Is Extended Resection for Locally Advanced Thoracic Cancer with Cardiopulmonary Bypass Justified?

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Joffrey Hsu, Ping-Ruey Chou, Jiann-Woei Huang, Yu-Wei Liu, Hung-Hsing Chiang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4527263/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Oct, 2024 Read the published version in BMC Surgery → Version 1 posted 11 You are reading this latest preprint version Abstract Background: Resection of intrathoracic tumor with cardiopulmonary bypass (CPB) remains a relatively under-reported intervention in literature, and its role in managing locally advanced mediastinal and lung cancers is a topic of ongoing debate. Our aim was to review our experience and assess the role of CPB for treatinglocally advanced mediastinal and lung cancers. Methods: Between 2015 and 2020, this study initially included 10 patients with primary locally advanced thoracic malignancies with apparent adjacent cardiovascular invasion demonstrated by thoracic imaging scans. Operation was performed based on a multidisciplinary tumor board consensus. Eventually, 8 patients (3 primary lung cancers and 5 mediastinal cancers) received either salvage or elective resection with CPB; two completed surgery without requiring CPB. Results: Regarding the extent of adjacent structure involvement, 4 patients presented with involvement of the superior vena cava (SVC), 1 involved the right atrium (RA), 2 involved the SVC and RA, and 1 involved the SVC, the origin of main pulmonary artery, and the ascending aorta. Thirty-day mortality occurred in two of three patients receiving salvage surgery due to respiratory insufficiency. With the long-term follow-up, one patient died of recurrence 25 months postoperatively, one survived with recurrence 30 months postoperatively, and four were alive without recurrence for 35, 36, 49, and 107months after operations. Conclusions: In certain patients, particularly for elective surgical candidates rather than salvage resection, CPB allows for extended resection of locally advanced thoracic cancerswith acceptable perioperative safety and survival. cardiopulmonary bypass (CPB) extended resection locally advanced thoracic cancer Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Surgical resection plays a crucial role in the treatment of patients with advanced thoracic malignant tumors with invasion of adjacent thoracic structures and may offer a chance for cure. However, such surgeries remain challenging even for experienced surgeons. Though controversial, cardiopulmonary bypass (CPB) can be used to allow resection and reconstruction of the great vessels and/or cardiac structures and, subsequently, complete extended resection of the tumor [ 1 – 5 ]. Radical resection of tumors has been shown to significantly improve the survival in select patients [ 6 – 8 ]. Even as the potential advantage and efficacy of CPB has been recognized, the underuse of CPB reflects the concerns of significant complications; including excessive bleeding secondary to full heparinization, increased pulmonary complications, and fears of CPB-related tumor dissemination [ 9 ]. Thus far, little is known about the true pros and cons of CPB use in locally advanced thoracic malignancies. Over the last decades, only a few case series describing the technical possibilities in extended radical resections, the associated morbimortalities, as well as the postoperative long-term survival outcomes have been published [ 3 , 5 – 8 , 10 , 11 ]. Hence, the underlying benefit of CPB in aiding complete extended resection merits further investigation. Consequently, the present study aims to review our surgical experience of treating such advanced intrathoracic tumors using CPB and the perioperative and survival outcomes. Further, the rationale of using CPB in complete extended resection among such complex surgical procedures will be discussed with a compendious review of current relevant literature. Methods Study design This study is a single institutional case series conducted between January 2015 and December 2020, focusing on patients with primary thoracic cancers. We assessed the role of CPB in facilitating complete resection of tumors with highly suspected neighboring cardiovascular invasion, as identified by preoperative thoracic computed tomographic (CT) scans. The study protocol adhered to ethical guidelines and was approved by the institutional review board (KMUHIRB-E(II)-20230169). Patient selection Patient inclusion algorithm is presented in Fig. 1 . A total of 10 patients with primary thoracic cancers highly suspected neighboring cardiovascular invasion based on CT scans were initially included in the study. Surgical indication and resection was principally performed with a curative intent and based on consensus reached by a multidisciplinary team including thoracic surgeons, cardiovascular surgeons, oncologists, and radiologists. Preoperative assessment was used to exclude patients with distant metastasis and advanced mediastinal lymph node disease. Two patients (mediastinal liposarcoma and thoracic rhabdomyosarcoma) were excluded because surgery was able to be completed without the need for CPB (these patients’ femoral artery and vein were catheterized in preparation for CPB). Regarding the intention of surgery, the remaining eight patients can be divided into elective and salvage surgeries. Patients undergoing elective surgery usually had good performance status with a well-organized perioperative therapeutic strategy, while patients receiving salvage surgery often exhibited inferior physical status and resection was determined when no alternative nonoperative therapy was available and based on the individual condition of each patient. Surgical techniques All eight patients, comprising 3 with primary lung cancers and 5 with mediastinal cancers, underwent complete resection with the assistance of CPB. The operation was approached through median sternotomy with or without lateral thoracotomy extension (n = 7) or postero-lateral thoracotomy (n = 1). CPB was employed via ascending aorta and right atrial or bicaval cannulation, following full heparinization. Once CPB was initiated, the aorta was cross-clamped and the heart arrested with the aid of cold blood cardioplegia. Extended tumor resection and surgical reconstruction of the cardiovascular structure involved was then performed (Fig. 2 D and 3 C). Pulmonary extension of tumors required pneumonectomy in 4 patients, and bilobectomy, lobectomy, and wedge resection in the remaining 3 cases respectively. In the majority of patients, several cardiovascular and mediastinal structures were affected simultaneously. Therefore, resection involving superior vena cava (SVC) was performed in 4 patients, the right atrium (RA) in 1 patient, the SVC and the RA in 2 patients, and the SVC with the root of main pulmonary artery, and the ascending aorta in 1 patient. Statistics Descriptive statistics were used to summarize patient demographics, tumor characteristics, perioperative variables, and outcomes. Categorical variables were expressed as numbers with percentages and compared by the Chi-square test. Non-normally distributed data were described by medians with interquartile range (IQR) and were analyzed using Mann-Whitney U test. The latest follow-up endpoint for data collection was December 31, 2023. Recurrence-free survival (RFS) was defined as the time interval between surgery and the occurrence of tumor recurrence or the last follow-up date. Overall survival (OS) was defined as the time interval between surgery and death from any cause or the last follow-up date. Kaplan-Meier survival curves were generated to assess RFS and OS. A statistical significance was set at a p -value less than 0.05. Results Patient demographics Clinical demographics of case details are listed in Table 1 . In total, eight patients underwent extended resection of locally advanced thoracic cancers with CPB; including 3 salvage surgeries and 5 elective surgeries. Six patients were male with an age range of 7 to 73 years old with a mean of 52 years. Pathological diagnosis of the 5 mediastinal cancers were mediastinal sarcoma, mediastinal germ cell tumor, mediastinal large cell neuroendocrine cancer, thymic carcinoma, and thymoma; 3 lung cancers including pulmonary blastoma, pleomorphic lung cancer, large cell neuroendocrine lung cancer. The representative patient #3 underwent salvage surgery using clamshell thoracotomy plus median sternotomy for en-bloc resection of giant mediastinal germ cell tumor (Fig. 2 A, 2 B, and 2 C), who required right pneumonectomy, partial SVC resection, pericardial resection and reconstruction [ 12 ]. Another representative patient #6 underwent elective surgery via median sternotomy for en-bloc resection of mediastinal large cell neuroendocrine carcinoma, who required bilobectomy, entire SVC resection, partial LA resection and reconstruction (Fig. 2 D and 2 E). Table 1 Patient demographics and perioperative outcomes Patient (intention of surgery) Pathology Age a Sex ECOG ASA Lung resection CVS resection OP Time b (min) Blood loss c (mL) ICU day d Hospital day e 1# (elective) Pulmonary blastoma 7 F 1 4 Pneumonectomy SVC 360 200 3 9 2# (salvage) Mediastinal sarcoma 73 M 3 4 Pneumonectomy SVC 400 3400 24 24 3# (salvage) Mediastinal teratoma 18 M 2 4 Pneumonectomy SVC 600 1750 4 27 4# (elective) Pleomorphic lung cancer 73 M 1 4 Lobectomy LA 450 1000 10 16 5# (salvage) Large cell neuroendocrine lung cancer 61 M 4 4 Pneumonectomy SVC, LA 570 3000 12 12 6# (elective) Mediastinal large cell neuroendocrine cancer 37 M 0 2 Bilobectomy SVC 480 1850 3 12 7# (elective) Thymic carcinoma 49 M 1 3 Wedge resection LBV, MPA, Aorta 650 700 7 17 8# (elective) Thymoma 53 F 1 3 Nil SVC, RA, Aorta 660 650 18 34 ECOG: Eastern Cooperative Oncology Group; ASA: American Society of Anesthesiologists; CVS: cardiovascular structure; OP: operation; ICU: intensive care unit; min: minute; mL: milliliter; F: female; M: male; SVC: superior vena cava; LA: left atrium; LBV: left brachiocephalic vein; MPA: main pulmonary artery; RA: right atrium. Values are expressed as means ± standard deviations (SD). a Mean ± SD, 46.4 ± 24.3 years. b Mean ± SD, 521 ± 114 mins. c Mean ± SD, 1,568 ± 1,153 mL. d Mean ± SD, 10.1 ± 7.6 days. e Mean ± SD, 18.9 ± 8.7 days. Perioperative and postoperative outcomes Perioperative and postoperative outcomes are summarized in Tables 1 and 2 . Postoperative complications were graded using the Clavien-Dindo classification, 2 out of 5 patients with elective surgery had no postoperative complications. 4 patients had grade II-III complications, including arrhythmia, sternal wound dehiscence, vocal cord palsy, vascular graft thrombosis (subsequently treated with endovascular intervention + thrombolytic therapy). The aforementioned complications were all managed successfully and the patients returned to monitoring in the clinic setting. Two patients presented with grade V complications (in-hospital mortality) due to respiratory insufficiency; both patients received salvage surgeries. Notably, patient #8 underwent elective surgery following neoadjuvant chemoradiotherapy, which achieved pathological complete response (pCR) after resection (Fig. 3 ). In the long term, 4 patients presented with recurrence-free survival 35, 36, 49, and 107 months after operations, and one survived with recurrence 30 months postoperatively. One patient died with recurrence 25 months postoperatively. The mean recurrence free survival (RFS) was 43 ± 17 months and the mean overall survival (OS) was 58 ± 17 months. The Kaplan-Meier plot of RFS and OS are shown in Fig. 4 . Table 2 Pathological and postoperative outcomes Patient Pathological tumor stage Complication (grade) Resection margin RFS a (months) OS b (months) Neoadjuvant Tx Postoperative adjuvant Tx 1# Lung blastoma, pT4NxM0, stage IIIA No R0 107 107 (alive) No Chemotherapy 2# Mediastinal sarcoma, pT4N0M0, stage III Mortality, grade 5 R1 0.8 0.8 (death) No No 3# Mediastinal teratoma, ypT1aN0M0, stage I Wound dehiscence, grade 3a R0 6 25 (death) Chemotherapy Chemotherapy + radiotherapy 4# Pleomorphic lung cancer, pT4N0M0, stage IIIA No R0 6 30 (lost follow-up) No chemotherapy 5# Large cell neuroendocrine lung cancer, pT4N2M0, stage IIIB Mortality, grade 5 R1 0.4 0.4 (death) No No 6# Mediastinal large cell neuroendocrine cancer, pT3N0M0, stage III Graft thrombosis, grade 3a R0 49 49 (alive) No chemotherapy 7# Thymic cancer, ypT3N0M0, stage III Vocal cord palsy, Graft thrombosis, grade 3a R0 36 36 (alive) chemotherapy No 8# Thymoma, ypT0N0M0, pCR Cardiac arrythmia required pacemaker implantation, grade 2 R0 35 35 (alive) Chemotherapy + radiotherapy No RFS: resurrence-free survival; OS: overall survival; Tx: therapy. Values are expressed as means ± standard deviations (SD). a Mean ± SD, 43 ± 17 months. b Mean ± SD, 58 ± 17 months. Comparison between patients, who underwent salvage and elective surgery with CPB is summarized in Table 3 . 5 patients received elective surgery and exhibited a significantly lower Eastern Cooperative Oncology Group (ECOG) scale ( p < 0.01) and blood loss ( p = 0.04). Though statistically insignificant, patients who received elective surgery versus salvage surgery presented with numerically shorter operative times (480 vs 570 min, p = 0.88), a higher number of R0 resections (5 vs 1, p = 0.11), shorter intensive care unit (ICU) stays (7 vs 12 days, p = 0.29), and shorter postoperative hospital stays (16 vs 24 days, p = 0.54) Table 3 Comparison between patients undergoing salvage and elective surgery Salvage surgery Elective surgery p value N = 3 N = 5 Age (year) a 61 [18–73] 49 [7–73] 0.54 Sex 0.46 Male 3 3 Female 0 2 ECOG scale 0.01 0–1 0 5 2–4 3 0 ASA grade 1.0 1–2 0 1 3–4 3 4 Operative time (mins) a 570 [400–600] 480 [360–660] 0.88 Blood loss (mL) a 3000 [1750–3400] 700 [200–1850] 0.04 Surgical margin 0.11 R0 resection 1 5 R1 resection 2 0 Extent of pulmonary resection 0.14 Pneumonectomy 3 1 Lobectomy 0 2 Wedge resection 0 1 ICU stay (day) a 12 [ 4 – 24 ] 7 [ 3 – 18 ] 0.29 Postoperative hospital stay (day) a 24 [ 12 – 27 ] 16 [9–34] 0.54 Postoperative complication 0.07 No 0 2 Grade 2 0 1 Grade 3a 1 2 Grade 5 (mortality) 2 0 ECOG: Eastern Cooperative Oncology Group; ASA: American Society of Anesthesiology; ICU: intensive care unit; mins: minutes; mL: milliliter. a Values are expressed as median with [interquartile range]. Discussion The surgical management of locally advanced thoracic cancer presents considerable challenges due to the proximity of vital structures such as the heart and major blood vessels. In the present series, we shared our experience and outcomes of extended resection procedures for both locally advanced lung and mediastinal cancer with the assistance of CPB. The present study demonstrates that patients with a better preoperative ECOG performance status undergoing elective surgery with CPB are more likely to have R0 resection, shorter operative times, lesser blood loss. In contrast, CPB use under salvage surgery was associated with higher morbimortality. Our findings emphasize the importance of discrete preoperative patient selection and surgical approaches with CPB. Complete surgical resection remains the primary factor contributing to the survival in patients undergoing resection under CPB [ 13 , 14 ]. For non-small cell lung cancer (NSCLC), stages up to pathology-proven T 4 N 0 − 1 may be acceptable for curative surgical resection [ 15 , 16 ]. For thymic malignancies, radical resection is considered part of the multimodal treatment in patients of stage III and even stage IVa with pleural spread [ 17 – 19 ]. This treatment principles is also applicable to other rare types of locally advanced thoracic cancers, including mediastinal sarcoma [ 20 ], mediastinal teratoma [ 21 ], mediastinal large cell neuroendocrine cancer [ 22 ], pulmonary blastoma [ 23 ], pleomorphic lung cancer [ 24 ], and large cell neuroendocrine lung cancer [ 25 ], which were all also reported in our series. Regardless of the tumor histology, the extent of invasion of adjacent anatomical structures is the key determinant of surgical difficulty. CPB use to achieve en bloc resection has been successfully reported in tumors invading the SVC and RA with acceptable perioperative morbidity and mortality rates [ 4 , 26 – 28 ]. CPB was utilized in our 8 patients with locally advanced thoracic tumors involving the SVC, atrium, main pulmonary artery, and ascending aorta. This highlighted the versatility of CPB in facilitating complete tumor resection in anatomically challenging cases. Nevertheless, limited studies and the lack of consensus complicate the debate on the setting of obtaining extended resection for locally advanced lung and mediastinal cancers under CPB. Proponents of CPB emphasize its role in enabling complete tumor resection and achieving negative surgical margins, which are crucial factors associated with improved long-term oncological outcomes. For example, a retrospective study by Ried et al. demonstrated that CPB-assisted extended resections for locally advanced thymic malignancies resulted in favorable survival outcomes, with a high rate of R0/R1 resection achieved [ 2 ]. Similarly, a systematic review by Muralidaran et al. concluded that CPB use was associated with improved overall survival and disease-free survival in patients undergoing extended resections for advanced lung cancer involving the mediastinum or great vessels [ 23 ]. Furthermore, Langer et al. [ 1 ] and Filippou et al. [ 5 ] supported that there is no inferiority in postoperative outcomes in CPB group compared with non-CPB group. However, CPB raise valid concerns regarding its associated risks and complications, including systemic inflammatory response, coagulopathy, end-organ dysfunction, and modest relationship with cancer progression [ 9 ]. In fact, controversy does exist in literature concerning the application of CPB for oncological interventions. No increase of distant metastases and tumor recurrence has been observed in systematic review by Muralidaran et al. [ 3 ]. In contrast, some authors hypothesize that increased intraoperative tumor cell dissemination promoted by the extracorporeal circulation could have been responsible for early relapse, as previously reported by other authors [ 29 ]. In a recent large case series, none of patients undergoing cardiac reconstruction with CPB support showed locoregional recurrence or distant metastasis within 6 months of the operation, thus, the authors concluded that evidence could not confirm the hypothesis of increased rate of early recurrence for tumors resected under CPB [ 8 ]. CPB itself is deemed to be a significant predictor of postoperative morbidity and mortality, particularly in cases involving extensive resections and prolonged CPB times [ 30 , 31 ]. Considering the high-risk nature of such procedures, perioperative mortality ranging from 7–15% had been reported [ 6 , 32 ]. The mortality rate in our series is relatively high (2/8, 25%), though both patients received salvage surgery. All the patients in the elective surgery group achieved at least 12 months of recurrence-free survival without lethal perioperative complications. These findings are consistent with the survival date found in literature [ 6 – 8 , 10 ]. However, Byrne et al. [ 32 ] reported 43% of all CPB procedures to be performed for emergency situations. These data underlies the importance of CPB availability when surgery for advanced thoracic malignancies is being considered. Wiebe et al. also advised that pneumonectomy is associated with life-threatening complications [ 6 ]. Though patient selection criteria for CPB-assisted extended resections is crucial for favorable outcomes [ 11 ], the criteria remain unclear, leading to variability in practice patterns and institutional preferences. Current literature indicates decisions to operate are situational due to the variability of the disease entity, surgical capabilities, and high surgical risk. While CPB may be justified in cases where complete tumor resection cannot be achieved with conventional techniques, the decision to utilize CPB requires detailed multidisciplinary preoperative evaluation, including individual patient factors, tumor characteristics, and institutional expertise. This is echoed by our experience preferring that CPB application in elective surgery group in the present series exhibited a better prognosis. It is important to acknowledge the limitations of our study, including its retrospective nature and relatively small sample size, which inherently limits firm statistical assessment. However, our data supports the feasibility of radical resection with CPB support for thoracic malignancies invading cardiovascular structures. Furthermore, the incidence of postoperative complications, including arrhythmias, pneumonia, and transient SVC syndrome, highlights the importance of close perioperative monitoring and management in optimizing patient outcomes. Conclusions In conclusion, while CPB can be considered a valuable surgical tool for locally advanced thoracic cancers, through patient selection, including lower ECOG scale and elective surgery, is necessary for CPB to confer its benefit. Future studies are warranted to validate our findings and to further elucidate the long-term survival benefits of CPB-assisted extended resection procedures in this patient population. Abbreviations CPB, Cardiopulmonary bypass ; SVC, Superior vena cava; RA, Right atrium ; CT, Computed tomographic; IQR, Interquartile range; RFS, Recurrence-free survival ; OS, Overall survival; pCR, Pathological complete response; ECOG, Eastern Cooperative Oncology Group; ICU, Intensive care unit; NSCLC, Non-small cell lung cancer. Declarations Ethics approval and consent to participate This study complies with the standards of the Declaration of Helsinki and current ethical guidelines. The study protocol adhered to ethical guidelines and was approved by the institutional review board (KMUHIRB-E(II)-20230169). Informed consent was obtained from individual participant included in the study. Consent for publication Written informed consent for publication of their clinical details and clinical images were obtained from the patient. A copy of the consent form is available for review by the Editor of this journal. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Authors' contributions Conceptualization, Y-W Liu; methodology, validation, formal analysis, and investigation, J-W Huang, H-H Chiang, J-Y Lee, H-P Li, P-C Chang, and S-H Chou; writing—original draft preparation and writing—review and editing, J. Hsu, P-R Chou, and Y-W Liu; visualization, Y-W Liu; supervision, Y-W Liu. All authors have read and agreed to the published version of the manuscript. Acknowledgements Not applicable. References Langer, N.B., et al., Outcomes After Resection of T4 Non-Small Cell Lung Cancer Using Cardiopulmonary Bypass. Ann Thorac Surg, 2016. 102 (3): p. 902-910. Ried, M., et al., Radical surgical resection of advanced thymoma and thymic carcinoma infiltrating the heart or great vessels with cardiopulmonary bypass support. J Cardiothorac Surg, 2015. 10 : p. 137. Muralidaran, A., et al., Long-term survival after lung resection for non-small cell lung cancer with circulatory bypass: a systematic review. J Thorac Cardiovasc Surg, 2011. 142 (5): p. 1137-42. De Giacomo, T., et al., Successful resection of thymoma directly invading the right atrium under cardiopulmonary bypass. Eur J Cardiothorac Surg, 2015. 48 (2): p. 332-3. Filippou, D., et al., Extended resections for the treatment of patients with T4 stage IIIA non-small cell lung cancer (NSCLC) (T(4)N(0-1)M(0)) with or without cardiopulmonary bypass: a 15-year two-center experience. J Thorac Dis, 2019. 11 (12): p. 5489-5501. Wiebe, K., et al., Extended pulmonary resections of advanced thoracic malignancies with support of cardiopulmonary bypass. Eur J Cardiothorac Surg, 2006. 29 (4): p. 571-7; discussion 577-8. Chen, L., et al., Cardiopulmonary bypass does not consequentially contribute to postoperative distant metastasis of giant refractory thoracic tumors: A retrospective study with long-term follow-up. Thorac Cancer, 2021. 12 (22): p. 2990-2995. D'Andrilli, A., et al., Reconstruction of the heart and the aorta for radical resection of lung cancer. J Thorac Cardiovasc Surg, 2024. 167 (4): p. 1481-1489. Pinto, C.A., et al., Cardiopulmonary bypass has a modest association with cancer progression: a retrospective cohort study. BMC Cancer, 2013. 13 : p. 519. Mei, J., et al., Reconstruction of the pulmonary trunk via cardiopulmonary bypass in extended resection of locally advanced lung malignancies. J Surg Oncol, 2012. 106 (3): p. 311-5. Weder, W., Editorial comment: Extended pulmonary resections of advanced thoracic malignancies with support of cardio-pulmonary bypass — is surgery justified? European Journal of Cardio-Thoracic Surgery, April 2006. 29 (4): p. 577–578. Kao, C.N., et al., Salvage surgery using simultaneous clamshell thoracotomy with median sternotomy for mediastinal growing teratoma syndrome. Thorac Cancer, 2020. 11 (3): p. 785-788. Menager, J.B., et al., Outcomes of extended resection for locally advanced thymic malignancies. Respir Med Res, 2023. 83 : p. 101009. Yokoi, K., et al., Surgical management of locally advanced lung cancer. Gen Thorac Cardiovasc Surg, 2014. 62 (9): p. 522-30. Chambers, A., et al., Does surgery have a role in T4N0 and T4N1 lung cancer? Interact Cardiovasc Thorac Surg, 2010. 11 (4): p. 473-9. Goldstraw, P., et al., The IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer. J Thorac Oncol, 2016. 11 (1): p. 39-51. Tosi, D., et al., Outcomes of extended surgical resections for locally advanced thymic malignancies: a narrative review. Gland Surg, 2022. 11 (3): p. 611-621. Marulli, G., et al., Surgical treatment of stage III thymic tumors: a multi-institutional review from four Italian centers. Eur J Cardiothorac Surg, 2011. 39 (3): p. e1-7. Moser, B., et al., Surgical therapy of thymic tumours with pleural involvement: an ESTS Thymic Working Group Project. Eur J Cardiothorac Surg, 2017. 52 (2): p. 346-355. Luo, D.X., et al., Primary mediastinal sarcoma: surgical outcomes of 21 cases. Interact Cardiovasc Thorac Surg, 2013. 17 (6): p. 982-6. Zhang, Z., et al., Surgical management of primary mediastinal mature teratoma: A single-center 20 years' experience. Front Surg, 2022. 9 : p. 902985. Huang, C., et al., Surgical treatment of intermediate to high grade thymic neuroendocrine neoplasms: case series of five patients and literature review. Transl Cancer Res, 2022. 11 (10): p. 3535-3547. Zamora, A.K., et al., The Effect of Gross Total Resection on Patients with Pleuropulmonary Blastoma. J Surg Res, 2020. 253 : p. 115-120. Eto, R., et al., Surgical resection of undifferentiated pleomorphic sarcoma (UPS) with jejunal perforation, a suspected case of metastasis of lung cancer. Clin J Gastroenterol, 2021. 14 (5): p. 1386-1391. Altieri, B., et al., Recurrence-Free Survival in Early and Locally Advanced Large Cell Neuroendocrine Carcinoma of the Lung after Complete Tumor Resection. J Pers Med, 2023. 13 (2). Yang, T., et al., An invasive thymoma extending into the superior vena cava and right atrium. Ann Transl Med, 2019. 7 (18): p. 498. Dong, Y.Q., et al., Surgical treatment of an invasive thymoma extending into the superior vena cava and right atrium. World J Surg Oncol, 2014. 12 : p. 6. Kono, T., et al., Successful resection of cardiac metastatic liposarcoma extending into the SVC, right atrium, and right ventricle. J Card Surg, 2005. 20 (4): p. 364-5. Akchurin, R.S., et al., Cardiopulmonary bypass and cell-saver technique in combined oncologic and cardiovascular surgery. Artif Organs, 1997. 21 (7): p. 763-5. Mork, C., et al., Prolonged cardiopulmonary bypass time as predictive factor for bloodstream infection. Heliyon, 2023. 9 (6): p. e17310. Salis, S., et al., Cardiopulmonary bypass duration is an independent predictor of morbidity and mortality after cardiac surgery. J Cardiothorac Vasc Anesth, 2008. 22 (6): p. 814-22. Byrne, J.G., et al., The use of cardiopulmonary bypass during resection of locally advanced thoracic malignancies: a 10-year two-center experience. Chest, 2004. 125 (4): p. 1581-6. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Oct, 2024 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 19 Jul, 2024 Reviews received at journal 17 Jul, 2024 Reviewers agreed at journal 11 Jul, 2024 Reviews received at journal 14 Jun, 2024 Reviewers agreed at journal 13 Jun, 2024 Reviewers agreed at journal 12 Jun, 2024 Reviewers invited by journal 12 Jun, 2024 Editor invited by journal 12 Jun, 2024 Editor assigned by journal 10 Jun, 2024 Submission checks completed at journal 10 Jun, 2024 First submitted to journal 04 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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University","correspondingAuthor":false,"prefix":"","firstName":"Hung-Hsing","middleName":"","lastName":"Chiang","suffix":""},{"id":317258832,"identity":"2f597df0-475b-4560-98d0-8e4cbac9490c","order_by":5,"name":"Jui-Ying Lee","email":"","orcid":"","institution":"Kaohsiung Medical University Hospital, Kaohsiung Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jui-Ying","middleName":"","lastName":"Lee","suffix":""},{"id":317258833,"identity":"4adf9a12-4b15-4b74-a120-ab8b366a75d7","order_by":6,"name":"Hsien-Pin Li","email":"","orcid":"","institution":"Kaohsiung Medical University Hospital, Kaohsiung Medical University","correspondingAuthor":false,"prefix":"","firstName":"Hsien-Pin","middleName":"","lastName":"Li","suffix":""},{"id":317258835,"identity":"7dbddb5e-c4ab-472d-a916-f4e453b92b88","order_by":7,"name":"Po-Chih Chang","email":"","orcid":"","institution":"Kaohsiung Medical University Hospital, Kaohsiung Medical University","correspondingAuthor":false,"prefix":"","firstName":"Po-Chih","middleName":"","lastName":"Chang","suffix":""},{"id":317258841,"identity":"31a78451-5c63-4759-8056-0577f7889407","order_by":8,"name":"Shah-Hwa Chou","email":"","orcid":"","institution":"Kaohsiung Medical University Hospital, Kaohsiung Medical University","correspondingAuthor":false,"prefix":"","firstName":"Shah-Hwa","middleName":"","lastName":"Chou","suffix":""}],"badges":[],"createdAt":"2024-06-04 10:25:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4527263/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4527263/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-024-02632-8","type":"published","date":"2024-10-26T15:58:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59434336,"identity":"bd351826-3e1c-4a27-ab68-2ffe663a6581","added_by":"auto","created_at":"2024-07-01 18:59:58","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":578521,"visible":true,"origin":"","legend":"\u003cp\u003eEnrollment of patients with locally advanced thoracic cancers undergoing extended resection via CPB support.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCPB: cardiopulmonary bypass\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4527263/v1/57eafebf5bea7288122b4faa.jpg"},{"id":59434338,"identity":"4c813c29-0bcb-4d6f-a516-eef3fdda6ab1","added_by":"auto","created_at":"2024-07-01 18:59:59","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":865558,"visible":true,"origin":"","legend":"\u003cp\u003eOperative pictures of the representative patients 3# and 6#\u003c/p\u003e\n\u003cp\u003e(A) Delayed healing of postoperative wound in patient 3#. (B) Intraoperative view following salvage surgery using clamshell thoracotomy plus median sternotomy approach. (C) Resected specimen after the en bloc tumor resection plus right pneumonectomy. (D) Prosthetic reconstruction of the SVC and left innominate vein after radical resection in patient 6#. (E) Resected specimen showing intraluminal tumor invasion of SVC (arrow).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSVC: superior vena cava\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4527263/v1/ba026a8723e47d00522afe3b.jpg"},{"id":59434337,"identity":"b36bd9b1-0061-4633-aa17-5fef2e8fc89b","added_by":"auto","created_at":"2024-07-01 18:59:58","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":848182,"visible":true,"origin":"","legend":"\u003cp\u003eOperative pictures of the representative patient 8#.\u003c/p\u003e\n\u003cp\u003e(A) Pretreatment CT scan demonstrating bulky mediastinal thymoma invading the cardiovascular structure. (B) Preoperative CT scan showing marked shrinkage of tumor after induction chemoradiotherapy. (C) Prosthetic reconstruction of the SVC, right atrium, and proximal ascending aorta after radical resection. (D), (E) and (F) Resected specimen with gross appearance of necrotic content which confirmed pathological complete response.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003enCRT: neoadjuvant chemoradiotherapy, pCR: pathological complete response, CT: computed tomography\u003c/em\u003e, \u003cem\u003eSVC: superior vena cava\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4527263/v1/1b26033f3a60c95103ea4172.jpg"},{"id":59434994,"identity":"ba983d2d-a2d0-4ca3-b617-f08037ae2913","added_by":"auto","created_at":"2024-07-01 19:07:59","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":189695,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier analysis of recurrence-free survival (RFS) and overall survival (OS) of included patients.\u003c/p\u003e","description":"","filename":"Figure4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4527263/v1/8b62aba729be9eb988faaabb.jpg"},{"id":67682009,"identity":"b93f4a8e-21aa-4832-b004-8fdacc9c022b","added_by":"auto","created_at":"2024-10-28 16:12:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3178789,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4527263/v1/507b6c82-a884-4232-b6da-1fc48d62c017.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is Extended Resection for Locally Advanced Thoracic Cancer with Cardiopulmonary Bypass Justified?","fulltext":[{"header":"Background","content":"\u003cp\u003eSurgical resection plays a crucial role in the treatment of patients with advanced thoracic malignant tumors with invasion of adjacent thoracic structures and may offer a chance for cure. However, such surgeries remain challenging even for experienced surgeons. Though controversial, cardiopulmonary bypass (CPB) can be used to allow resection and reconstruction of the great vessels and/or cardiac structures and, subsequently, complete extended resection of the tumor [\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Radical resection of tumors has been shown to significantly improve the survival in select patients [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Even as the potential advantage and efficacy of CPB has been recognized, the underuse of CPB reflects the concerns of significant complications; including excessive bleeding secondary to full heparinization, increased pulmonary complications, and fears of CPB-related tumor dissemination [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus far, little is known about the true pros and cons of CPB use in locally advanced thoracic malignancies. Over the last decades, only a few case series describing the technical possibilities in extended radical resections, the associated morbimortalities, as well as the postoperative long-term survival outcomes have been published [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Hence, the underlying benefit of CPB in aiding complete extended resection merits further investigation. Consequently, the present study aims to review our surgical experience of treating such advanced intrathoracic tumors using CPB and the perioperative and survival outcomes. Further, the rationale of using CPB in complete extended resection among such complex surgical procedures will be discussed with a compendious review of current relevant literature.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis study is a single institutional case series conducted between January 2015 and December 2020, focusing on patients with primary thoracic cancers. We assessed the role of CPB in facilitating complete resection of tumors with highly suspected neighboring cardiovascular invasion, as identified by preoperative thoracic computed tomographic (CT) scans. The study protocol adhered to ethical guidelines and was approved by the institutional review board (KMUHIRB-E(II)-20230169).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePatient selection\u003c/h2\u003e \u003cp\u003ePatient inclusion algorithm is presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. A total of 10 patients with primary thoracic cancers highly suspected neighboring cardiovascular invasion based on CT scans were initially included in the study. Surgical indication and resection was principally performed with a curative intent and based on consensus reached by a multidisciplinary team including thoracic surgeons, cardiovascular surgeons, oncologists, and radiologists. Preoperative assessment was used to exclude patients with distant metastasis and advanced mediastinal lymph node disease. Two patients (mediastinal liposarcoma and thoracic rhabdomyosarcoma) were excluded because surgery was able to be completed without the need for CPB (these patients\u0026rsquo; femoral artery and vein were catheterized in preparation for CPB). Regarding the intention of surgery, the remaining eight patients can be divided into elective and salvage surgeries. Patients undergoing elective surgery usually had good performance status with a well-organized perioperative therapeutic strategy, while patients receiving salvage surgery often exhibited inferior physical status and resection was determined when no alternative nonoperative therapy was available and based on the individual condition of each patient.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurgical techniques\u003c/h2\u003e \u003cp\u003eAll eight patients, comprising 3 with primary lung cancers and 5 with mediastinal cancers, underwent complete resection with the assistance of CPB. The operation was approached through median sternotomy with or without lateral thoracotomy extension (n\u0026thinsp;=\u0026thinsp;7) or postero-lateral thoracotomy (n\u0026thinsp;=\u0026thinsp;1). CPB was employed via ascending aorta and right atrial or bicaval cannulation, following full heparinization. Once CPB was initiated, the aorta was cross-clamped and the heart arrested with the aid of cold blood cardioplegia. Extended tumor resection and surgical reconstruction of the cardiovascular structure involved was then performed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). Pulmonary extension of tumors required pneumonectomy in 4 patients, and bilobectomy, lobectomy, and wedge resection in the remaining 3 cases respectively. In the majority of patients, several cardiovascular and mediastinal structures were affected simultaneously. Therefore, resection involving superior vena cava (SVC) was performed in 4 patients, the right atrium (RA) in 1 patient, the SVC and the RA in 2 patients, and the SVC with the root of main pulmonary artery, and the ascending aorta in 1 patient.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize patient demographics, tumor characteristics, perioperative variables, and outcomes. Categorical variables were expressed as numbers with percentages and compared by the Chi-square test. Non-normally distributed data were described by medians with interquartile range (IQR) and were analyzed using Mann-Whitney U test. The latest follow-up endpoint for data collection was December 31, 2023. Recurrence-free survival (RFS) was defined as the time interval between surgery and the occurrence of tumor recurrence or the last follow-up date. Overall survival (OS) was defined as the time interval between surgery and death from any cause or the last follow-up date. Kaplan-Meier survival curves were generated to assess RFS and OS. A statistical significance was set at a \u003cem\u003ep\u003c/em\u003e-value less than 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient demographics\u003c/h2\u003e \u003cp\u003eClinical demographics of case details are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In total, eight patients underwent extended resection of locally advanced thoracic cancers with CPB; including 3 salvage surgeries and 5 elective surgeries. Six patients were male with an age range of 7 to 73 years old with a mean of 52 years. Pathological diagnosis of the 5 mediastinal cancers were mediastinal sarcoma, mediastinal germ cell tumor, mediastinal large cell neuroendocrine cancer, thymic carcinoma, and thymoma; 3 lung cancers including pulmonary blastoma, pleomorphic lung cancer, large cell neuroendocrine lung cancer. The representative patient #3 underwent salvage surgery using clamshell thoracotomy plus median sternotomy for en-bloc resection of giant mediastinal germ cell tumor (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC), who required right pneumonectomy, partial SVC resection, pericardial resection and reconstruction [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Another representative patient #6 underwent elective surgery via median sternotomy for en-bloc resection of mediastinal large cell neuroendocrine carcinoma, who required bilobectomy, entire SVC resection, partial LA resection and reconstruction (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eD and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographics and perioperative outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient (intention of surgery)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePathology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eECOG\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eASA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLung resection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCVS resection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOP\u003c/p\u003e \u003cp\u003eTime\u003csup\u003eb\u003c/sup\u003e (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eBlood loss\u003csup\u003ec\u003c/sup\u003e (mL)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eICU day\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eHospital day\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1# (elective)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePulmonary blastoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePneumonectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2# (salvage)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMediastinal sarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePneumonectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3# (salvage)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMediastinal teratoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePneumonectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1750\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4# (elective)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePleomorphic lung cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5# (salvage)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLarge cell neuroendocrine\u003c/p\u003e \u003cp\u003elung cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePneumonectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSVC, LA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e570\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6# (elective)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMediastinal large cell neuroendocrine cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBilobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSVC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1850\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7# (elective)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThymic carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWedge resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLBV, MPA, Aorta\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e650\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8# (elective)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThymoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSVC, RA, Aorta\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e660\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e650\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003eECOG: Eastern Cooperative Oncology Group; ASA: American Society of Anesthesiologists; CVS: cardiovascular structure; OP: operation; ICU: intensive care unit; min: minute; mL: milliliter; F: female; M: male; SVC: superior vena cava; LA: left atrium; LBV: left brachiocephalic vein; MPA: main pulmonary artery; RA: right atrium. Values are expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SD).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003e\u003csup\u003ea\u003c/sup\u003e Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, 46.4\u0026thinsp;\u0026plusmn;\u0026thinsp;24.3 years.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003e\u003csup\u003eb\u003c/sup\u003e Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, 521\u0026thinsp;\u0026plusmn;\u0026thinsp;114 mins.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003e\u003csup\u003ec\u003c/sup\u003e Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, 1,568\u0026thinsp;\u0026plusmn;\u0026thinsp;1,153 mL.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003e\u003csup\u003ed\u003c/sup\u003e Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, 10.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6 days.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"13\"\u003e\u003csup\u003ee\u003c/sup\u003e Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, 18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7 days.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePerioperative and postoperative outcomes\u003c/h2\u003e \u003cp\u003ePerioperative and postoperative outcomes are summarized in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Postoperative complications were graded using the Clavien-Dindo classification, 2 out of 5 patients with elective surgery had no postoperative complications. 4 patients had grade II-III complications, including arrhythmia, sternal wound dehiscence, vocal cord palsy, vascular graft thrombosis (subsequently treated with endovascular intervention\u0026thinsp;+\u0026thinsp;thrombolytic therapy). The aforementioned complications were all managed successfully and the patients returned to monitoring in the clinic setting. Two patients presented with grade V complications (in-hospital mortality) due to respiratory insufficiency; both patients received salvage surgeries. Notably, patient #8 underwent elective surgery following neoadjuvant chemoradiotherapy, which achieved pathological complete response (pCR) after resection (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In the long term, 4 patients presented with recurrence-free survival 35, 36, 49, and 107 months after operations, and one survived with recurrence 30 months postoperatively. One patient died with recurrence 25 months postoperatively. The mean recurrence free survival (RFS) was 43\u0026thinsp;\u0026plusmn;\u0026thinsp;17 months and the mean overall survival (OS) was 58\u0026thinsp;\u0026plusmn;\u0026thinsp;17 months. The Kaplan-Meier plot of RFS and OS are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePathological and postoperative outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePathological tumor stage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplication (grade)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResection margin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRFS\u003csup\u003ea\u003c/sup\u003e (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOS\u003csup\u003eb\u003c/sup\u003e (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNeoadjuvant Tx\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePostoperative adjuvant Tx\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLung blastoma, pT4NxM0, stage IIIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e107 (alive)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMediastinal sarcoma, pT4N0M0, stage III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMortality, grade 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.8 (death)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMediastinal teratoma, ypT1aN0M0, stage I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWound dehiscence, grade 3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25 (death)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eChemotherapy\u0026thinsp;+\u0026thinsp;radiotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePleomorphic lung cancer, pT4N0M0, stage IIIA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e30 (lost follow-up)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003echemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLarge cell neuroendocrine lung cancer, pT4N2M0, stage IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMortality, grade 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.4 (death)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMediastinal large cell neuroendocrine cancer, pT3N0M0, stage III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGraft thrombosis, grade 3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49 (alive)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003echemotherapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThymic cancer, ypT3N0M0, stage III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVocal cord palsy,\u003c/p\u003e \u003cp\u003eGraft thrombosis, grade 3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e36 (alive)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003echemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThymoma, ypT0N0M0, pCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCardiac arrythmia required pacemaker implantation, grade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35 (alive)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eChemotherapy\u0026thinsp;+\u0026thinsp;radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eRFS: resurrence-free survival; OS: overall survival; Tx: therapy. Values are expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations (SD).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003csup\u003ea\u003c/sup\u003e Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, 43\u0026thinsp;\u0026plusmn;\u0026thinsp;17 months.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003csup\u003eb\u003c/sup\u003e Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, 58\u0026thinsp;\u0026plusmn;\u0026thinsp;17 months.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eComparison between patients, who underwent salvage and elective surgery with CPB is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. 5 patients received elective surgery and exhibited a significantly lower Eastern Cooperative Oncology Group (ECOG) scale (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and blood loss (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.04). Though statistically insignificant, patients who received elective surgery versus salvage surgery presented with numerically shorter operative times (480 vs 570 min, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.88), a higher number of R0 resections (5 vs 1, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.11), shorter intensive care unit (ICU) stays (7 vs 12 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.29), and shorter postoperative hospital stays (16 vs 24 days, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.54)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison between patients undergoing salvage and elective surgery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSalvage surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eElective surgery\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep value\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (year) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 [18\u0026ndash;73]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49 [7\u0026ndash;73]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eECOG scale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA grade\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (mins)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e570 [400\u0026ndash;600]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e480 [360\u0026ndash;660]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (mL) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3000 [1750\u0026ndash;3400]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e700 [200\u0026ndash;1850]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.04\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical margin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0 resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR1 resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtent of pulmonary resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWedge resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU stay (day)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 [\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16 CR17\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospital stay (day)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16 CR17 CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25 CR26\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 [9\u0026ndash;34]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 3a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade 5 (mortality)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eECOG: Eastern Cooperative Oncology Group; ASA: American Society of Anesthesiology; ICU: intensive care unit; mins: minutes; mL: milliliter. \u003csup\u003ea\u003c/sup\u003e Values are expressed as median with [interquartile range].\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe surgical management of locally advanced thoracic cancer presents considerable challenges due to the proximity of vital structures such as the heart and major blood vessels. In the present series, we shared our experience and outcomes of extended resection procedures for both locally advanced lung and mediastinal cancer with the assistance of CPB. The present study demonstrates that patients with a better preoperative ECOG performance status undergoing elective surgery with CPB are more likely to have R0 resection, shorter operative times, lesser blood loss. In contrast, CPB use under salvage surgery was associated with higher morbimortality. Our findings emphasize the importance of discrete preoperative patient selection and surgical approaches with CPB.\u003c/p\u003e \u003cp\u003eComplete surgical resection remains the primary factor contributing to the survival in patients undergoing resection under CPB [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. For non-small cell lung cancer (NSCLC), stages up to pathology-proven T\u003csub\u003e4\u003c/sub\u003eN\u003csub\u003e0\u0026thinsp;\u0026minus;\u0026thinsp;1\u003c/sub\u003e may be acceptable for curative surgical resection [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. For thymic malignancies, radical resection is considered part of the multimodal treatment in patients of stage III and even stage IVa with pleural spread [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This treatment principles is also applicable to other rare types of locally advanced thoracic cancers, including mediastinal sarcoma [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], mediastinal teratoma [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], mediastinal large cell neuroendocrine cancer [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], pulmonary blastoma [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], pleomorphic lung cancer [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], and large cell neuroendocrine lung cancer [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], which were all also reported in our series. Regardless of the tumor histology, the extent of invasion of adjacent anatomical structures is the key determinant of surgical difficulty. CPB use to achieve en bloc resection has been successfully reported in tumors invading the SVC and RA with acceptable perioperative morbidity and mortality rates [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. CPB was utilized in our 8 patients with locally advanced thoracic tumors involving the SVC, atrium, main pulmonary artery, and ascending aorta. This highlighted the versatility of CPB in facilitating complete tumor resection in anatomically challenging cases. Nevertheless, limited studies and the lack of consensus complicate the debate on the setting of obtaining extended resection for locally advanced lung and mediastinal cancers under CPB.\u003c/p\u003e \u003cp\u003eProponents of CPB emphasize its role in enabling complete tumor resection and achieving negative surgical margins, which are crucial factors associated with improved long-term oncological outcomes. For example, a retrospective study by Ried et al. demonstrated that CPB-assisted extended resections for locally advanced thymic malignancies resulted in favorable survival outcomes, with a high rate of R0/R1 resection achieved [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Similarly, a systematic review by Muralidaran et al. concluded that CPB use was associated with improved overall survival and disease-free survival in patients undergoing extended resections for advanced lung cancer involving the mediastinum or great vessels [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, Langer et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and Filippou et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] supported that there is no inferiority in postoperative outcomes in CPB group compared with non-CPB group. However, CPB raise valid concerns regarding its associated risks and complications, including systemic inflammatory response, coagulopathy, end-organ dysfunction, and modest relationship with cancer progression [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In fact, controversy does exist in literature concerning the application of CPB for oncological interventions. No increase of distant metastases and tumor recurrence has been observed in systematic review by Muralidaran et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In contrast, some authors hypothesize that increased intraoperative tumor cell dissemination promoted by the extracorporeal circulation could have been responsible for early relapse, as previously reported by other authors [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In a recent large case series, none of patients undergoing cardiac reconstruction with CPB support showed locoregional recurrence or distant metastasis within 6 months of the operation, thus, the authors concluded that evidence could not confirm the hypothesis of increased rate of early recurrence for tumors resected under CPB [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCPB itself is deemed to be a significant predictor of postoperative morbidity and mortality, particularly in cases involving extensive resections and prolonged CPB times [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Considering the high-risk nature of such procedures, perioperative mortality ranging from 7\u0026ndash;15% had been reported [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The mortality rate in our series is relatively high (2/8, 25%), though both patients received salvage surgery. All the patients in the elective surgery group achieved at least 12 months of recurrence-free survival without lethal perioperative complications. These findings are consistent with the survival date found in literature [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, Byrne et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] reported 43% of all CPB procedures to be performed for emergency situations. These data underlies the importance of CPB availability when surgery for advanced thoracic malignancies is being considered. Wiebe et al. also advised that pneumonectomy is associated with life-threatening complications [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThough patient selection criteria for CPB-assisted extended resections is crucial for favorable outcomes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], the criteria remain unclear, leading to variability in practice patterns and institutional preferences. Current literature indicates decisions to operate are situational due to the variability of the disease entity, surgical capabilities, and high surgical risk. While CPB may be justified in cases where complete tumor resection cannot be achieved with conventional techniques, the decision to utilize CPB requires detailed multidisciplinary preoperative evaluation, including individual patient factors, tumor characteristics, and institutional expertise. This is echoed by our experience preferring that CPB application in elective surgery group in the present series exhibited a better prognosis.\u003c/p\u003e \u003cp\u003eIt is important to acknowledge the limitations of our study, including its retrospective nature and relatively small sample size, which inherently limits firm statistical assessment. However, our data supports the feasibility of radical resection with CPB support for thoracic malignancies invading cardiovascular structures. Furthermore, the incidence of postoperative complications, including arrhythmias, pneumonia, and transient SVC syndrome, highlights the importance of close perioperative monitoring and management in optimizing patient outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, while CPB can be considered a valuable surgical tool for locally advanced thoracic cancers, through patient selection, including lower ECOG scale and elective surgery, is necessary for CPB to confer its benefit. Future studies are warranted to validate our findings and to further elucidate the long-term survival benefits of CPB-assisted extended resection procedures in this patient population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCPB, Cardiopulmonary bypass\u003cstrong\u003e;\u0026nbsp;\u003c/strong\u003eSVC, Superior vena cava; RA, Right atrium\u003cstrong\u003e;\u0026nbsp;\u003c/strong\u003eCT,\u0026nbsp;Computed tomographic;\u0026nbsp;IQR, Interquartile range; RFS,\u0026nbsp;Recurrence-free survival\u003cstrong\u003e;\u0026nbsp;\u003c/strong\u003eOS, Overall survival; pCR, Pathological complete response; ECOG, Eastern Cooperative Oncology Group; ICU, Intensive care unit; NSCLC, Non-small cell lung cancer.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study complies with the standards of the Declaration of Helsinki and current ethical guidelines.\u0026nbsp;The study protocol adhered to ethical guidelines and was approved by the institutional review board (KMUHIRB-E(II)-20230169).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from individual participant included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of their clinical details and clinical images were obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization, Y-W Liu; methodology, validation, formal analysis, and investigation, J-W Huang, H-H Chiang, J-Y Lee, H-P Li, P-C Chang, and S-H Chou; writing\u0026mdash;original draft preparation and writing\u0026mdash;review and editing, J. Hsu, P-R Chou, and Y-W Liu; visualization, Y-W Liu; supervision, Y-W Liu. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLanger, N.B., et al., \u003cem\u003eOutcomes After Resection of T4 Non-Small Cell Lung Cancer Using Cardiopulmonary Bypass.\u003c/em\u003e Ann Thorac Surg, 2016. \u003cstrong\u003e102\u003c/strong\u003e(3): p. 902-910.\u003c/li\u003e\n\u003cli\u003eRied, M., et al., \u003cem\u003eRadical surgical resection of advanced thymoma and thymic carcinoma infiltrating the heart or great vessels with cardiopulmonary bypass support.\u003c/em\u003e J Cardiothorac Surg, 2015. \u003cstrong\u003e10\u003c/strong\u003e: p. 137.\u003c/li\u003e\n\u003cli\u003eMuralidaran, A., et al., \u003cem\u003eLong-term survival after lung resection for non-small cell lung cancer with circulatory bypass: a systematic review.\u003c/em\u003e J Thorac Cardiovasc Surg, 2011. \u003cstrong\u003e142\u003c/strong\u003e(5): p. 1137-42.\u003c/li\u003e\n\u003cli\u003eDe Giacomo, T., et al., \u003cem\u003eSuccessful resection of thymoma directly invading the right atrium under cardiopulmonary bypass.\u003c/em\u003e Eur J Cardiothorac Surg, 2015. \u003cstrong\u003e48\u003c/strong\u003e(2): p. 332-3.\u003c/li\u003e\n\u003cli\u003eFilippou, D., et al., \u003cem\u003eExtended resections for the treatment of patients with T4 stage IIIA non-small cell lung cancer (NSCLC) (T(4)N(0-1)M(0)) with or without cardiopulmonary bypass: a 15-year two-center experience.\u003c/em\u003e J Thorac Dis, 2019. \u003cstrong\u003e11\u003c/strong\u003e(12): p. 5489-5501.\u003c/li\u003e\n\u003cli\u003eWiebe, K., et al., \u003cem\u003eExtended pulmonary resections of advanced thoracic malignancies with support of cardiopulmonary bypass.\u003c/em\u003e Eur J Cardiothorac Surg, 2006. \u003cstrong\u003e29\u003c/strong\u003e(4): p. 571-7; discussion 577-8.\u003c/li\u003e\n\u003cli\u003eChen, L., et al., \u003cem\u003eCardiopulmonary bypass does not consequentially contribute to postoperative distant metastasis of giant refractory thoracic tumors: A retrospective study with long-term follow-up.\u003c/em\u003e Thorac Cancer, 2021. \u003cstrong\u003e12\u003c/strong\u003e(22): p. 2990-2995.\u003c/li\u003e\n\u003cli\u003eD\u0026apos;Andrilli, A., et al., \u003cem\u003eReconstruction of the heart and the aorta for radical resection of lung cancer.\u003c/em\u003e J Thorac Cardiovasc Surg, 2024. \u003cstrong\u003e167\u003c/strong\u003e(4): p. 1481-1489.\u003c/li\u003e\n\u003cli\u003ePinto, C.A., et al., \u003cem\u003eCardiopulmonary bypass has a modest association with cancer progression: a retrospective cohort study.\u003c/em\u003e BMC Cancer, 2013. \u003cstrong\u003e13\u003c/strong\u003e: p. 519.\u003c/li\u003e\n\u003cli\u003eMei, J., et al., \u003cem\u003eReconstruction of the pulmonary trunk via cardiopulmonary bypass in extended resection of locally advanced lung malignancies.\u003c/em\u003e J Surg Oncol, 2012. \u003cstrong\u003e106\u003c/strong\u003e(3): p. 311-5.\u003c/li\u003e\n\u003cli\u003eWeder, W., \u003cem\u003eEditorial comment: Extended pulmonary resections of advanced thoracic malignancies with support of cardio-pulmonary bypass \u0026mdash; is surgery justified?\u003c/em\u003e European Journal of Cardio-Thoracic Surgery, April 2006. \u003cstrong\u003e29\u003c/strong\u003e(4): p. 577\u0026ndash;578.\u003c/li\u003e\n\u003cli\u003eKao, C.N., et al., \u003cem\u003eSalvage surgery using simultaneous clamshell thoracotomy with median sternotomy for mediastinal growing teratoma syndrome.\u003c/em\u003e Thorac Cancer, 2020. \u003cstrong\u003e11\u003c/strong\u003e(3): p. 785-788.\u003c/li\u003e\n\u003cli\u003eMenager, J.B., et al., \u003cem\u003eOutcomes of extended resection for locally advanced thymic malignancies.\u003c/em\u003e Respir Med Res, 2023. \u003cstrong\u003e83\u003c/strong\u003e: p. 101009.\u003c/li\u003e\n\u003cli\u003eYokoi, K., et al., \u003cem\u003eSurgical management of locally advanced lung cancer.\u003c/em\u003e Gen Thorac Cardiovasc Surg, 2014. \u003cstrong\u003e62\u003c/strong\u003e(9): p. 522-30.\u003c/li\u003e\n\u003cli\u003eChambers, A., et al., \u003cem\u003eDoes surgery have a role in T4N0 and T4N1 lung cancer?\u003c/em\u003e Interact Cardiovasc Thorac Surg, 2010. \u003cstrong\u003e11\u003c/strong\u003e(4): p. 473-9.\u003c/li\u003e\n\u003cli\u003eGoldstraw, P., et al., \u003cem\u003eThe IASLC Lung Cancer Staging Project: Proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer.\u003c/em\u003e J Thorac Oncol, 2016. \u003cstrong\u003e11\u003c/strong\u003e(1): p. 39-51.\u003c/li\u003e\n\u003cli\u003eTosi, D., et al., \u003cem\u003eOutcomes of extended surgical resections for locally advanced thymic malignancies: a narrative review.\u003c/em\u003e Gland Surg, 2022. \u003cstrong\u003e11\u003c/strong\u003e(3): p. 611-621.\u003c/li\u003e\n\u003cli\u003eMarulli, G., et al., \u003cem\u003eSurgical treatment of stage III thymic tumors: a multi-institutional review from four Italian centers.\u003c/em\u003e Eur J Cardiothorac Surg, 2011. \u003cstrong\u003e39\u003c/strong\u003e(3): p. e1-7.\u003c/li\u003e\n\u003cli\u003eMoser, B., et al., \u003cem\u003eSurgical therapy of thymic tumours with pleural involvement: an ESTS Thymic Working Group Project.\u003c/em\u003e Eur J Cardiothorac Surg, 2017. \u003cstrong\u003e52\u003c/strong\u003e(2): p. 346-355.\u003c/li\u003e\n\u003cli\u003eLuo, D.X., et al., \u003cem\u003ePrimary mediastinal sarcoma: surgical outcomes of 21 cases.\u003c/em\u003e Interact Cardiovasc Thorac Surg, 2013. \u003cstrong\u003e17\u003c/strong\u003e(6): p. 982-6.\u003c/li\u003e\n\u003cli\u003eZhang, Z., et al., \u003cem\u003eSurgical management of primary mediastinal mature teratoma: A single-center 20 years\u0026apos; experience.\u003c/em\u003e Front Surg, 2022. \u003cstrong\u003e9\u003c/strong\u003e: p. 902985.\u003c/li\u003e\n\u003cli\u003eHuang, C., et al., \u003cem\u003eSurgical treatment of intermediate to high grade thymic neuroendocrine neoplasms: case series of five patients and literature review.\u003c/em\u003e Transl Cancer Res, 2022. \u003cstrong\u003e11\u003c/strong\u003e(10): p. 3535-3547.\u003c/li\u003e\n\u003cli\u003eZamora, A.K., et al., \u003cem\u003eThe Effect of Gross Total Resection on Patients with Pleuropulmonary Blastoma.\u003c/em\u003e J Surg Res, 2020. \u003cstrong\u003e253\u003c/strong\u003e: p. 115-120.\u003c/li\u003e\n\u003cli\u003eEto, R., et al., \u003cem\u003eSurgical resection of undifferentiated pleomorphic sarcoma (UPS) with jejunal perforation, a suspected case of metastasis of lung cancer.\u003c/em\u003e Clin J Gastroenterol, 2021. \u003cstrong\u003e14\u003c/strong\u003e(5): p. 1386-1391.\u003c/li\u003e\n\u003cli\u003eAltieri, B., et al., \u003cem\u003eRecurrence-Free Survival in Early and Locally Advanced Large Cell Neuroendocrine Carcinoma of the Lung after Complete Tumor Resection.\u003c/em\u003e J Pers Med, 2023. \u003cstrong\u003e13\u003c/strong\u003e(2).\u003c/li\u003e\n\u003cli\u003eYang, T., et al., \u003cem\u003eAn invasive thymoma extending into the superior vena cava and right atrium.\u003c/em\u003e Ann Transl Med, 2019. \u003cstrong\u003e7\u003c/strong\u003e(18): p. 498.\u003c/li\u003e\n\u003cli\u003eDong, Y.Q., et al., \u003cem\u003eSurgical treatment of an invasive thymoma extending into the superior vena cava and right atrium.\u003c/em\u003e World J Surg Oncol, 2014. \u003cstrong\u003e12\u003c/strong\u003e: p. 6.\u003c/li\u003e\n\u003cli\u003eKono, T., et al., \u003cem\u003eSuccessful resection of cardiac metastatic liposarcoma extending into the SVC, right atrium, and right ventricle.\u003c/em\u003e J Card Surg, 2005. \u003cstrong\u003e20\u003c/strong\u003e(4): p. 364-5.\u003c/li\u003e\n\u003cli\u003eAkchurin, R.S., et al., \u003cem\u003eCardiopulmonary bypass and cell-saver technique in combined oncologic and cardiovascular surgery.\u003c/em\u003e Artif Organs, 1997. \u003cstrong\u003e21\u003c/strong\u003e(7): p. 763-5.\u003c/li\u003e\n\u003cli\u003eMork, C., et al., \u003cem\u003eProlonged cardiopulmonary bypass time as predictive factor for bloodstream infection.\u003c/em\u003e Heliyon, 2023. \u003cstrong\u003e9\u003c/strong\u003e(6): p. e17310.\u003c/li\u003e\n\u003cli\u003eSalis, S., et al., \u003cem\u003eCardiopulmonary bypass duration is an independent predictor of morbidity and mortality after cardiac surgery.\u003c/em\u003e J Cardiothorac Vasc Anesth, 2008. \u003cstrong\u003e22\u003c/strong\u003e(6): p. 814-22.\u003c/li\u003e\n\u003cli\u003eByrne, J.G., et al., \u003cem\u003eThe use of cardiopulmonary bypass during resection of locally advanced thoracic malignancies: a 10-year two-center experience.\u003c/em\u003e Chest, 2004. \u003cstrong\u003e125\u003c/strong\u003e(4): p. 1581-6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cardiopulmonary bypass (CPB), extended resection, locally advanced thoracic cancer","lastPublishedDoi":"10.21203/rs.3.rs-4527263/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4527263/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Resection of intrathoracic tumor with cardiopulmonary bypass (CPB) remains a relatively under-reported intervention in literature, and its role in managing locally advanced mediastinal and lung cancers is a topic of ongoing debate. Our aim was to review our experience and assess the role of CPB for treatinglocally advanced mediastinal and lung cancers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eBetween 2015 and 2020, this study initially included 10 patients with primary locally advanced thoracic malignancies with apparent adjacent cardiovascular invasion demonstrated by thoracic imaging scans. Operation was performed based on a multidisciplinary tumor board consensus. Eventually, 8 patients (3 primary lung cancers and 5 mediastinal cancers) received either salvage or elective resection with CPB; two completed surgery without requiring CPB.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eRegarding the extent of adjacent structure involvement, 4 patients presented with involvement of the superior vena cava (SVC), 1 involved the right atrium (RA), 2 involved the SVC and RA, and 1 involved the SVC, the origin of main pulmonary artery, and the ascending aorta. Thirty-day mortality occurred in two of three patients receiving salvage surgery due to respiratory insufficiency. With the long-term follow-up, one patient died of recurrence 25 months postoperatively, one survived with recurrence 30 months postoperatively, and four were alive without recurrence for 35, 36, 49, and 107months after operations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eIn certain patients, particularly for elective surgical candidates rather than salvage resection, CPB allows for extended resection of locally advanced thoracic cancerswith acceptable perioperative safety and survival.\u003c/p\u003e","manuscriptTitle":"Is Extended Resection for Locally Advanced Thoracic Cancer with Cardiopulmonary Bypass Justified?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-01 18:59:54","doi":"10.21203/rs.3.rs-4527263/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-19T12:58:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-17T13:34:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"13485876980814046300575435934965634996","date":"2024-07-11T07:23:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-14T22:39:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"93731251639135619758696927695726469091","date":"2024-06-13T10:00:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334072711420419365470022599017757767995","date":"2024-06-13T00:18:01+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-12T20:39:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-12T11:31:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-10T09:53:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-10T09:53:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2024-06-04T10:24:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0c5813b2-41dd-44b6-bb9e-55ed75a4c392","owner":[],"postedDate":"July 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-28T16:05:39+00:00","versionOfRecord":{"articleIdentity":"rs-4527263","link":"https://doi.org/10.1186/s12893-024-02632-8","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2024-10-26 15:58:18","publishedOnDateReadable":"October 26th, 2024"},"versionCreatedAt":"2024-07-01 18:59:54","video":"","vorDoi":"10.1186/s12893-024-02632-8","vorDoiUrl":"https://doi.org/10.1186/s12893-024-02632-8","workflowStages":[]},"version":"v1","identity":"rs-4527263","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4527263","identity":"rs-4527263","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}