Surgical resection and survival of patients with unsuspected single node positive lung cancer (NSCLC) invading the descending aorta

Abstract

Background: Surgical treatment of non-small cell lung cancer (NSCLC) with aortic invasion is still debated.

Methods: Thirteen patients with locally advanced (T4) NSCLC and invasion of the descending aorta underwent pneumonectomy (n=9) or lobectomy (n=4) together with aorta en bloc resection and reconstruction (n=8) or subadventitial dissection (n=5), complete lymph node dissection, and had microscopic unsuspected node metastasis at N1 (n=5) and N2/3 (n=8) levels of whom 12 received radiation therapy. Clamp-and-sew was used to resect and reconstruct the aorta.

Results: Operative mortality and morbidity rate was 0% and 23%, respectively. Four patients died of systemic tumor relapse and 2 of local recurrence. Six patients were alive after a median follow-up of 40 months (range 15-125 months). Overall 5-year survival rate was 45%. Median survival time and 5-year survival rate of patients after aortic resection was 35 months and 67%, respectively, and was 17 months and 0%, respectively, after aortic subadventi-tial dissection (p=0.001). N1 and N2 nodal status adversely affected survival, but survival difference was not significant (N1 versus N2/3; 52% versus 39% at 5 years; p=0.998).

Conclusions: Aortic resection with single station node positive T4 lung cancer can achieve long-term survival. The data indicate that aortic resection-reconstruction is associated with better outcome than subadventitial dissection.

Keywords: aortic operation; lung cancer surgery; off pump; outcomes.

Table 1. Literature research: aortic resection for lung cancer (1989–2005)

Table 2. Patients demographics

Table 3. Operative characteristics of the 8 patients who underwent resection and reconstruction for T4 lung cancer

Table 4. Recurrence

Figure 1. (A) Chest computed tomographic (CT) scan at the level (Th V) of the descending aorta, demonstrating aortic invasion (arrow) of a centrally located tumor. (B) The CT scan of the level of six thoracic vertebra shows a tumor abutting the descending aorta (arrow) .

Figure 2. Operative findings showing localized tumor invasion of the aortic media (arrow). The left lower lobe (LLL) is detached. The left upper lobe (LUL) is in situ and anastomosed by double sleeve (not shown).

Figure 3. Operative view.

(A) Tumor removed from the descending aorta by subadventitial dissection (arrow). (B) Graft replacement of the descending aorta (arrow); lung removed. Bronchus (Br) cut and closed by manual sutures.

Figure 4. Survival of patients after aortic resection (n=8; solid line) and subadventitial dissection (n=5; dotted line) for T4 lung cancer with aortic involvement. There was a significant difference in the 5-year survival rate (p=0.001).

Figure 5. Survival of patients with T4 non small cell lung cancer invading the thoracic aorta, grouped by nodal status. The 5 year survival rate were 52% and 39% for N1 and N2/N3, respectively (p=0.998).