Re-VATS Left Upper Lobectomy With Pulmonary Artery Plasty After Induction Cemotherapy

<p>Partial or complete resection of the pulmonary artery is a well-known technique in the context of the treatment of non-small cell lung cancer that provides optimal results in terms of disease control and blood flow[1,2]. In this video tutorial we demonstrate how to carry out a left upper lobectomy associated to a plasty of the left pulmonary artery using a re-VATS approach. Careful pre-operative planning and evaluation of the patient is mandatory in order to safely perform this procedure.<br></p> <p> </p> <p>We here present the case of a 69 year old patient affected by an adenocarcinoma of the left upper lobe and several other comorbidities, such as: atrial fibrillation, GOLD 2 chronic-obstructive pulmonary disease, type 2 diabetes mellitus and hyperuricemia. The NSCLC was diagnosed by means of a biopsy of the nodal station 5L, performed via a minimally invasive thoracoscopic approach. Then, the patient underwent 3 cycles of neoadjuvant chemotherapy (carboplatin and gemcitabine). After the systemic treatment, the case was discussed by the multidisciplinary team and considered for surgery. The pre-operative CT scan demonstrated the stability in size of the pulmonary nodule and of the hilar lymphadenopathies, that reached and infiltrated the first two branches of the left pulmonary artery. Moreover, the PET-TC revealed a consistent decrease in SUV of the pulmonary mass and of the hilar and subcarinal lymphadenopathies, without any other site of pathologic uptake of FDG. The pre-operative functional evaluation of the patient consisted of an echocardiogram, pulmonary function tests with DLCO, arterial blood gas analysis and full blood tests. </p> <p><br></p> <p>The post-operative period was uneventful, the chest drain was removed in the second post-operative day(POD). The patient was discharged in the 5th POD. Final pathological examination described a T2aN2M0 (stage IIIa TNM8th) mucinous adenocarcinoma of the lung. The patient underwent adjuvant chemo-radiotherapy and after eight months follow up the patient is free from disease recurrence.</p> <p> </p> <p>Pulmonary artery plasty is an important technique in the field of the treatment of lung cancer; indeed, it allows to spare pulmonary parenchyma while achieving an oncologically radical resection, as demonstrated by many authors [3,4]. Moreover, it has been proved that performing a pneumonectomy has an adverse effect on survival on quality of life [5,6,7]. Therefore, we adopted this technique together with a minimally invasive approach, as many studies indicate that should be preferred to open thoracotomy because of many advantages in terms of lower complication rates[8], lower post-operative pain[9], reduced hospital stay[10] faster recovery and return to daily activities[10]. We think that this combination can lead to optimal results in terms of disease treatment and post-operative quality of life. The technical aspects that must be addresses are that the residual lumen must be wide enough to allow an unimpeded blood flow, and that there must not be any kinking of the vessel, especially when the remaining lung is inflated; otherwise, a thrombosis of the segment may occur.</p> <p>We also demonstrated that this procedure is feasible also when facing a re-VATS after a neoadjuvant chemotherapy treatment. In the video tutorial, it is clearly visible the extensive presence of adhesions which were easily divided at the beginning, in order to better visualize and mobilize the lung parenchyma. It must be kept in mind that also at the hilum dense fibrous tissue may be present, hindering the isolation of the structures; therefore, it is necessary to proceed with great care as not to damage any vessel or bronchus. </p> <p>Obviously, this a challenging technique that requires a precise pre-operative planning; indeed, it is of paramount importance to obtain recent CT scan images as not to face any unexpected situation during the operation. Moreover, the function evaluation of the patient must be very accurate because also the eventuality of a pneumonectomy should be take into consideration. </p> <p><b>References</b></p><p>1. Cerfolio RJ, Bryant AS. Surgical Techniques and Results for Partial or Circumferential Sleeve Resection of the Pulmonary Artery for Patients with Non-Small Cell Lung Cancer. Ann Thorac Surg. 2007;83(6):1971-1977.</p><p>2. Vannucci J, Matricardi A, Potenza R, Ragusa M, Puma F, Cagini L. Lobectomy with angioplasty: Which is the best technique for pulmonary artery reconstruction? J Thorac Dis. 2018;10(3):S1892-S1898.</p><p>3. Schiavon M, Comacchio GM, Mammana M, Faccioli E, Stocca F, Gregori D, Lorenzoni G, Zuin A, Nicotra S, Pasello G, Calabrese F, Dell'Amore A, Rea F. Lobectomy with artery reconstruction and pneumonectomy for NSCLC: a propensity score weighting study. Ann Thorac Surg. 2021 Jan 9 Epub ahead of print. PMID: 33434540.</p><p>4. Venuta F, Ciccone AM, Anile M, et al. Reconstruction of the pulmonary artery for lung cancer: Long-term results. J Thorac Cardiovasc Surg. 2009;138(5):1185-1191.</p><p>5. Alexiou C, Beggs D, Onyeaka P, et al. Pneumonectomy for stage I (T1N0 and T2N0) nonsmall cell lung cancer has potent, adverse impact on survival. Ann Thorac Surg. 2003;76(4):1023-1028.</p><p>6. Ferguson MK, Lehman AG. Sleeve Lobectomy or Pneumonectomy: Optimal Management Strategy Using Decision Analysis Techniques. Ann Thorac Surg. 2003;76(6):1782-1788.</p><p>7. Stella F, Dell'Amore A, Caroli G, Dolci G, Cassanelli N, Luciano G, Davoli F, Bini A. Surgical results and long-term follow-up of T(4)-non-small cell lung cancer invading the left atrium or the intrapericardial base of the pulmonary veins. Interact Cardiovasc Thorac Surg. 2012 Apr;14(4):415-9.</p><p>8. Paul S, Altorki NK, Sheng S, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg. 2010;139(2):366-378.</p><p>9. Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol. 2016;17(6):836-844.</p><p>10. Nwogu CE, D’Cunha J, Pang H, et al. VATS lobectomy has better perioperative outcomes than open lobectomy: CALGB 31001, an ancillary analysis of CALGB 140202 (Alliance). 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