Keywords
combined surgery - aortic - coronary - thoracic oncology - clinical decision making
Introduction
For a widespread range of cardiothoracic diseases, we have already established evidence-based
guideline recommendations. However, cases combining multiple cardiothoracic conditions,
in particular cardiac, aortic, and onco-thoracic disease, still require individual
decision making as evidence remains inconclusive. Herein we present a complex case
from our clinic with critical discussion of the decision-making process and outcome.
Case Description
A 73-year-old male was referred to our center with a non-ST-elevation myocardial infarction
(NSTEMI) due to a subtotal left main stem stenosis combined with a collateralized
chronic occlusion of the right coronary artery, not applicable to percutaneous coronary
intervention ([Fig. 1]). As the chest radiograph showed a suspect opacity on the right side, and the patient
reported cough and hemoptysis for the last 6 months, a thoracic computed tomography
(CT) scan was performed and revealed a suspected bronchial carcinoma of the middle
lobe, later confirmed by biopsy as non-small cell lung carcinoma. Staging by positron
emission tomography-CT scan showed infiltration of the adjacent thoracic wall but
no signs of lymph node or metastatic dissemination. Furthermore, a heavily calcified
eccentric aneurysm of the ascending aorta with signs of contained rupture could be
seen ([Fig. 2A, B]). Preoperative forced expiratory volume in 1 second was 72% but above the lower
limit of normal. Echocardiography showed a preserved left and right ventricular ejection
fraction.
Fig. 1 Coronary angiography.
Fig. 2 Chest computed tomography. (A) Tissue window, coronary view: eccentric ascending/ arch aortic aneurysm and right-sided
lung carcinoma. (B) Lung window, transverse view: right-sided lung carcinoma with thoracic wall infiltration
and eccentric ascending aortic aneurysm.
Clinical Problem
For NSTEMI in three-vessel disease with left main stem stenosis and chronic total
occlusion of the right coronary artery, this patient had a clear indication for coronary
artery bypass surgery.[1] With the eccentric ascending aortic aneurysm carrying a high risk of rupture, concomitant
replacement of the ascending aorta and proximal arch would be indicated once undergoing
cardiac surgery. The bronchial carcinoma should be resected as soon as possible, with
a curative approach.[2] The complete surgical approach in curative intention would comprise combined surgery
of the ascending aorta, coronary artery bypass surgery, and lobectomy with partial
thoracic wall resection—a truly high-risk operation with a EuroSCORE II of 18.16%
plus the circumstance of malignant tumor surgery with the use of extracorporeal circulation.
Treatment and Outcome
After weighing the risks in interdisciplinary consultation of thoracic and cardiovascular
surgeons, we decided on combined triple surgery with informed consent of the patient
who expressed the wish to be treated. Intraoperatively, coronary bypass surgery was
uneventful, as was the ascending and proximal aortic arch replacement with the help
of short-term hypothermic circulatory arrest. During reperfusion we performed lung
surgery with the help of additional thoracotomy. The lung carcinoma had infiltrated
both the middle and upper lobe and the adjacent thoracic wall, so an upper bilobectomy
and partial thoracic wall resection including the 5th rib was performed. Instantaneous
histopathologic section confirmed R0 resection, lymph nodes were negative. Postoperative
care was prolonged due to respiratory insufficiency and the need for noninvasive ventilation,
but otherwise uncomplicated. Complete histopathologic analysis confirmed tumor stage:
G3 pT3 pN0 (27) L0 V0 Pn0 R0. After an uneventful postoperative stay, the patient
was able to be discharged directly to the rehabilitation clinic.
Unfortunately, during short-term follow-up the patient developed recurrent pleural
effusion on the right side. Thoracoscopy revealed short-term tumor progress with carcinosis
of the pleura. Palliative treatment was initiated. The patient died several months
later, 10 months following the surgery.
Discussion
This case clearly illustrates the difficulties in clinical decision making when treating
patients presenting with more than one severe and life-threatening cardiothoracic
disease. Is it justified to deny high-risk surgical therapy to a patient who is an
older, but not elderly, man, living independently and who has expressed his clear
will and informed consent to full therapy? In our opinion, it was not. Is it ethically
correct to recommend a complex and high-risk combined cardiothoracic surgery? Even
with a EuroSCORE of 18% we did so as the tumor staging made a curative approach viable.
A two-stage surgical approach (first cardiac, second thoracic) would have unnecessarily
delayed oncological therapy with the risk of promoting tumor metastasis by the use
of extracorporeal circulation. In vitro and in vivo studies have shown progression
of tumor cell proliferation by cardiopulmonary bypass.[3]
[4] The little evidence available of simultaneous treatment of cardiac and malignant
disease from the literature is encouraging, especially in lung cancer stages I or
II. Despite an elevated risk of bleeding, the simultaneous procedure is safe and feasible
in lung cancer without mediastinal lymph node or metastatic involvement.[4]
[5]
[6]
[7]
[8] Unfortunately, within short-term follow-up the patient suffered from early aggressive
tumor progress with pleural carcinosis. In retrospect, one could raise the objection
that a conservative and palliative approach might have given the patient more quality
of life, but that remains speculative. One must not forget that the patient suffered
from his medical condition with exertional shortness of breath, cough, and hemoptysis.
In addition, it is not possible to determine if the operation with the use of extracorporeal
circulation might have triggered the progress somehow.
To conclude, it cannot be emphasized enough that indication for high-risk surgical
procedures must take into consideration not only a patient's comorbidities, but also
cocircumstances as well as their will and informed consent. As such, each case requires
individual consideration by an experienced team of cardiac and thoracic surgeons.
