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INTRODUCTION

To completely resect a primary lung cancer that extends through the visceral pleura into a neighboring structure, the pulmonary and extrapulmonary portions of that tumor must be removed as a single specimen (“en bloc”). Most locally invasive tumors are amenable to en bloc resection, including cancers that involve the chest wall, vertebral bodies, or diaphragm. A subset of extended tumor resections for T4 disease, such as those in proximity to the heart or central vasculature, may be facilitated using cardiopulmonary bypass (CPB). CPB can make surgery easier (by decompressing the heart and creating more space in the surgical field), and some reconstructions are not technically possible without it (i.e., tumor invasion of the main pulmonary artery [PA]). The use of CPB also has some negative considerations such as requirements for anticoagulation, potential for tumor dissemination, and technical considerations associated with cannulation. More specifically, CPB is associated with prolonged anesthesia, longer operations, and risk for cardiovascular and pulmonary complications.14 Therefore, we reserve the use of CPB for those cases that absolutely cannot be performed without it.

This chapter defines techniques to assist in the resection of locally advanced tumors involving the heart or central vasculature on CPB, as well as strategies that may be attempted to avoid bypass. The outcomes associated with lung cancer resection on CPB are discussed to help guide clinical decision making when managing these potentially complex patients.

GENERAL PRINCIPLES

The classic “could I do it?” and “should I do it?” deliberation is particularly salient in the setting of tumors invading the central vasculature. The rationale for resecting tumors that could potentially require CPB is similar to the rationale for resecting tumors completely contained within the parenchyma. That is, local control at the site of the primary tumor will translate into meaningful gains in survivorship. The best support for this assumption can be found by performing the clinical staging evaluation. Patients with systemic metastases are far less likely to benefit from local control at the site of the primary tumor. Therefore, PET scanning and brain MRI should be performed to exclude systemic metastases in all patients before considering resection of a T4 tumor with or without CPB. Most would consider mediastinal lymph node metastases to be a contraindication to extended resection, in part because randomized trial results have not identified a clear advantage to surgery over definitive chemoradiation (although post hoc analysis indicates lobectomy-amenable stage III [non–small-cell lung cancer] NSCLC may benefit from surgery).5 Therefore, invasive mediastinal staging should also be performed in this subset. Finally, patient health is a critical factor because patients in poor health have an increased risk of dying from surgery and are less likely to survive long enough to benefit from local control. Therefore, a thorough cardiovascular and general health assessment should be performed.

The case for surgical resection of early-stage NSCLC is founded in large clinical trials ...

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