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Extrapleural Pneumonectomy With VenousConfluence Resection for Stage IVA ThymicTumorsMichel Gonzalez, MD, Thorsten Krueger, MD, Jean Yannis Perentes, MD, PhD,Oskar Matzinger, MD, Solange Peters, MD, PhD, and Hans-Beat Ris, MD

Thoracic and Vascular Surgery Service, Radio Oncology Service, and Oncology Service, Centre Hospitalier Universitaire Vaudois,Lausanne, Switzerland

We report 4 patients with stage IVA thymic tumors whounderwent extrapleural pneumonectomy and thymec-tomy with venous confluence resection using a tempo-rary percutaneous venous jugular-femoral bypass tech-nique. The superior vena cava was replaced in 2 patients, andthe innominate vein was resected in 2 patients. Completetumor resection was obtained in all patients. There was

no 90-day postoperative mortality. One patient died at 6

Service, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46,1011 Lausanne, Switzerland; e-mail: michel.gonzalez@chuv.ch.

© 2011 by The Society of Thoracic SurgeonsPublished by Elsevier Inc

months postoperatively of an unrelated cause, withoutrecurrent disease, and 3 are alive and disease-free with afollow-up ranging from 19 to 80 months. Extrapleuralpneumonectomy can be combined with thymectomy andvenous confluence resection for stage IVA thymic tumors.

(Ann Thorac Surg 2011;91:941–3)

© 2011 by The Society of Thoracic Surgeons

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Complete resection is the treatment of choice in pa-tients with nonmetastatic thymic tumors. It should

e attempted whenever possible, even in the presence ofbviously invasive tumor, because it represents the mostonstant and significant prognostic factor for progres-ion-free and overall survival [1, 2]. This is also true oftage IVA disease confined to one chest cavity, but theurgical management remains controversial becausehese tumors are relatively rare. According to the extentf pleural involvement, thymectomy with pleurectomyay be justified in a multimodal treatment context.However, enthusiasm is increasing for combining

hymectomy with extrapleural pneumonectomy (EPP) forxtensive or recurrent stage IVA disease [3–5]. EPP offersmore radical approach and probably a better cytore-

uction for extensive disease, and it allows for a moreniform postoperative hemithoracic irradiation at thera-eutic dosages than pleurectomy. Conversely, EPP is asso-iated with a higher postoperative morbidity and functionaloss than pleurectomy, especially in combination with ve-ous confluence resection, which may be required to obtaincomplete resection. This report presents our experience ofPP combined with thymectomy extended to the venousonfluence in patients with stage IVA thymic tumors.

Technique

This study was approved by the Local Ethics Committee,and individual consent of the presented patients waswaived.

Accepted for publication July 14, 2010.

Address correspondence to Dr Gonzalez, Thoracic and Vascular Surgery

Four patients (2 men and 2 women) with nonmetastaticstage IVA thymic tumors undergoing EPP with thymec-tomy extended to the venous confluence between 2004and 2009 are presented. Median patient age was 57.5years (range, 28 to 60 years). Three patients had de novodiagnosed stage IVA disease, and 1 presented with astage IVA recurrence 2 years after minimally invasiveresection through a minithoracotomy. Histologic evalua-tion revealed 1 B3 and 3 B2 thymic tumors.

In all patients, the computed tomography scan re-vealed a bulky mediastinal tumor associated with multi-ple pleural implants confined to one chest cavity (Fig 1).Computed tomography imaging revealed invasion of thesuperior vena cava (SVC) in 2 patients and the innomi-nate vein in 2. Two patients underwent induction che-motherapy and 2 did not, 1 because of previous chemo-therapy administered for lymphoma and 1 because of themagnitude of the planned operation (right-sided EPPcombined with SVC resection). The clinical response inthe 2 patients undergoing preoperative chemotherapywas estimated at 30% and 50%, respectively.

The EPP procedure was left-sided in 3 patients andright-sided in 1 patient. In all patients, a temporarypercutaneously introduced external venous jugulofemo-ral shunt was introduced in the supine patient afteranesthesia and before the operation. Two patients under-went left-sided EPP and resection of the innominate veinwithout reconstruction through a posterolateral thoraco-lumbotomy, and 2 patients underwent SVC resectionthrough a sternotomy, followed by EPP (1 right-sided, 1left-sided) through a posterolateral thoracolumbotomy.

In patients with SVC infiltration, the sternotomy al-lowed the tumor dissection in healthy tissues at the level

of the noninvolved opposite chest cavity while carefully

0003-4975/$36.00doi:10.1016/j.athoracsur.2010.07.048

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942 HOW TO DO IT GONZALEZ ET AL Ann Thorac SurgEPP WITH VENOUS CONFLUENCE RESECTION 2011;91:941–3

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preserving the phrenic nerve. The pericardium was thenincised in healthy tissue, and the tumor was intrapericar-dially dissected towards the affected chest cavity byextending the pericardial resection. At the level of thechest wall, the dissection was performed extrapleurally.The pulmonary vessels of the involved side were dis-sected intrapericardially. En bloc resection of the SVCwas performed and replaced by a reinforced polytetra-fluoroethylene graft. A Vicryl mesh (Ethicon, Summer-ville, NJ) was sutured into the pericardial defect at itsanterior part and the sternotomy was closed.

EPP was performed in all patients through a postero-lateral thoracolumbotomy through the seventh intercos-tal space while creating a pedicled latissimus dorsi mus-cle flap. Extrapleural dissection of the lung wasaccompanied with circumferential disinsertion of thediaphragm. The pericardium was incised circumferen-tially on the involved side in healthy tissues if not alreadyperformed by the previous dissection through sternot-omy. The pulmonary vessels were divided intrapericar-dially by use of the EndoGIA 30 stapling device (U.S.Surgical Corp, Norwalk, CT) and the main bronchus wasstapled (Ethicon TL30, Summerville, NJ). The diaphragmand the pericardium were reconstructed by use of apolypropylene mesh (Marlex, Ethicon, Summerville, NJ)and a Vicryl mesh, respectively. In case of mediastinalaccess by sternotomy, the same Vicryl mesh alreadysutured to the anterior edges of the pericardial defect wasused to complete the pericardial reconstruction in theposterior and lateral part. Primary mediastinal reinforce-ment was achieved by intrathoracic transposition of thepedicled latissimus dorsi muscle flap. The percutaneousjugulofemoral shunt was removed at the end of theprocedure.

Histologic evaluation of the surgical specimen revealeda complete resection but a diffuse microscopic invasion ofthe visceral pleura in all patients, including those withpreoperative chemotherapy. There was no overall mor-tality at 90 days, and recovery was uneventful in 3patients. Necrotizing cervical mediastinitis developed in

Fig 1. (A) Computed tomography scan of patient with stage IVA B3 tdissemination. (C) Positron-emission tomography imaging with high

1 patient due to extravasation of vasoactive compounds

injected into the jugular vein, which was successfullymanaged by repeated debridement and cervical-mediastinal reconstruction by pedicled musculocutane-ous flaps. The median length of hospital stay was 43.5days (range, 23 to 70 days).

Both SVC reconstructions remained patent during fol-low-up, and there were no signs of permanent venoushypertension on the left upper extremity after resection(without reconstruction) of the innominate vein. Threepatients received adjuvant hemithoracic irradiation,whereas the patient with major postoperative complica-tions did not. Median survival was 21 months, and thefollow-up time ranged from 19 to 80 months. One patientwith innominate vein resection died of pulmonary em-bolism, without evidence of disease, 6 months after theoperation. The other 3 patients were alive without recur-rent disease during follow-up.

Comment

Thymectomy combined with EPP for stage IVA thymictumors has been reported in several case reports and inthree small series. Wright and colleagues [3] operated on

patients with B3 thymoma, without postoperative mor-ality despite preoperative chemotherapy and previous

ediastinal irradiation [3]. Complete resection waschieved in 3 of 5 patients, and the median survivalas 86 months. Huang and colleagues [4] reported 4

patients with extensive pleural involvement who weretreated by EPP. All patients underwent cisplatin-basedinduction chemotherapy and postoperative hemithoracicirradiation. There were no postoperative deaths, and 3 of4 patients were alive and without evidence of diseasewith a median follow-up of 32 months. Recently,Ishikawa and colleagues [5] reported 11 patients treatedby pleurectomy (n �7) and EPP (n � 4) for stage IVAhymoma, and all patients received preoperative chemo-herapy. There was no postoperative mortality after ei-her procedure, but EPP resulted in a better tumorontrol (3 of 4 vs 1 of 7).

ma with superior vena cava infiltration and (B) right-sided pleuraluptake of thymoma.

hymo

Our results endorse the previous findings that EPP

943Ann Thorac Surg HOW TO DO IT GONZALEZ ET AL2011;91:941–3 EPP WITH VENOUS CONFLUENCE RESECTION

with thymectomy offers excellent tumor control even forrecurrent disease. All surgical specimens in our seriesrevealed diffuse microscopic invasion of the visceralpleura, which underlines the value of EPP to obtaincomplete resection for stage IVA disease. Our results alsodemonstrate that EPP can be safely combined withthymectomy extended to the venous confluence withSVC replacement, provided specific surgical maneuversare applied.

References

1. Mornex F, Resbeut M, Richaud P, et al. Radiotherapy andchemotherapy for invasive thymomas: a multicentric retro-

spective review of 90 cases. The FNCLCC trialists. Int J RadiatOncol Biol Phys 1995;32:651–9.

2. Lardinois D, Rechsteiner R, Lang RH, et al. Prognostic rele-vance of Masaoka and Muller-Hermelink classification inpatients with thymic tumors. Ann Thorac Surg 2004;77:1183–8.

3. Wright CD. Pleuropneumonectomy for the treatment ofMasaoka stage IVA thymoma. Ann Thorac Surg 2006;82:1234–9.

4. Huang J, Rizk NP, Travis WD, et al. Feasibility of multimo-dality therapy including extended resections in stage IVAthymoma. J Thorac Cardiovasc Surg 2007;134:1477–83.

5. Ishikawa Y, Matsugama H, Nakahara R, et al. Multimodalitytherapy for patients with invasive thymoma disseminated

into the pleural cavity: the potential role of extrapleuralpneumonectomy. Ann Thorac Surg 2009;88:952–7.

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