Ma, Deruo Liu, Yongqing Guo, Bin Shi, Yanchu Tian, Zhiyi Song, Zhenrong Zhang, Bingsheng Ge, Xiaofei Wang, Thomas A D'Amico, Qianli Ma, Deruo Liu, Yongqing Guo, Bin Shi, Yanchu Tian, Zhiyi Song, Zhenrong Zhang, Bingsheng Ge, Xiaofei Wang, Thomas A D'Amico

Abstract

Background: It is difficult to achieve a margin-negative resection (R0) for non-small cell lung cancer (NSCLC) patients with infiltration of the pulmonary artery. We report our experience of the pulmonary artery reconstruction with regard to long-term survival.

Methods: Clinical records of 118 patients with NSCLC who underwent partial or circumferential pulmonary artery resection during a 21-year period were reviewed retrospectively. Techniques and survival outcomes were analyzed.

Results: We performed 22 pulmonary artery sleeve resections, 51 reconstructions by autologous pericardial patch, 36 tangential resections, 3 left main pulmonary artery (PA) angioplasties during pneumonectomy without cardiopulmonary bypass, and 6 by only preserving the apical and anterior (1(st)) branch of pulmonary arterial trunk. In 41 patients, bronchial sleeve resection was associated; in 7 cases, superior vena cava reconstruction was also required. Thirty-one patients received induction therapy. Thirteen patients had stage IB disease, 41 stage II, 53 IIIA, and 11 IIIB. Ninety-three patients had squamous cell carcinoma, 22 adenocarcinoma, 2 mixed and 1 large cell carcinoma. Negative vascular margins were achieved in all. 5 positive bronchial margins were due to limited lung function. The analysis of 118 cases yielded follow-up data in 94 cases. The mean follow-up was 70 months (range 1-156 months). There was no in hospital death, and the overall 5-year survival was 50.2%. Five-year survivals for stages I and II versus III were 63.9% versus 37.0% (p = 0.0059). Multivariate analysis yielded non-squamous cell carcinoma, stage III and patch pulmonary arterioplasty as negative prognosis factors. PA reconstruction associated with bronchial sleeve resection was the positive prognostic factor.

Conclusions: Pulmonary artery resection and reconstruction is feasible and safe, with favorable long-term survival. Our results support this technique as an effective alternative to selected patients with infiltration of the pulmonary artery, such as stage I and II and those who proved down-staged from stage III. Accurate preoperative evaluation, precise and suitable surgical techniques are crucial to achieve good results. Only preserving the anterior and apical pulmonary arteries and reconstruction of the main pulmonary artery by using the artery conduit technique without cardiopulmonary bypass in association with left pneumonectomy can be performed successfully. Postoperative anticoagulation is unnecessary.

Figures

Figure 1
Figure 1
Tangential arterial resection with direct sutures. A. Left upper lobectomy. Left apical, anterior and lingular arteries were invaded. B. Left lower lobectomy. Left common basal and superior segmental arteries were invaded. C. Right upper lobectomy. Right truncus anterior and posterior ascending arteries were invaded. D. Right lower lobectomy. Right common basal and superior segmental arteries were invaded.
Figure 2
Figure 2
The left main pulmonary artery wall was resected along the vertical axis of main PA (around the invasion) and then primary repair was performed along the horizontal axis. Left anterior and apical pulmonary arteries were invaded.
Figure 3
Figure 3
Patch and circumferential resection. A. Left apical and anterior arteries were invaded. B. Left apical, anterior, and lingular pulmonary arteries were all invaded.
Figure 4
Figure 4
Only preserved the truncus anterior (both anterior and apical pulmonary artery branches) for bilobectomy (Right middle & lower lobectomy).
Figure 5
Figure 5
Only preserved the anterior and apical pulmonary artery branches for Left lower lobectomy.
Figure 6
Figure 6
Temporary intra pulmonary artery conduit technique was used for 3 patients who underwent left pneumonectomy. The root of the left pulmonary artery (bifurcation of the main pulmonary artery) was invaded.
Figure 7
Figure 7
Overall survival curve. 5-year survival rate is 50.2% (95%CI: 40.0%-59.5%, calculate on 115 cases).
Figure 8
Figure 8
Survival curves by stage (0 = stage I and II, 1 = stage III). Five-year survival for stages I and II, versus III were 63.9% versus 37.0% (p = 0.0059), calculate on 115 cases.

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