Salvage surgery for Stage IVa thymic carcinoma combined with aortic arch resection-Case report

Salvage surgery for Stage IVa thymic carcinoma combined with aortic arch resection-Case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case report Salvage surgery for Stage IVa thymic carcinoma combined with aortic arch resection-Case report Hiroyuki Yamato, Soichiro Funaki, Kazuo Shimamura, Keiwa Kin, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-53944/v2 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Oct, 2020 Read the published version in Journal of Cardiothoracic Surgery → Version 2 posted 4 You are reading this latest preprint version Show more versions Abstract Background Although complete surgical resection of thymic carcinoma is a prognostic factor, extended surgery combined with a major blood vessel procedure remains controversial because of the increased risk of mortality. We report a case of Stage IVa thymic carcinoma successfully resected with a pneumonectomy along with aortic arch replacement after chemotherapy. Case presentation A 45-year-old male was diagnosed with thymic carcinoma invasion to the aortic arch and left pulmonary artery. Malignant pericardial effusion was also noted, though disappeared after chemotherapy, thus surgical options were considered. A radical resection procedure including left pneumonectomy, aortic arch replacement with total rerouting of the supra-arch vessels, and right pulmonary artery plication was performed. The postoperative course was uneventful and the patient has been disease-free for 3 years. Conclusion Extended salvage surgery might be a valuable option for advanced thymic carcinoma. Cardiothoracic Surgery thymic carcinoma salvage surgery aortic arch replacement pneumonectomy Figures Figure 1 Figure 2 Figure 3 Background A thymic carcinoma is typically asymptomatic, thus invasion of adjacent structures is usually first noted at the time of diagnosis (1). Since survival is significantly better for patients who undergo a complete resection, it is necessary to perform an extended operation (2). We report here successful resection of a Stage IVa thymic carcinoma performed using salvage surgery combined with a pneumonectomy and great vessel replacement after chemotherapy. Case Presentation A 45-year-old male was diagnosed with an anterior mediastinal tumor and referred to our hospital. Open biopsy results of the tumor revealed a squamous cell carcinoma and cytology findings were positive for pericardial effusion. Chest computed tomography (CT) showed a mass approximately 10 cm in size with invasion to the left hilar part of the left lung and aortic arch, as well as pericardial effusion (Fig. 1A-C), thus the patient was diagnosed with a thymic carcinoma, c-Stage IVa (cT4N0M1a). Six courses of chemotherapy with carboplatin and paclitaxel were performed, followed by tegafur/gimeracil/oteracil (S-1) administration for 1 year. Chest CT findings showed disappearance of pericardial effusion and slightly decreased tumor size (Fig. 1D-F), while fluorodeoxyglucose (FDG)-position emission tomography also revealed that FDG uptake was decreased after the chemotherapy regimen (Fig. 2). However, at this time the patient was affected by liver dysfunction due to chemotherapy, thus our multidisciplinary team considered surgical options because that administration could not be continued. Preoperative systemic restaging was yc-Stage IIIb (yc-T4N0M0). A salvage operation including aortic arch replacement was considered to be challenging, thus we carefully explained the risk of surgery to the patient and his family, and obtained informed consent. A left lateral thoracotomy was initially performed, and the findings ruled out pleural or pericardial dissemination, thus a median sternotomy was added. Invasion of the chest wall by the tumor was noted, thus resection of the chest wall 8 x 5 in size as well as the pectoralis major muscle was performed. The tumor was suspected to have invaded the main pulmonary artery (PA) trunk as well as the aortic arch. The left brachiocephalic vein showed obvious tumor invasion and was dissected, though the mass could not be divided from the aorta. Moreover, the left PA could not be encircled in the pericardium. Following systemic heparinization (300 U/kg), a cardiopulmonary bypass (CPB) was established with right atrium drainage, as well as 2 points of arterial perfusion via the femoral and right axillary arteries. The shrunken left main trunk of the PA was then dissected and divided with a stapler, and the upper and lower pulmonary veins, and left main bronchus were also divided. Finally, the tumor was sharply separated from the aorta and removed along with the left lung. The left recurrent laryngeal and phrenic nerve were involved in the tumor and resected, whereas the cutting edge was negative for viable tumor cells in the pericardium and pulmonary artery, as shown by frozen section findings. Some tumor residue remained on the aortic wall and was confirmed to be viable, thus a residual tumor resection with replacement of the aortic arch using total rerouting of the supra-arch vessels (3) was performed. To confirm that no tumor remained other than in the aortic wall, selected points such as fat near the pulmonary artery and the aorta in the remaining area were confirmed to be negative by frozen section findings. Anastomoses of the ascending aorta and trunk of the trifurcation graft (Hemashield three-branch graft, 12-8-8 mm) were performed with side-clamping, and subsequently the brachiocephalic artery, left common carotid artery, and left subclavian artery were reconstructed one by one using a simple clamping method. Next, after clamping the ascending aorta just distal to the trifurcated graft inflow anastomosis and proximal descending aorta, the aortic arch was resected with the residual tumor and reconstructed using a 26-mm graft. Cardiac arrest was not introduced at any time during the procedure, though CPB could not be weaned because of right heart failure caused by PA bifurcation stenosis. Therefore, we reconstructed the PA bifurcation, the stenosis of which was due to the division line of the left PA being too close to the PA trunk, using an 18-mm tube graft (Fig. 3) for replacing the PA trunk and right PA. After PA repair, CPB was weaned uneventfully. For repair of the defect in the chest wall, a polypropylene mesh was fixed to the chest wall when the chest was closed. The operation time was 958 minutes and CPB time was 254 minutes, while blood loss was 7980 ml. The patient was extubated on postoperative day (POD) 2 and the postoperative course was uneventful. Pathological diagnosis results revealed that viable tumor cells were present in the resected aortic wall, indicating that the final pathological stage was IIIb (yp-T4N0M0). Discussion And Conclusions Few cases of thymic carcinoma have been reported and consensus regarding treatment other than complete resection is lacking (4). A patient with a locally advanced thymic carcinoma invading the heart or great vessels can be treated with radical surgical resection, though the risk of perioperative morbidity will increase. However, usage of CBP has been reported to improve the chance of complete tumor resection in selected patients and might lead to prolonged survival (5). Furthermore, Petrella et al. noted that salvage surgery may represent the sole effective therapy for patients with thymic malignancy who do not respond to other curative treatments, and offers a chance for curative treatment in selected patients with acceptable morbidity and mortality (6). The indications for salvage surgery with aortic resection should be carefully considered. We previously reported results of ascending aortic replacement (7) and aortic arch replacement (8) performed in a conventional manner for thymic carcinoma cases. In the present patient, though the tumor had shrunk and pericardial effusion disappeared after chemotherapy, the treatment could not be continued due to liver dysfunction, while irradiation therapy was not indicated because the lesion was wide and malignant pericardial effusion was present. Therefore, the only therapeutic treatment option considered to be relevant for this case was salvage surgery. Our novel technique for aortic replacement may be advantageous, because with it aortic arch resection can be completed under a tepid temperature and beating heart condition (3). Furthermore, it has potential to avoid side-effects associated with deep hypothermic circulatory arrest and ischemia-reperfusion injury of multiple organs. Since the right PA was stenotic after resection, that was also replaced in the present case. The result was successful macroscopic complete resection performed as salvage surgery combined with replacement of the great vessels and the postoperative course was uneventful, even following aggressive surgery. In conclusion, salvage extended surgery has been shown to improve the prognosis in select patients with advanced thymic cancer. List Of Abbreviations CPB, cardiopulmonary bypass; CT, computed tomography; FDG, fluorodeoxyglucose; PA, pulmonary artery; POD, postoperative day Declarations Ethics approval and consent to participate Not applicable Consent for publication The patient provided written informed consent. Availability of data and materials Not applicable. Competing interests The authors have no competing interests to declare. Funding Not applicable. Acknowledgements Not applicable. Authors’ contributions HY is the first author of this manuscript. Y Shintani is the corresponding author. HY, SF, KS, KK, TK and Y Shintani performed the surgery. Y Sawa and Y Shintani supervised the writing of the manuscript. All authors have read and approved the final version of the manuscript. References Zhai Y, Hui Z, Ji W, Wang X, Liang J, Mao Y, et al. A Single-Center Analysis of the Treatment and Prognosis of Patients With Thymic Carcinoma. Ann Thorac Surg. 2017;104(5):1718-24. Shintani Y, Inoue M, Kawamura T, Funaki S, Minami M, Okumura M. Multimodality treatment for advanced thymic carcinoma: outcomes of induction therapy followed by surgical resection in 16 cases at a single institution. Gen Thorac Cardiovasc Surg. 2015;63(3):159-63. Shintani Y, Shimamura K, Funaki S, Kimura K, Kin K, Kuratani T, et al. Combined Aortic Arch Resection for Lung Cancer Using Total Rerouting of Supra-Arch Vessels. Ann Thorac Surg. 2019;107(6):e399-e401. Ruffini E, Detterbeck F, Van Raemdonck D, Rocco G, Thomas P, Weder W, et al. Thymic carcinoma: a cohort study of patients from the European society of thoracic surgeons database. J Thorac Oncol. 2014;9(4):541-8. Ried M, Neu R, Schalke B, von Susskind-Schwendi M, Sziklavari Z, Hofmann HS. Radical surgical resection of advanced thymoma and thymic carcinoma infiltrating the heart or great vessels with cardiopulmonary bypass support. J Cardiothorac Surg. 2015;10:137. Petrella F, Leo F, Veronesi G, Solli P, Borri A, Galetta D, et al. "Salvage" surgery for primary mediastinal malignancies: is it worthwhile? J Thorac Oncol. 2008;3(1):53-8. Momozane T, Inoue M, Shintani Y, Funaki S, Kawamura T, Minami M, et al. Trimodality Therapy for an Advanced Thymic Carcinoma With Both Aorta and Vena Cava Invasion. Ann Thorac Surg. 2016;102(2):e139-41. Kuno H, Funaki S, Kimura K, Shimamura K, Kin K, Kuratani T, et al. Complete resection of local advanced thymic carcinoma with total aortic arch replacement after chemotherapy: a case report. Surg Case Rep. 2019;5(1):198. Supplementary Files CAREchecklistsubmission.pdf CAREchecklistsubmission.pdf Cite Share Download PDF Status: Published Journal Publication published 07 Oct, 2020 Read the published version in Journal of Cardiothoracic Surgery → Version 2 posted Editorial decision: Accept 04 Oct, 2020 Editor assigned by journal 09 Sep, 2020 Submission checks completed at journal 08 Sep, 2020 Editor invited by journal 08 Sep, 2020 You are reading this latest preprint version Show more versions 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. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-53944","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case report","associatedPublications":[],"authors":[{"id":2221414,"identity":"1883ed01-2a7f-4a34-a358-26ba043879f7","order_by":0,"name":"Hiroyuki Yamato","email":"","orcid":"","institution":"Osaka Daigaku Daigakuin Igakukei Kenkyuka Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Hiroyuki","middleName":"","lastName":"Yamato","suffix":""},{"id":2221415,"identity":"7aa57b72-a6bc-4db0-a7d3-50dc64733055","order_by":1,"name":"Soichiro Funaki","email":"","orcid":"","institution":"Osaka Daigaku Daigakuin Igakukei Kenkyuka Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Soichiro","middleName":"","lastName":"Funaki","suffix":""},{"id":2221416,"identity":"014dd435-8b06-4308-8103-c0e0b9004ea7","order_by":2,"name":"Kazuo Shimamura","email":"","orcid":"","institution":"Osaka Daigaku Daigakuin Igakukei Kenkyuka Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Kazuo","middleName":"","lastName":"Shimamura","suffix":""},{"id":2221417,"identity":"fce96848-b599-47dd-aad4-fa1835e56f3d","order_by":3,"name":"Keiwa Kin","email":"","orcid":"","institution":"Osaka Daigaku Daigakuin Igakukei Kenkyuka Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Keiwa","middleName":"","lastName":"Kin","suffix":""},{"id":2221418,"identity":"1c55adfe-47cc-4e56-a592-598b69c33a19","order_by":4,"name":"Toru Kuratani","email":"","orcid":"","institution":"Osaka Daigaku Daigakuin Igakukei Kenkyuka Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Toru","middleName":"","lastName":"Kuratani","suffix":""},{"id":2221419,"identity":"e536f4d0-e6c6-4ceb-88c8-82c494db6390","order_by":5,"name":"Yoshiki Sawa","email":"","orcid":"","institution":"Osaka Daigaku Daigakuin Igakukei Kenkyuka Igakubu","correspondingAuthor":false,"prefix":"","firstName":"Yoshiki","middleName":"","lastName":"Sawa","suffix":""},{"id":2221420,"identity":"a2fbcb47-1893-4eb0-b2ba-4ae274ee6c75","order_by":6,"name":"Yasushi Shintani","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-2540-5288","institution":"Osaka University Graduate School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Yasushi","middleName":"","lastName":"Shintani","suffix":""}],"badges":[],"createdAt":"2020-08-05 10:12:18","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-53944/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-53944/v2","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-020-01354-1","type":"published","date":"2020-10-07T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":2385763,"identity":"458c7526-4bcb-404a-aa27-d17a6a40a779","added_by":"auto","created_at":"2020-09-13 23:02:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":131522,"visible":true,"origin":"","legend":"Radiographic images obtained (A-C) before and (D-E) after chemotherapy. Chest computed tomography (CT) findings showed an anterior mediastinal tumor invading the (A) aortic arch and (B) left hilar part of the left lung, as well as (C) pericardial effusion. After the end of the course of chemotherapy, CT showed that the tumor had shrunk, though invasion to (D) the aorta and (E) left pulmonary artery was still evident, while (F) pericardial effusion had disappeared. \nLt PA, left pulmonary artery\n","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-53944/v2/Figure1.jpg"},{"id":2385764,"identity":"2ddc9d50-a3c9-4a07-8084-5fa347b566e4","added_by":"auto","created_at":"2020-09-13 23:02:04","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":73457,"visible":true,"origin":"","legend":"Fluorodeoxyglucose-positron emission tomography images obtained (A-B) before and (C-D) after chemotherapy.","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-53944/v2/Figure2.jpg"},{"id":2385765,"identity":"f46eb90b-5d73-42fe-8f3f-652a1c83e1fb","added_by":"auto","created_at":"2020-09-13 23:02:04","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":237269,"visible":true,"origin":"","legend":"(A) Intraoperative image showing aortic arch replacement using total rerouting of supra-arch vessels combined with right pulmonary artery replacement. (B) Schematic drawing of surgical procedure. \nAo, aorta; BCA, brachiocephalic artery; CCA, common carotid artery; Rt PA, right pulmonary artery; SCA, subclavian artery\n","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-53944/v2/Figure3.jpg"},{"id":13590806,"identity":"fcd7175e-54cd-483b-87ae-eb411f11c7ce","added_by":"auto","created_at":"2021-09-17 05:06:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":525493,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-53944/v2/2443895f-1e2a-409f-a923-252ca4aeaeb1.pdf"},{"id":2385762,"identity":"02a91ea4-049f-4e3c-932d-be5cae94510c","added_by":"auto","created_at":"2020-09-13 23:02:04","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":319580,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistsubmission.pdf","url":"https://assets-eu.researchsquare.com/files/rs-53944/v2/CAREchecklistsubmission.pdf"},{"id":2385767,"identity":"5cdf67b1-0d9c-4131-b90d-ded43dd0ef45","added_by":"auto","created_at":"2020-09-13 23:02:04","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":319580,"visible":true,"origin":"","legend":"","description":"","filename":"CAREchecklistsubmission.pdf","url":"https://assets-eu.researchsquare.com/files/rs-53944/v2/CAREchecklistsubmission.pdf"}],"financialInterests":"","formattedTitle":"Salvage surgery for Stage IVa thymic carcinoma combined with aortic arch resection-Case report","fulltext":[{"header":"Background","content":"\u003cp\u003eA thymic carcinoma is typically asymptomatic, thus invasion of adjacent structures is usually first noted at the time of diagnosis (1). Since survival is significantly better for patients who undergo a complete resection, it is necessary to perform an extended operation (2). We report here successful resection of a Stage IVa thymic carcinoma performed using salvage surgery combined with a pneumonectomy and great vessel replacement after chemotherapy.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 45-year-old male was diagnosed with an anterior mediastinal tumor and referred to our hospital. Open biopsy results of the tumor revealed a squamous cell carcinoma and cytology findings were positive for pericardial effusion. Chest computed tomography (CT) showed a mass approximately 10 cm in size with invasion to the left hilar part of the left lung and aortic arch, as well as pericardial effusion (Fig. 1A-C), thus the patient was diagnosed with a thymic carcinoma, c-Stage IVa (cT4N0M1a). Six courses of chemotherapy with carboplatin and paclitaxel were performed, followed by tegafur/gimeracil/oteracil (S-1) administration for 1 year. Chest CT findings showed disappearance of pericardial effusion and slightly decreased tumor size (Fig. 1D-F), while fluorodeoxyglucose (FDG)-position emission tomography also revealed that FDG uptake was decreased after the chemotherapy regimen (Fig. 2). However, at this time the patient was affected by liver dysfunction due to chemotherapy, thus our multidisciplinary team considered surgical options because that administration could not be continued.\u003c/p\u003e\n\u003cp\u003ePreoperative systemic restaging was yc-Stage IIIb (yc-T4N0M0). A salvage operation including aortic arch replacement was considered to be challenging, thus we carefully explained the risk of surgery to the patient and his family, and obtained informed consent. A left lateral thoracotomy was initially performed, and the findings ruled out pleural or pericardial dissemination, thus a median sternotomy was added. Invasion of the chest wall by the tumor was noted, thus resection of the chest wall 8 x 5 in size as well as the pectoralis major muscle was performed. The tumor was suspected to have invaded the main pulmonary artery (PA) trunk as well as the aortic arch. The left brachiocephalic vein showed obvious tumor invasion and was dissected, though the mass could not be divided from the aorta. Moreover, the left PA could not be encircled in the pericardium. Following systemic heparinization (300 U/kg), a cardiopulmonary bypass (CPB) was established with right atrium drainage, as well as 2 points of arterial perfusion via the femoral and right axillary arteries. The shrunken left main trunk of the PA was then dissected and divided with a stapler, and the upper and lower pulmonary veins, and left main bronchus were also divided. Finally, the tumor was sharply separated from the aorta and removed along with the left lung. The left recurrent laryngeal and phrenic nerve were involved in the tumor and resected, whereas the cutting edge was negative for viable tumor cells in the pericardium and pulmonary artery, as shown by frozen section findings. Some tumor residue remained on the aortic wall and was confirmed to be viable, thus a residual tumor resection with replacement of the aortic arch using total rerouting of the supra-arch vessels (3) was performed. To confirm that no tumor remained other than in the aortic wall, selected points such as fat near the pulmonary artery and the aorta in the remaining area were confirmed to be negative by frozen section findings. Anastomoses of the ascending aorta and trunk of the trifurcation graft (Hemashield three-branch graft, 12-8-8 mm) were performed with side-clamping, and subsequently the brachiocephalic artery, left common carotid artery, and left subclavian artery were reconstructed one by one using a simple clamping method. Next, after clamping the ascending aorta just distal to the trifurcated graft inflow anastomosis and proximal descending aorta, the aortic arch was resected with the residual tumor and reconstructed using a 26-mm graft. Cardiac arrest was not introduced at any time during the procedure, though CPB could not be weaned because of right heart failure caused by PA bifurcation stenosis. Therefore, we reconstructed the PA bifurcation, the stenosis of which was due to the division line of the left PA being too close to the PA trunk, using an 18-mm tube graft (Fig. 3) for replacing the PA trunk and right PA. After PA repair, CPB was weaned uneventfully. For repair of the defect in the chest wall, a polypropylene mesh was fixed to the chest wall when the chest was closed. The operation time was 958 minutes and CPB time was 254 minutes, while blood loss was 7980 ml. The patient was extubated on postoperative day (POD) 2 and the postoperative course was uneventful. Pathological diagnosis results revealed that viable tumor cells were present in the resected aortic wall, indicating that the final pathological stage was IIIb (yp-T4N0M0).\u003c/p\u003e"},{"header":"Discussion And Conclusions","content":"\u003cp\u003eFew cases of thymic carcinoma have been reported and consensus regarding treatment other than complete resection is lacking (4). A patient with a locally advanced thymic carcinoma invading the heart or great vessels can be treated with radical surgical resection, though the risk of perioperative morbidity will increase. However, usage of CBP has been reported to improve the chance of complete tumor resection in selected patients and might lead to prolonged survival (5). Furthermore, Petrella et al. noted that salvage surgery may represent the sole effective therapy for patients with thymic malignancy who do not respond to other curative treatments, and offers a chance for curative treatment in selected patients with acceptable morbidity and mortality (6).\u003c/p\u003e\n\u003cp\u003eThe indications for salvage surgery with aortic resection should be carefully considered. We previously reported results of ascending aortic replacement (7) and aortic arch replacement (8) performed in a conventional manner for thymic carcinoma cases. In the present patient, though the tumor had shrunk and pericardial effusion disappeared after chemotherapy, the treatment could not be continued due to liver dysfunction, while irradiation therapy was not indicated because the lesion was wide and malignant pericardial effusion was present. Therefore, the only therapeutic treatment option considered to be relevant for this case was salvage surgery. Our novel technique for aortic replacement may be advantageous, because with it aortic arch resection can be completed under a tepid temperature and beating heart condition (3). Furthermore, it has potential to avoid side-effects associated with deep hypothermic circulatory arrest and ischemia-reperfusion injury of multiple organs. Since the right PA was stenotic after resection, that was also replaced in the present case. The result was successful macroscopic complete resection performed as salvage surgery combined with replacement of the great vessels and the postoperative course was uneventful, even following aggressive surgery.\u003c/p\u003e\n\u003cp\u003eIn conclusion, salvage extended surgery has been shown to improve the prognosis in select patients with advanced thymic cancer.\u003c/p\u003e"},{"header":"List Of Abbreviations","content":"\u003cp\u003eCPB, cardiopulmonary bypass; CT, computed tomography; FDG, fluorodeoxyglucose; PA, pulmonary artery; POD, postoperative day\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHY is the first author of this manuscript. Y Shintani is the corresponding author.\u003c/p\u003e\n\u003cp\u003eHY, SF, KS, KK, TK and Y Shintani performed the surgery.\u003c/p\u003e\n\u003cp\u003eY Sawa and Y Shintani supervised the writing of the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final version of the manuscript.\u003cbr /\u003e \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eZhai Y, Hui Z, Ji W, Wang X, Liang J, Mao Y, et al. A Single-Center Analysis of the Treatment and Prognosis of Patients With Thymic Carcinoma. Ann Thorac Surg. 2017;104(5):1718-24.\u003c/li\u003e\n\u003cli\u003eShintani Y, Inoue M, Kawamura T, Funaki S, Minami M, Okumura M. Multimodality treatment for advanced thymic carcinoma: outcomes of induction therapy followed by surgical resection in 16 cases at a single institution. Gen Thorac Cardiovasc Surg. 2015;63(3):159-63.\u003c/li\u003e\n\u003cli\u003eShintani Y, Shimamura K, Funaki S, Kimura K, Kin K, Kuratani T, et al. Combined Aortic Arch Resection for Lung Cancer Using Total Rerouting of Supra-Arch Vessels. Ann Thorac Surg. 2019;107(6):e399-e401.\u003c/li\u003e\n\u003cli\u003eRuffini E, Detterbeck F, Van Raemdonck D, Rocco G, Thomas P, Weder W, et al. Thymic carcinoma: a cohort study of patients from the European society of thoracic surgeons database. J Thorac Oncol. 2014;9(4):541-8.\u003c/li\u003e\n\u003cli\u003eRied M, Neu R, Schalke B, von Susskind-Schwendi M, Sziklavari Z, Hofmann HS. Radical surgical resection of advanced thymoma and thymic carcinoma infiltrating the heart or great vessels with cardiopulmonary bypass support. J Cardiothorac Surg. 2015;10:137.\u003c/li\u003e\n\u003cli\u003ePetrella F, Leo F, Veronesi G, Solli P, Borri A, Galetta D, et al. \"Salvage\" surgery for primary mediastinal malignancies: is it worthwhile? J Thorac Oncol. 2008;3(1):53-8.\u003c/li\u003e\n\u003cli\u003eMomozane T, Inoue M, Shintani Y, Funaki S, Kawamura T, Minami M, et al. Trimodality Therapy for an Advanced Thymic Carcinoma With Both Aorta and Vena Cava Invasion. Ann Thorac Surg. 2016;102(2):e139-41.\u003c/li\u003e\n\u003cli\u003eKuno H, Funaki S, Kimura K, Shimamura K, Kin K, Kuratani T, et al. Complete resection of local advanced thymic carcinoma with total aortic arch replacement after chemotherapy: a case report. Surg Case Rep. 2019;5(1):198.\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":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"thymic carcinoma, salvage surgery, aortic arch replacement, pneumonectomy","lastPublishedDoi":"10.21203/rs.3.rs-53944/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-53944/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Background\n\nAlthough complete surgical resection of thymic carcinoma is a prognostic factor, extended surgery combined with a major blood vessel procedure remains controversial because of the increased risk of mortality. We report a case of Stage IVa thymic carcinoma successfully resected with a pneumonectomy along with aortic arch replacement after chemotherapy.\n\nCase presentation\n\nA 45-year-old male was diagnosed with thymic carcinoma invasion to the aortic arch and left pulmonary artery. Malignant pericardial effusion was also noted, though disappeared after chemotherapy, thus surgical options were considered. A radical resection procedure including left pneumonectomy, aortic arch replacement with total rerouting of the supra-arch vessels, and right pulmonary artery plication was performed. The postoperative course was uneventful and the patient has been disease-free for 3 years.\n\nConclusion\n\nExtended salvage surgery might be a valuable option for advanced thymic carcinoma.","manuscriptTitle":"Salvage surgery for Stage IVa thymic carcinoma combined with aortic arch resection-Case report","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2020-09-13 23:01:56","doi":"10.21203/rs.3.rs-53944/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-10-04T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-09T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-08T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-08T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-08-14 17:20:24","doi":"10.21203/rs.3.rs-53944/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-08-23T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-22T12:00:00+00:00","index":1,"fulltext":"Recommendation: Minor Revision\nForm responses:\n---\n\nComments to Author:\n---\nThe authors should be congratulated for the excellent surgical case I have read with great interest.\nI have only some minor suggestions.\n\nPlease define better S-1\nI would advise an accurate English editing before publication.\n\nFinally, since from the PET imaging the invasion of the thoracic was is significant, I was wondering whether anything has been done . Please clarify, discuss more in depth how this was dealt and how it influenced the patient's clinical course\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Level of interest: **An article of importance in its field**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **NO**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2020-08-13T12:00:00+00:00","index":3,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-08-13T12:00:00+00:00","index":2,"fulltext":"Recommendation: Minor Revision\nForm responses:\n---\n\nComments to Author:\n---\nDear Authors,\nI reviewed your manuscript with great interest. It is well written.\nKindly respond to the following points:\n1.was this case discussed in a multidisciplinary team meeting prior to surgery\n2.you elected to operate because the patient could not tolerate further chemotherapy due to impaired liver function.\n3.please did you re-stage the disease after completing chemotherapy to asses for respectability prior to surgery... if yes what was the new stage prior to surgery..... What sort of risk of morbidity and mortality did you quantify for the patient.\n4.How did you ensure complete resection.. did you perform a frozen section guided resection\n5. Did you preserve the recurrent laryngeal and phrenic nerves.\n6.what was the final pathological stage post surgery.\n7. How did you follow up this patient\n8.Best wishes\n\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Level of interest: **An article of importance in its field**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n"},{"type":"editorInvitedReview","content":"","date":"2020-08-13T12:00:00+00:00","index":3,"fulltext":"Recommendation: Accept\nForm responses:\n---\n\nComments to Author:\n---\nThe authors present the case of a patient with a thymic carcinoma invading the aortic arch and the left pulmonary artery, successfully treated with an extended salvage surgery.\nThe case, well presented, will be of sure interest for the readers of Journal of Cardiothoracic Surgery; I, therefore, recommend its publication.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Level of interest: **An exceptional article**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published.: **\nI agree to the open peer review policy of the journal**\n"},{"type":"reviewerAgreed","content":"","date":"2020-08-12T12:00:00+00:00","index":2,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-08-11T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-08-11T12:00:00+00:00","index":1,"fulltext":""},{"type":"submitted","content":"","date":"2020-08-10T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-08-10T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-08-09T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-08-09T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"715b5a59-763d-4b3d-bf5a-63cfeefd00d7","owner":[],"postedDate":"September 13th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":299709,"name":"Cardiothoracic Surgery"}],"tags":[],"updatedAt":"2020-10-11T15:02:30+00:00","versionOfRecord":{"articleIdentity":"rs-53944","link":"https://doi.org/10.1186/s13019-020-01354-1","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2020-10-07 12:00:00","publishedOnDateReadable":"October 7th, 2020"},"versionCreatedAt":"2020-09-13 23:01:56","video":"","vorDoi":"10.1186/s13019-020-01354-1","vorDoiUrl":"https://doi.org/10.1186/s13019-020-01354-1","workflowStages":[]},"version":"v2","identity":"rs-53944","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-53944","identity":"rs-53944","version":["v2"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}