The surgical management of locally advanced thoracic cancer presents considerable challenges due to the proximity of vital structures such as the heart and major blood vessels. In the present series, we shared our experience and outcomes of extended resection procedures for both locally advanced lung and mediastinal cancer with the assistance of CPB. The present study demonstrates that patients with a better preoperative ECOG performance status undergoing elective surgery with CPB are more likely to have R0 resection, shorter operative times, lesser blood loss. In contrast, CPB use under salvage surgery was associated with higher morbimortality. Our findings emphasize the importance of discrete preoperative patient selection and surgical approaches with CPB.
Complete surgical resection remains the primary factor contributing to the survival in patients undergoing resection under CPB [13, 14]. For non-small cell lung cancer (NSCLC), stages up to pathology-proven T4N0 − 1 may be acceptable for curative surgical resection [15, 16]. For thymic malignancies, radical resection is considered part of the multimodal treatment in patients of stage III and even stage IVa with pleural spread [17–19]. This treatment principles is also applicable to other rare types of locally advanced thoracic cancers, including mediastinal sarcoma [20], mediastinal teratoma [21], mediastinal large cell neuroendocrine cancer [22], pulmonary blastoma [23], pleomorphic lung cancer [24], and large cell neuroendocrine lung cancer [25], which were all also reported in our series. Regardless of the tumor histology, the extent of invasion of adjacent anatomical structures is the key determinant of surgical difficulty. CPB use to achieve en bloc resection has been successfully reported in tumors invading the SVC and RA with acceptable perioperative morbidity and mortality rates [4, 26–28]. CPB was utilized in our 8 patients with locally advanced thoracic tumors involving the SVC, atrium, main pulmonary artery, and ascending aorta. This highlighted the versatility of CPB in facilitating complete tumor resection in anatomically challenging cases. Nevertheless, limited studies and the lack of consensus complicate the debate on the setting of obtaining extended resection for locally advanced lung and mediastinal cancers under CPB.
Proponents of CPB emphasize its role in enabling complete tumor resection and achieving negative surgical margins, which are crucial factors associated with improved long-term oncological outcomes. For example, a retrospective study by Ried et al. demonstrated that CPB-assisted extended resections for locally advanced thymic malignancies resulted in favorable survival outcomes, with a high rate of R0/R1 resection achieved [2]. Similarly, a systematic review by Muralidaran et al. concluded that CPB use was associated with improved overall survival and disease-free survival in patients undergoing extended resections for advanced lung cancer involving the mediastinum or great vessels [23]. Furthermore, Langer et al. [1] and Filippou et al. [5] supported that there is no inferiority in postoperative outcomes in CPB group compared with non-CPB group. However, CPB raise valid concerns regarding its associated risks and complications, including systemic inflammatory response, coagulopathy, end-organ dysfunction, and modest relationship with cancer progression [9]. In fact, controversy does exist in literature concerning the application of CPB for oncological interventions. No increase of distant metastases and tumor recurrence has been observed in systematic review by Muralidaran et al. [3]. In contrast, some authors hypothesize that increased intraoperative tumor cell dissemination promoted by the extracorporeal circulation could have been responsible for early relapse, as previously reported by other authors [29]. In a recent large case series, none of patients undergoing cardiac reconstruction with CPB support showed locoregional recurrence or distant metastasis within 6 months of the operation, thus, the authors concluded that evidence could not confirm the hypothesis of increased rate of early recurrence for tumors resected under CPB [8].
CPB itself is deemed to be a significant predictor of postoperative morbidity and mortality, particularly in cases involving extensive resections and prolonged CPB times [30, 31]. Considering the high-risk nature of such procedures, perioperative mortality ranging from 7–15% had been reported [6, 32]. The mortality rate in our series is relatively high (2/8, 25%), though both patients received salvage surgery. All the patients in the elective surgery group achieved at least 12 months of recurrence-free survival without lethal perioperative complications. These findings are consistent with the survival date found in literature [6–8, 10]. However, Byrne et al. [32] reported 43% of all CPB procedures to be performed for emergency situations. These data underlies the importance of CPB availability when surgery for advanced thoracic malignancies is being considered. Wiebe et al. also advised that pneumonectomy is associated with life-threatening complications [6].
Though patient selection criteria for CPB-assisted extended resections is crucial for favorable outcomes [11], the criteria remain unclear, leading to variability in practice patterns and institutional preferences. Current literature indicates decisions to operate are situational due to the variability of the disease entity, surgical capabilities, and high surgical risk. While CPB may be justified in cases where complete tumor resection cannot be achieved with conventional techniques, the decision to utilize CPB requires detailed multidisciplinary preoperative evaluation, including individual patient factors, tumor characteristics, and institutional expertise. This is echoed by our experience preferring that CPB application in elective surgery group in the present series exhibited a better prognosis.
It is important to acknowledge the limitations of our study, including its retrospective nature and relatively small sample size, which inherently limits firm statistical assessment. However, our data supports the feasibility of radical resection with CPB support for thoracic malignancies invading cardiovascular structures. Furthermore, the incidence of postoperative complications, including arrhythmias, pneumonia, and transient SVC syndrome, highlights the importance of close perioperative monitoring and management in optimizing patient outcomes.