[Surgery for lung cancer invading the great vessels and left atrium]

Surgery for early-stage lung cancer is associated with higher survival rates. Minimally invasive surgery such as segmentectomy and video-assisted thoracoscopic surgery is well established for peripheral small-sized lung tumors. On the other hand, advanced lung cancer invading the mediastinal organs has high morbidity rates and poor long-term survival if resection is achieved. According to the General Rules for Clinical and Pathological Records of Lung Cancer, lung cancer invading the atrium and great vessels including the superior vena cava (SVC) and aorta is classified as T4. In lung cancer involving the atrium and great vessels, T4N0 or T4N1 nodal status is an indication for surgery. Among cases with involvement of the atrium or great vessels in which combined resection is performed, those with invasion of the aorta have a favorable prognosis (5-year survival rate : 17-48%). After SVC and atrial resection, the 5-year survival rate is 11-24% and 14-16%, respectively. The postoperative morbidity rate is approximately 12.5%, 14%, and 9%, respectively. The Society of Japanease Thoracic Surgeons data demonstrate that the mortality rate after lobectomy and pneumonectomy is 0.4% and 1.8% respectively, and is thus higher after pnemonectomy. Patients who undergo resection of the great vessels and atrium have higher mortality rates compared with those who undergo pneumonectomy alone, which indicates that the former is a higer-risk procedure. The numerous pneumonectomy patients included in these groups may be associated with the increased morbidity. Occasionally, resection of the aorta and atrium requires cardiopulmonary bypass, which may allow complete resection with increased safety. Careful patient selection based on cardiovascular and pulmonary function, the use of advanced imaging systems, and improved management should be considered indications for the type of surgery performed. Resection of the aorta and atrium should be avoided in patients with N2 status. En-bloc resection in node-negative patients may have higher survival rates with low morbidity. Surgery in the treatment of lung cancer invading the great vessels and atrium may improve the results in selected patients, in which advanced new drugs such as targeted therapies, positron emission tomographic imaging, new approaches including aortic stent grafting, and improved surgical techniques all play a role.