V.A.Tarasov, Yu.K.Sharov, P.I.Azarov, V.V.Stavrovietskiy, E.S.Pobegalov, K.P.Zhidkov, M.B.Blum, I.V.Lvov, K.K.Lezhnev, V.M.Senin, A.V.Senina.

 

Combined surgical treatment of Stage IV malignant neoplasms of the chest and abdominal organs involving great vessels, lungs and liver

• Department of Thoracic Surgery, Medical Academy of Postgraduate Education, St.Petersburg, Russia;
• Department of Thoracoabdominal Surgery, City Hospital No. 26, St.Petersburg, Russia.

1st International Congress on Thorax Surgery. Athens, Greece, July 1997. Final Program.

• SUMMARY
• INTRODUCTION
• MATERIALS AND METHODS
• RESULTS AND CONCLUSION

SUMMARY

78 operations were performed in 63 patients for Stage IV malignancies with multiple distant metastases or involvement of vitally important structures, all of them having been considered to be inoperable by usual criteria in other clinics. Secondary affection of 1 organ or anatomical region was revealed in 7 cases, 2 - in 20, 3 - in 18, 4 and more - in 18 patients. 18 interventions on great vessels were performed. Reconstructive techniques are thoroughly described. Postoperative morbidity made up 31.7%, postoperative mortality - 15.9%. Complex immunotherapy was conducted postoperatively to survivers. 70.0% patients are alive 3 - 50 months after surgery. Modern surgical techniques may provide radical and extended cytoreductive operations in a number of Stage IV malignancies.

INTRODUCTION

Despite progress in development of conservative methods for treatment of malignant tumours, - chemotherapy, radiotherapy, and immunotherapy, - surgery remains a crucial method for the vast majority of malignancies. Yet, extended invasion of ajacent organs by a malignant tumour, multiple distant metastases have been considered to be a strong restriction for radical surgery up to our days. However, modern potentials of surgery and anaesthesiology permit more aggressive surgical approach to these patients. Extended surgery combined with methods of conservatine oncology might prolonge survival rate of certain group of patients having been considered inoperable previously, as well as improve their life quality.

MATERIALS AND METHODS

63 patients with Stage IV cancer and other advanced malignant neoplasms (33 male and 30 female) underwent 84 surgical operations in the clinic of thoracoabdominal surgery of St.Petersburg City Hospital No. 26 (clinical base of the Department of Thoracic Surgery of Medical Academy of Postgraduate Education, St.Petersburg, Russia). Age of patients varied from 22 to 83 years: 6 patients were below 30, 8 - 31-40, 17 - 41-50, 14 - 51-60, 2 - more than 70 years old. Primary localization of malignancy in 2 patients was lung, in 8 - pancreas, in 8 - oesophagus and stomac, in 22 - colon and rectum, in 4 - kidneys, in 5 - breast, in 3 - thymus, in 5 - soft tissues, in 6 - other malignancies. All of them were previously investigated in other clinics, diagnosed as Stage IV, and symptomatic therapy only was recommended. 25 (39.7%) patients survived radical surgery for malignancies in the past, 6 (9.5%) had palliative surgery. All the patients were informed of their disease and prognosis, and insisted on attempt of surgery.

Clinical investigation in our clinic which included radiological examinations, endoscopy, sonography in all cases, and also computed tomography, contrast angiography and/or magnetic resonance imaging when needed, revealed secondary (due to distant metastases and/or direct invasion) affection of 1 organ or anatomical region in 7 cases, of 2 - in 20, of 3 - in 18, of 4 - in 8, of 5 and more - in 10 patients. 27 of them had liver metastases in one (7 patients) or both (20 patients) lobes, varying in number from 2 to 39 (median 9). In 12 cases, metastases were discovered in one (2 patients) or both (10 patients) lungs, number of metastases varied from 1 to 84 (median 21). Recurrency of primary tumours was discovered in 26 (41.4%) cases.

All the patients were operated in conditions of general anaesthesia, using endotracheal narcosis combined with prolonged epidural anaesthesia in 21 case, and prolonged subpleural - in 15 ones. To maintain adequate transfusion, subclavian vein was catheterized in all the patients; in 4 cases when intervention on superior vena cava and its branches was supposed, iliac vein was also catheterized through femoral access.

49 patients were operated in 1 stage, 9 - in 2, 3 - in 3, 2 - in 4 stages. Surgical approach included 17 thoracotomies, 10 sternotomies, 10 combined thoracolaparotomies, 38 laparotomies, 9 other approaches. Radical operations consisted in complete removal of an organ or tissue invaded by the tumour, as well as nearby and distant metastases. Cytoreductive surgery included usually bypass anastomoses, decompression of mediastinum, abdominal or pelvic cavity, and always - significant reduction of malignant tissue by means of its partial resection or electric coagulation. Radical surgery was performed in 48 (76.2%) patients, cytoreductive interventions - in 15 (23.8%).

While primary affected organ was extirpated completely as a rule, we applied an economical approach to the secondarily invaded organs, trying to preserve them as much as possible. Radicalism of resection of such organs was controlled by intraoperative hystological examination. In case of multiple liver metastases located in one lobe we performed anatomical hemihepatectomy (4 cases). Metastases located in both lobes were removed by atypical resections; we always tried to remove several nodes through one incision of the liver capsula.

Lung metastases were excised mostly atypically, - simultaneously from both lungs through total vertical sternotomy (5 cases), or in 2 stages through thoracotomies (7 patients), depending greatly of their number, size, and relations to the bronchi and blood vessels. If the number of metastases in one lung exceeded 15, or if their adhesion into bronchi and main blood vessels of the lung was supposed, 2-staged thoracotomies were preferred. In 3 cases we have had to perform typical lobectomies for giant or multiple metastases which occupied the majority of parenchyma of the lung lobe or invaded its hilus.

Surgical removal of malignancies included 18 interventions on great vessels because of their invasion. Superior vena cava was resected in 3 cases, brachiocephalic veins - in 3, inferior vena cava - in 3 (in 1 of those patients aorto-iliac arterial segment was also resected), vena portae - in 3, intravascular tumorous components were removed in 5 patients. In all but one cases resected vessels were reconstructed. Arterial reconstruction was performed using a Dacron arterial graft; veins were restored with “Vitaflon” polytetrafluorethylene grafts (“Ecoflon” Scientific-Industrial Enterprise, St.Petersburg, Russia). In one case azygos vein was also converted into an autograft.

In all cases, samples of primary tumour and metastases were obtained for morphological investigation, cytomorphometry etc., and for preparation of autologous vaccines, metastatic tissue being preferred for the last.

10 - 20 days postoperatively, cellular immunity was checked in all patients who survived, and immunomodulative therapy was started, including enforcement of presentation of neoplastic antigens by intracutaneous injections of autologous vaccines prepared of the patient’s own malignant tissue (metastatic one was preferred, if possible). Presentation was also increased by Sendai and Newcastle viral antigens. Simultaneously, cytotoxicity of natural killers was stimulated by "Lymphokinin" drug (Oncological Research Center of Russian Academy of Medical Sciences, Moscow, Russia) containing Interleukin-2. After finishing this adoptive immunotherapy patients were investigated every 3 months, including computed tomography and lymphocytes cytotoxic activity tests. If the last appeared to decrease, one more cycle of "Lymphokinin" was conducted.

RESULTS AND CONCLUSION

21 postoperative complication occured in 20 (31.7%) patients, 10 of them (15.9%) died during the 30-day period; the most common cause of death was polyorganic failure. Both postoperative morbidity and mortality rates were significantly lower in cytoreductive operations than in radical, and in cases of lung metastases removal than in liver ones (see Table 1).

Catamnesis was obtained from 50 patients of 53 who survived, in terms from 3 to 52 months. In those terms, 16 of them (32.0%) were alive without signs of malignancy recurrence. 7 (14.0%) patients were alive and doing well despite signs of recurrence discovered by clinical investigation. 12 (24.0%) patients had recurrency with marked clinical presentation. 15 (30.0%) patients died; in 3 of those cases death was caused by concurrent cardiovascular diseases, and in 12 - by relapse of malignancy. Survival rates after different kinds of operations are presented in Table 1.

Only two cases of thrombosis of blood vessel grafts were detected after great vessel replacements: one of them - in the early postoperative period, and another - 3 months later.

Thus, it appeared to be possible to provide effective surgical aid in 84.1% cases of fatal stage IV malignant tumours having been considered to be inoperable according to common oncosurgical criteria, with comparatively moderate morbidity rate. Considering this experience, we advocate that borders of surgical activity should be enlarged for this category of patients, especially those with minor sensitivity of tumours to radio- and chemotherapy. As for long-term results of aggressive surgical approach to stage IV malignant tumours, they strongly need further and thorough studies.

 Table 1. Mortality, morbidity, and survival rates.

 

 

 

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