Surgical treatment for locally advanced lung cancer involving the heart and great vessels: a mini-review
Review Article

累及心脏和大血管的局部晚期肺癌的手术治疗——一篇小型综述

Giacomo Argento, Erino Angelo Rendina, Giulio Maurizi

Department of Thoracic Surgery, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy

Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Giulio Maurizi, MD. Department of Thoracic Surgery, “Sapienza” University of Rome, “Sant’Andrea” Hospital, Via di Grottarossa, 1035, 00189 Rome, Italy. Email: giuliomaurizi@libero.it.

摘要：目前，对于局部晚期肺癌的手术适应证没有一致意见，尤其是当肺癌累及了心脏和大血管。尽管在这种情况下大部分患者不会选择手术治疗，但是对于一些高度选择的患者，如果可以做到根治性切除，且不存在远处或淋巴结转移，手术仍然可以进行。在过去的几十年中，许多作者探索了肺癌累及心脏和（或）大血管（胸主动脉、肺动脉、上腔静脉）的手术切除可能性。在本文中，我们探讨他们在血管重建技术方面的经验。

关键词：肺癌；手术；心脏；大血管

Received: 12 February 2020; Accepted: 28 February 2020; Published: 25 August 2020.

doi: 10.21037/ccts.2020.02.07

引言

非小细胞肺癌（NSCLC）累及邻近结构，特别是心脏和大血管，往往被认为是手术治疗的相对禁忌证，主要原因包括对技术的考虑、达到根治性切除的困难、对围术期发病率和死亡率的担忧以及较差的肿瘤学结果。但是，在过去几十年中，许多作者报道了一些接受肺切除扩展到心血管结构的患者的短期和长期令人鼓舞的结果。这些手术包括心脏（主要是左心房）、上腔静脉（SVC）、肺动脉和胸主动脉。

肺动脉

在累及肺动脉的肺癌切除术后进行肺动脉重建的优势已经被充分证实。它避免了全肺切除，保留了呼吸功能，并且具有与标准肺叶切除术可比的肿瘤学结果[1]。它也可能与支气管成形步骤有关[2]。重建术中根据血管累及的程度选择特定的重建技术。通常来说，当累及范围小于血管周长的25%时，可以作切向切除和一期缝合[3]；如果累及血管的比例更大，但仍小于血管周长的一半时，可以通过部分切除和放置补片来进行重建，补片可以来自自体、牛或猪心包，或者自体肺静脉；如果肿瘤累及范围超过血管周长的一半，可以作环形切除和端端吻合，且如果切除段太长，可以在心包或肺静脉取假体导管置入[4,5]。肺动脉袖状切除已经成为了胸外科中相对常见的手术，使用体外循环（CPB）切除肺动脉主干分叉处也有报道，但适应证尚不清楚[6,7]。

上腔静脉

上腔静脉的切除和重建是一个复杂的过程[8]。累及上腔静脉的肺癌往往也累及了支气管树，尤其是隆突，这类肿瘤的切除往往需要肺叶切除并支气管成形术，甚至是全肺切除术。与原发肿瘤直接浸润相比，上腔静脉可能也会被转移的淋巴结浸润，这是一个不良的预后因素[9]。夹闭上腔静脉可导致头部静脉压升高，存在颅内出血、脑水肿、心排出量严重减少等并发症的风险，因此手术中必须谨慎处理。虽然夹闭长期阻塞的上腔静脉在血流动力学上具有更好的耐受性，但这也导致了根治性切除可能性的降低，因此患者的选择至关重要。术中减少血流动力学不稳的措施包括下肢静脉导管补液、应用血管收缩剂和尽可能减少夹闭时间。血管内或血管外分流可能会被用于减少血管夹闭的副作用。为了避免血栓并发症，术中和术后肝素化是必要的。根据血管累及的程度，上腔静脉重建可以作切向切除并直接缝合，或者用自体或牛心包补片置入，但是最常见的是用假体导管替代，材料通常是聚四氟乙烯或自体/牛心包[10,11]。当无名静脉交汇处被肿瘤浸润时，最好只对一条无名静脉进行血管重建，通常选择左侧[12]。

胸主动脉

侵犯胸主动脉的肺癌整体切除是另一个有争议的话题[13]。这是一个非常精细且复杂的过程，许多技术已被报道过[14]。虽然难以实现，但根治性切除术可以获得良好的肿瘤学结果，并具有合理的发病率和死亡率。重建技术的选择基于受侵部位（主动脉弓或降主动脉）、管周受累程度和管壁受累深度。如果主动脉浸润局部局限于外膜，且主动脉壁内的切除平面可以容易构建，则可以在包围浸润区域下方和上方的主动脉进行外膜下切除，方便最终紧急夹闭。当主动脉中层有确认或可疑的侵犯，且肿瘤侵犯大于主动脉周长的30%，不同的方法可以选用：直接夹闭主动脉进行主动脉壁切除和重建，特别是在侵犯血管定位在降主动脉水平的情况下[15]；当主动脉弓受侵犯时，可以在股静脉和股动脉之间进行部分体外循环，或者从升主动脉到降主动脉行临时旁路移植术，这样有可能重建受浸润的锁骨下动脉或颈动脉[16]。另外，最近，术前或术中主动脉内移植物的放置和主动脉/主动脉弓交叉夹闭技术切除成功地应用于安全的主动脉壁切除，避免了使用体外循环[17,18]（图1）。

图1
图1 术中图片示由涤纶补片重建的主动脉弓

心脏

尽管肺癌伴心脏转移往往被视为无法手术治疗，但在完全切除似乎可行且没有远处转移的情况下也偶尔行手术治疗。鉴于非常少量的文献病例报道，手术的适应证仍有争议 [6,7,19-25]。大多数现有的病例关注了左心房切除。解剖学上，因为右肺静脉更短，右侧肿瘤侵犯左心房比左侧肿瘤快。此外，左侧肿瘤快速多器官浸润（左心房、主动脉、食道等）更常见，因此排除了采取手术的选择。心脏停搏液或细波室颤与体外循环联合使用使得可以安全打开心腔，辅助肿瘤的完全切除。一些作者[19,24,25]描述了使用 Sondergaard 技术解剖房间沟，可以延长左心房袖带，然后安全地夹住，从而无需使用体外循环即可进行左心房切除术；然后可以直接缝合心房缺损或插入心包补片以重建心房壁（图2）。

图2
图2 浸润至左心房的肺癌被切除后行牛心包补片重建

体外循环

 既往描述的一些复杂的心血管重建步骤包含体外循环的应用。很早之前体外循环就已经用于扩大肺切除术治疗癌症的研究中了[26]，但尽管有先进的技术，还是只有少量的病例被报道，一方面是因为外科医生不愿意接受激进的方法治疗局部晚期肺癌，另一方面是担心出现出血等主要的围术期并发症。有趣的是，Muralidaran及其同事[27]的一篇荟萃分析总结说，相比于因为术中并发症紧急使用体外循环，计划使用体外循环能够提供最佳生存获益。此外，从理论上讲，体外循环介导的免疫抑制和直接的机械传播组合可能导致肺切除术中疾病的全身传播，尽管这并未得到证实[28]。

总结

 累及心脏和大血管的肿瘤是T4期肿瘤里的一组异质性疾病，其治疗仍然存在争议。根据最新的ESMO指南[29]，如果R0切除可以实现，活检证实为T4N0（IIIA期）的肿瘤患者被认为是潜在的手术候选者。新辅助化疗或化放疗在其中的角色仍存在争议[30-32]。但是，由于缺乏足够的随机数据，治疗方法只能由肺癌多学科团队的专家根据个案进行选择。随着现代外科技术和围术期护理的进步，现有的数据表明，在过去的几十年中，肿瘤累及胸主动脉、肺动脉、上腔静脉和左心房的患者行扩大切除术后的发病率和死亡率有了显著改善。长期生存数据似乎证明这种复杂的手术是合理的，因此应该在经验丰富的中心提供给高度选择的患者。

Acknowledgments

We thank Marta Silvi and Carla Conversi for administrative support.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Francesco Zaraca, Reinhold Perkmann, Luca Bertolaccini and Roberto Crisci) for the Focused Issue “Thoracic Surgery Without Borders” published in Current Challenges in Thoracic Surgery. The article was sent for external peer review organized by the Guest Editors and the editorial office.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ccts.2020.02.07). The Focused Issue “Thoracic Surgery Without Borders” was commissioned by the editorial office without any funding or sponsorship. EAR serves as an unpaid editorial board member of Current Challenges in Thoracic Surgery from Mar 2019 to Mar 2021. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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译者介绍
黄旭华
浙江大学。临床医学5+3学生。（更新时间：2021/9/13）

（本译文仅供学术交流，实际内容请以英文原文为准。）

doi: 10.21037/ccts.2020.02.07
Cite this article as: Argento G, Rendina EA, Maurizi G. Surgical treatment for locally advanced lung cancer involving the heart and great vessels: a mini-review. Curr Chall Thorac Surg 2020;2:29.

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