bDepartmentofThoracicSurgery,ShanghaiPulmonaryHospital,TongjiUniversity,Shanghai,China
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Articlehistory:
Received24September2019 Receivedinrevisedform 28November2019 Accepted4December2019 Availableonline16December2019 Keywords:
Lungsparing Carinaresection Bronchogenictumor Lungcarinatumor
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INTRODUCTION:Carinalresection(CR)withorwithoutlungparenchymasparingisoneofthechallenging issuesinthoracicsurgeryandperformedrarely.Itisusuallynotusedforthedifficultyofthetechnique, or,inthemajorityofthesituations,itisreplacedbypneumonectomywhenthepatientconditionsand thetumorcharacteristicsallowtheradicalsurgicalapproach.Thedifficultyincludesthedissectionof thetracheaandmainbronchi,theresectionofthecarinaandthereconstructionofthetracheaand bronchus.Inspiteoftheknowledgeofthetechnique,oneofthemostimportantproblemistheincidence ofpostoperativecomplicationswhichishighercomparedtostandardresections.
CLINICALCASES:Weshowtwocasesofcarinaresectionforabronchogenictumorwithlungparenchyma sparingandgoodpostoperativeoutcomes.
CONCLUSION:Ourresultsdemonstratethatthistypeofsurgeryispossibleinselectedcenterswithgood qualityoflifeforthepatientaftersurgery.
©2019TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
1. Introduction
Cancer involving the carina without systemic or lymphatic metastases are uncommon but not rare [1–3]. Most of these patientswerediagnosedatanadvancedstageandwerelikelyto benolongercandidatesforsurgicalresection[1].However,innot solownumberofcentres,eveninlocaltumorofthecarina,surgeon choosesfortheoptionofpneumonectomy,ifthepatients’ condi-tionsarefavourable[4].However,ifsurgeryisnotthebestchoice duetothelimitedpulmonaryfunctionorforthepatient comor-bidities,somethoracicsurgeonsendsdirectlythepatienttothe attentionoftheoncologistformedicaltreatment[5].Ontheother hand,thischoiceisnotsorarelyadoptedalsoincaseofpossibility toperformcarinaresection.Inmiddle-lowvolumecentresinfact, thiskindofsurgeryis notperformed,forthelowexperienceof thesurgeonsandtheconsequenthighfrequencyofpostoperative comorbidities.Asforourexperience,weshowtwocasesofcarina resectionforabronchogenictumorwithlungsparing.Ourmessage istoshowthatcarinaresectioninselectedpatientsispossiblewith
Abbreviations:CR,carinaresection;CT,computedtomography;18FFDGPET/CT, 18F-labeled fluoro-2-deoxyglucose Positron emission tomography–computed tomography.
∗ Correspondingauthorat:DivisionofThoracicSurgery,DepartmentofMedical andSurgicalSciences,UniversityofModenaandReggioEmilia,Modena,Italy.
E-mailaddresses:beatrice.aramini@unimore.it(B.Aramini),jgnwp@aliyun.com
(G.Jiang),fanjiang@tongji.edu.cn(J.Fan).
nocomplicationsaftersurgeryandgoodresultsafter6monthsof followup.Ourcasescouldhighlighttheimportancetochoosea highvolumecenterforthiskindofsurgicalresection,whichcould guaranteesatisfyingresultsandanacceptablequalityoflifefor thepatientaftersurgery.Theworkhasbeenreportedinlinewith SCAREcriteria[6].
2. Case1
A 27 years old male patient suffering from cough and dis-comfortofthroatforhalfamonthwasadmittedtoourHospital. Hereferred a smokinghistory of 5–10cigarettes perdayfor 5 years. Chestcomputed tomography (CT)showed a tumor infil-tratingtheentirewallofthecarinaatthelevelofthemainright bronchus(Fig.1).18F-labeledfluoro-2-deoxyglucosePositron
emis-siontomography–computedtomography(18FFDGPET-CT)showed
amildmetabolicareaatthelevelofthecarinawithnolymphnodes activity.Amalignancywassuspected.Noothermetabolicactivity washighlighted.BrainMRIshowednoabnormalities.Preoperative assessmentsrevealedagoodpulmonaryfunctiontestandnoother comorbiditiesweredeclaredbythepatient.Tracheoscopyrevealed aneoplasmintheopeningoftherightmainbronchus,and pathol-ogyrevealedhighlydifferentiatedmucoepidermoidcarcinoma.He receivedatrachealcarinaresectionattheleveloftherightmain bronchusandreconstructionwithlungparenchymapreservation throughaposterolateralthoracotomy.Theoperationtimewas3h and40min.Intraoperativebleedingwaslessthan200ml.Hewas discharged7daysafteroperationwithnocomplications. Postop-https://doi.org/10.1016/j.ijscr.2019.12.007
2210-2612/©2019TheAuthors.PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons. org/licenses/by/4.0/).
Fig.1.Case1.ChestCTshowstumorinfiltrationbetweencarinaandtherightmainbronchus(seethearrow).
Fig.2.ChestCTincase2.Tumorinfiltratesthemiddlepartofthecarinaclosedtotheleftmainbronchus(seethearrow).
Fig.3.Operativetechniqueandventilationincase1.Thetrachealtubewaspusheddownintotheleftmainbronchusandthesurgeonproceededwiththeresectionofthe tumorandsubsequentanastomosis.
erativepathologyrevealeda 1.2cm low-grademucoepidermoid carcinomainvolvingtheentirewallofthecarina.Thedistaland proximalstumpwerefoundnegative.The2,4,7and10lymph nodesstationswerenegative.Aftersurgerypatienthasbeensentto theoncologistforclinicalmonitoring.Bronchoscopyafter6months
fromsurgeryshowedamoderatestenosisatthelevelofthe anas-tomosis.Abiopsywasperformedshowingagranulomatreatedby laserwithcompletelyeffectiveresult.Nosignofrecurrenceof gran-ulomaafter3monthsfromthelaserprocedure,aswellasnosign ofrecurrenceafter6monthsfromsurgery.
Fig.4.Operativetechniqueandventilationincase2.A–B.Thetumourinfiltratedthemiddlepartofthecarinacloselytotheleftmainbronchus.Thetumorwasresected.
C–D.Theventilationtubewasthenpushedthroughtherightmainbronchusintotheleftmainbronchustoguaranteepatientventilation,assoonasthesurgeoncompletes thetumorresection.Duringtheanastomosis,thetubestayedinthispositionuntilthesurgeoncompletesthebronchialanastomosis.Aftertheanastomosis,atrachealtube hasbeenreplaced.
3. Case2
A43yearsoldmalepatientwithcoughandbloodysputumfor aweekwasadmitted toourHospital.ChestCT showeda solid massbetweenthetrachealcarinainvolvingmainlytheleftmain bronchus(Fig.2).Amalignantmasswassuspected.18FFDG
PET-CTshowedahighmetabolicareaatthelevelofthecarinawithno lymphnodesinvolvement.Tracheoscopyconfirmedaneoplasmin thetrachealcarinaatthelevelofitsbifurcationwiththeleftmain bronchus.Preoperativeassessmentsrevealeda goodpulmonary functiontest.Thepatientundergonetrachealcarinaresectionat theleveloftheleftmainbronchusandreconstructionwithnolung resectionthroughaposterolateralthoracotomy.Nocomplications aftersurgery.Postoperativepathologyrevealeda2cm
sarcoma-toushigh-gradecarcinoma.Thedistalandproximalstumpwere negative.The3and10lymphnodesstationswerenegative.After surgerypatienthasbeensenttotheoncologistfortreatmentand followup.After6monthsfromsurgerynosignificantabnormalities orsignsofrecurrencewerenoted.
4. Discussionandconclusion
Themostcommonapproachforcarinaresectionisright tho-racotomythrough thefourthorfifth intercostalspace.Leftside approachduetoleftaorticarchisdifficultorsometimesimpossible [7].However,asweshowedinourbriefreport,theposterolateral thoracotomymaybea good choicetoimprovetheview, espe-ciallyforbigtumormassinfiltratingthecarinaandtheleftmain
Fig.5.Carinaresectionincase2.Thetumorisinthemiddleofthecarina.
bronchus.Bilateralsub-mammarytrans-sternal“clamshell” thora-cotomyandmediansternotomyareotherwaystoapproachcarina inselectedpatients[8].Recently,video-assistedthoracoscopic tra-chealresectionandcarinalreconstructionhasalsobeenreported, butthisismainlyperformedbyexpertthoracicsurgeonandinhigh volumecentreswherethistechniqueisquitefrequentlyadopted [9].Withregardsofthecarinareconstructiontechniques,various approacheshavebeenproposed.Theyalldependintheextentof theresectedtrachea,leftandrightmainbronchus[7].Ventilation isanotherimportantstepofthistechnique.Inparticular,incases oftumorinfiltratingonemainbronchus,itisquitecomfortableto resectthetumorclosedtocarinaandmaketheanastomosis(Fig.3), althoughincaseofcarinainfiltrationandinveryselectedcases,it ispossibletoresectthetumorwithanaccuratetracheal ventila-tionprocesssetbytheanaesthesiologist(Fig.4).Infact,thesesteps neededtobemanagebyexpertanaesthesiologists’team coordi-natedbythesurgeon.
On the other hand,carina resection (Fig.5) is considered a goodoptiontopneumonectomyorlobectomy,especiallyincases wherethecomorbiditiesorpulmonaryfunctionaltestnotallowed toperform lung parenchyma resection.We believe that, ifthe preoperativeradiologicalassessmentsshownolymphnodes infil-trationorothersuspicioustumormetastaticinfiltrations,acarina resectionwithlungparenchymasparingmaybeconsideredasthe bestchoice,eveninhighgradetumor,asweshowedfor sarco-matoidmassdescribedincase2.Thepossibilitytochoosecarina resectionoption insteadof pneumonectomyismainlybased of surgeonexperience, althougha very accurateclinicaland radi-ological assessment, before defining the surgical approach, is mandatoryasguaranteefor satisfyingresults, especiallyto pre-ventpostoperativecomplications.Inconclusion,ourcasesshow thepossibilitytoperformcarina resectionwithlung sparingin lowgradetumorsaswellasforhighgradetumors,asweshowed for case n.2. In both situations, the choice must be driven by expertsurgeoninordertopreventcomplicationsaswellasshort termrecurrence.Ourreportisthebasementtosetfurther stud-iesregardingcarinaresectionwithorwithoutlungparenchyma surgery. Further studies need to be plan in order to compare longterm resultsbetweenthecasesof carina resection associ-atedwithpneumonectomyorlobectomyandtheothercaseswith lungsparing,forlow-and high-gradelungmalignanciesand no lymphnodes involvement.This willbevery helpfulfordriving thesurgicalchoicesincaseofresectabletumourinfiltratingthe carina, especially in patientswith compromised clinical condi-tions.
Funding
Nofunding.
Ethicalapproval
ForcaseseriesreportNOethicalapprovalneeds.Patientsigned aconsentforpublishingthecasereport.
Consent
Patientssignedaconsentforthepublicationofthiscasereport.
Authorcontribution
BAand JFwrotethecasereport.TheotherAuthorsreadand revisedthecasereport.
Registrationofresearchstudies
EthicalBoardapprovalisnotrequiredforcasereportsinour Center.
Guarantor
Prof.JiangFanistheGuarantorofthiscasereport.
Provenanceandpeerreview
Notcommissioned,externallypeer-reviewed
DeclarationofCompetingInterest
TheAuthorshavenofinancialandpersonalrelationshipsto dis-close.
Acknowledgement
Notapplicable.
References
[1]W.Weder,I.Inci,Carinalresectionandsleevepneumonectomy,J.Thorac.Dis.8 (November(Suppl11))(2016)S882–S888.
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