Eur J Cardiothorac Surg 2008;33:315-316. doi:10.1016/j.ejcts.2007.10.022
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Induction chemoradiotherapy prior to surgery for non-small cell lung cancer invading the left atrium
Shinichi Toyookaa,*,
Hideaki Moria,
Katsuyuki Kiurab,
Hiroshi Datea
a Department of Cancer and Thoracic Surgery, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Okayama 700-8558, Japan
b Department of Hematology, Oncology and Respiratory Medicine, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata-cho, Okayama 700-8558, Japan
Received 23 August 2007;
received in revised form 9 October 2007;
accepted 29 October 2007.
* Corresponding author. Tel.: +81 86 235 7265; fax: +81 86 235 7269. (Email: toyooka{at}md.okayama-u.ac.jp).
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Abstract
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We present a case of a 58-year-old man with diagnosis of lung adenocarcinoma invading the left atrium. He was treated with induction chemoradiotherapy for T4N1M0 disease, showing objective response. Then, a left upper lobectomy with a partial resection of the left atrium was performed without cardiopulmonary bypass. No residual tumor cells existed in the resected specimens, showing pathological complete response. Our case suggests that induction chemoradiotherapy prior to surgery can be an appropriate strategy among carefully selected patients with non-small cell lung cancer invading the left atrium.
Key Words: Lung cancer • Neoadjuvant therapy • Left atrium • Cardiopulmonary bypass
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1. Introduction
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The therapeutic strategy for locally advanced non-small cell lung cancer (NSCLC) has not been established. Among T4 disease, patients with limited invasion of the left atrium have a chance of cure if the complete resection is performed [1,2]. Thus, surgical resection remains an important part of the therapy for patients with left atrial invasion. Here, we reported a case that induction chemoradiotherapy was useful in controlling the local disease invading the left atrium so that the surgery was performed without cardiopulmonary bypass.
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2. Case report
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A 58-year-old man with abnormal chest X-ray findings was referred to our institution. A computed tomography (CT) guided needle biopsy for a lung tumor demonstrated a poorly differentiated lung adenocarcinoma. Image analyses, including positron emission tomography (PET) CT findings, revealed a tumor that had extensively invaded the left atrium through the pulmonary vein and the positive hilar lymph node, resulting in a UICC TNM classification of T4N1M0 (stage IIIB) (Fig. 1
). Transesophageal echocardiography (TEE) revealed a tumor with poor mobility in the left atrium; the tumor was 26 mm x 20 mm in diameter. We judged that initial surgery would require cardiac arrest under cardiopulmonary bypass (CPB) for the complete resection of the extended tumor. Thus, he was treated with chemoradiotherapy in an induction setting: cisplatin and docetaxel with concurrent thoracic radiation at a dose of 40 Gy [3]. An objective response to the induction chemoradiotherapy was obtained, as shown in Fig. 2
. Thirty-four days after the completion of the induction therapy, a left upper lobectomy with a partial resection of the left atrium and systemic lymph node dissection was performed by a posterolateral thoracotomy. An intraoperative echogram via a saline-filled thoracic cavity confirmed the tumor margin in the left atrium, then, a vascular clamp was used for the left atrium resection. The defective portion was directly sutured. Macroscopic and microscopic examination of the resected specimens showed that the tumor invasion to the left atrium had occurred contiguously from the primary site via the upper pulmonary vein. No residual tumor cells existed in the specimens, demonstrating a pathological complete response (CR). The postoperative course was uneventful except for the development of chylothorax, which was treated conservatively (7 days of oral intake cessation). He received two cycles of adjuvant chemotherapy with cisplatin and docetaxel. While further follow-up would be necessary, he has had a disease free status for 1 year.
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Fig. 1. Image analyses before induction chemoradiotherapy. (A) CT scan of the chest. (B) PET–CT scan. A lung tumor with swollen lymph node at left hilar is visible. Tumor invasion to the left atrium is also visible.
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Fig. 2. Image analyses after induction chemoradiotherapy. (A) CT scan of the chest. (B) PET–CT scan. A lung tumor, swollen lymph node and tumor invading the left atrium are remarkably shrunk.
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3. Discussion
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NSCLC invading the left atrium is a locally advanced disease classified as T4. The resection of the left atrium because of tumor invasion is an infrequent procedure, and a standard strategy for this disease has not been established. To resect the left atrium that has been invaded by a tumor safely, CPB with blood transfusion is sometimes necessary but may increase the surgical risk and compromise the immune system's defense against cancer [4,5]. Thus, the indications for a CPB require careful consideration [4]. Spaggiari et al. [5] reported that induction chemotherapy is a useful strategy for managing locally advanced NSCLC invading the left atrium and may enable CPB to be avoided during surgery. However, induction chemoradiotherapy is not used because of concerns about heart toxicity derived from radiation before surgery [5]. According to recent reports, concurrent chemoradiotherapy is superior to chemotherapy for the control of local disease [6]. We have also reported the usefulness of induction chemoradiotherapy for locally advanced NSCLC, enabling pathological downstaging in 64% of patients and pathological CR in 23% [3]. In the present patient, induction chemoradiotherapy successfully controlled the local disease, enabling us to avoid performing a CPB during the en bloc resection of his tumor. Although the safety of induction chemoradiotherapy has not been established for pulmonary surgery combined with a partial resection of the left atrium, the present case suggests that this strategy may be optimal for decreasing surgical invasiveness as well as increasing the patient's chances of survival.
Two patterns of tumor invasion to the left atrium exist: (1) direct invasion of a primary tumor or metastatic lymph nodes, and (2) tumor invasion contiguously through the pulmonary vein draining from the primary site. The latter type is less frequent, but special attention regarding tumor emboli during surgery is necessary, especially when the tumor exhibits polypoid extrusion [4,7]. Although critical embolism has not been reported during induction therapy, the possibility of this complication should be kept in mind. Fortunately, no critical emboli occurred during the clinical course of the present patient, in whom the tumor seemed to be tightly connected to the left atrium, as estimated using TEE. We suspect that a pedunculated polypoid tumor would present a great risk for tumor emboli; thus, evaluation of the tumor's characteristics using TEE may be useful for the selection of candidates for induction chemoradiotherapy.
Regarding oncological aspects, because the chance of micrometastasis is considered to be high in this condition, resulting in a dismal prognosis [7], systemic chemotherapy is mandatory to reduce the risk of disease recurrence. Whereas the follow-up period of our case is not long enough to discuss long-term survival, the induction chemoradiotherapy prior to surgery can be an appropriate strategy among carefully selected patients with NSCLC invading the left atrium.
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References
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Abstract
1. Introduction
