Cancer of the lung is the most common cause of death from cancer in both men and women in the United States. As these cancers grow, they begin to invade local structures, organs, and vessels within the chest. Local progression of disease may occur before metastatic spread and does not necessarily preclude resection. Any contiguous structure in the chest can be involved, although chest wall invasion is the most common, occurring in approximately 5% of patients. Other contiguous intrathoracic structures include the left atrium, aorta, superior vena cava, vertebral bodies, diaphragm, and esophagus. Surgical intervention can achieve local control. Selection of patients may be complex. The potential for complete resection varies widely, and increased morbidity and mortality are well documented for these complex extended resections. The long-term prognosis depends on accurate pretreatment staging to assist in the selection of therapy and complete resection. Cardiopulmonary bypass (CPB) can be a necessary component for surgical resection in certain complex cases. This chapter reviews the role of CPB for the extended resection of lung cancer, as well as the clinical and technical considerations and expected surgical outcomes.
Centrally Advanced Tumors
Locally advanced tumors that involve the central pulmonary vasculature or the heart (T4 lesions) are classically considered to be unresectable. Achieving a tumor-free proximal margin or satisfactory proximal vascular control may not be possible with standard (non-CBP) techniques. A small but definable subset of such patients will benefit from surgery if CPB is used to facilitate these complex resections. Accurate preoperative evaluation, including aggressive staging, must be performed to exclude the presence of occult metastatic disease, determine the patient's physiologic fitness, and establish the limits of resection to achieve the optimal long-term survival for each individual patient. Since these tumors are often larger and more centrally located, preoperative imaging should include PET and CT scanning. Mediastinoscopy also must be performed (see Chap. 61).
Most thoracic surgeons are reluctant to perform pulmonary resections with patients on CPB. Several authors1–4 have reviewed the results and safety of combined cardiac and pulmonary procedures requiring CPB. Their opinions are varied, and several authors have expressed concerns for the adverse effects of CPB on hemostasis and pulmonary function. Others5–7 with significant institutional experience have written more extensively on the subject, describing the advantages, disadvantages, and parameters for patient selection when CPB is used as an adjunct to conventional thoracic surgical techniques.
Byrne and colleagues reviewed a decade of experience at Brigham and Women's Hospital and Massachusetts General Hospital in Boston.5 Between January 1992 and September 2002, CPB was used in 14 patients during planned curative resection of locally advanced thoracic malignancies. In 8 of the 14 patients, CPB use was planned to facilitate resection. In the remaining 6 patients, CPB was required as an emergent therapy to manage central vascular injury. Indications for planned CPB included tumor involvement of the left atrium, pulmonary artery, and superior ...