Sleeve Resection of the Bronchus, Pulmonary Artery, and Superior Vena Cava Reconstruction for Locally Advanced Non-Small Cell Lung Cancer: A Single-Center Retrospective Study

Sleeve Resection of the Bronchus, Pulmonary Artery, and Superior Vena Cava Reconstruction for Locally Advanced Non-Small Cell Lung Cancer: A Single-Center Retrospective Study | 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 Research Article Sleeve Resection of the Bronchus, Pulmonary Artery, and Superior Vena Cava Reconstruction for Locally Advanced Non-Small Cell Lung Cancer: A Single-Center Retrospective Study Kai-li Huang, Pengfei Li, Wu Qiang, Li Wen, Xiaojun Tang, qinghua Zhou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4853915/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Background Combined sleeve resection of the bronchus, pulmonary artery (PA), and reconstruction of the superior vena cava (SVC) is occasionally indicated in the treatment of non-small cell lung cancer. However, simultaneous reconstruction of the SVC, sleeve resection of the bronchus and PA for right upper lobe central-type lung cancers presents significant technical challenges for surgeons. In this study, we describe our experience with this surgical procedure and the associated clinical outcomes. Methods From 31st January 2014 to 30th December 2023, 15 patients confirmed with non-small cell lung cancer (NSCLC) who underwent SVC resection combined with sleeve resection of the bronchus and/or PA following induction treatment were enrolled in this stuy. The surgical approaches employed included mid-sternal incision in 4 patients (26.7%), right posterolateral thoracotomy in 6 patients (40%), and two-step surgical approach (initially via a mid-sternal incision followed by a right posterolateral thoracotomy) in 5 cases (33.3%). Among these patients, 7 (46.7%) cases underwent simultaneous SVC reconstruction and double sleeve resection (bronchus and PA), 3 (20%) underwent simultaneous SVC reconstruction and double sleeve resection (bronchus and PA) with carina reconstruction, 4 (26.7%) underwent simultaneous SVC reconstruction and bronchus sleeve resection, and 1 (6.7%) underwent SVC reconstruction and PA plasty. Systemic lymphadenectomy was performed in all patients. Results All resections were completely resectable (R0). Histological analysis revealed 7 patients (46.7%) were adenocarcinoma and 8 (53.3%) patients were squamous cell carcinoma. Besides, 1 (6.7%) patient was classified as stage pT4N0M0-IIIA, 12 (80%) patients as stage pT4N2M0-IIIB, and 2 (13.3%) patients as stage pT4N3M0-IIIC. No perioperative deaths occurred. The major complication rate was 40% after surgery. The median follow-up duration was 29 months, and the overall survival rates at 1, 3, and 5 years were 80%, 28.6%, and 28.6%, respectively. Conclusions Combined resections of the bronchus, PA and SVC are technically feasible and safe for patients with locally advanced NSCLC. For carefully selected patients, this extended resection surgery may lead to favorable long-term survival. NSCLC superior vena cava (SVC) bronchus sleeve pulmonary artery (PA) sleeve Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Locally advanced lung cancers invading bronchus, pulmonary artery (PA), and superior vena cava (SVC) present with a unique management challenge in clinical practice[ 1 ]. Most patients are not offered surgical resection due to technical difficulties, concerns about postoperative morbidity and mortality, or minimal survival benefit[ 2 ]. However, for certain patients, radical resection might achieve long-term survival[ 3 ]. Although double sleeve lobectomies are routine in most thoracic surgical centers, simultaneous SVC resection and reconstruction combined with bronchus sleeve resection, PA sleeve resection, or both, are rarely reported. In this report, we present our preliminary experience with combined extended resection for NSCLC in patients with concomitant involvement of the SVC and bronchus, PA, or both, analyzing technical feasibility and the early and late postoperative outcomes. Material and Methods Patients Between 31st January 2014 and 30th December 2023, resection and reconstruction procedures involving the main bronchus, PA, and SVC were performed on 15 patients with NSCLC in our department, including 13 male patients and 2 female patients, with a mean age of 57.5 ± 4.95 years. Clinical symptoms included SVC obstruction syndrome, persistent dry cough, dyspnea, bloody sputum, and refractory moderate fever. Two patients were found to have a pulmonary mass on physical examination (Table 1 ). Table 1 Main clinicopathologic data Patient No Sex Age (y) Histology Tumor size (cm) Clinical TNM Induction Treatment Approach Operation time (min) Blood loss (mL) Resection Type pTNM 1 M 61 Squamous cell carcinoma 8.3 T4N2M0-IIIB Paclitaxel +Cisplatin mid-sternal incision 360 1200 SVC reconstruction ,bronchus sleeve, PA sleeve T4N2M0-IIIB 2 M 55 Adenocarcinoma 10 T4N2M0-IIIB Vinorelbine +Cisplatin two-step surgical 420 1500 SVC reconstruction ,bronchus sleeve, PA sleeve T4N2M0-IIIB 3 M 55 Adenocarcinoma 8.2 T4N2M0-IIIB Furmonertinib two-step surgical 300 1000 SVC reconstruction ,bronchus sleeve, PA sleeve T4N2M0-IIIB 4 M 56 Squamous cell carcinoma 7.5 T4N2M0-IIIB Paclitaxel +Cisplatin Posterior lateral thoracotomy 230 6000 SVC reconstruction ,bronchus sleeve, PA sleeve T4N2M0-IIIB 5 M 54 Adenocarcinoma 6 T3N2M0-IIIB Pemetrexed +Cisplatin Posterior lateral thoracotomy 180 600 SVC reconstruction ,Carina reconstruction,bronchus sleeve, PA sleeve T4N3M0-IIIC 6 M 59 Squamous cell carcinoma 5 T4N2M0-IIIB .... Posterior lateral thoracotomy 200 800 SVC reconstruction, PA plasty T4N2M0-IIIB 7 F 47 Adenocarcinoma 5 T3N2M0-IIIB .... Posterior lateral thoracotomy 180 400 SVC reconstruction, bronchus sleeve T4N2M0-IIIB 8 M 68 Adenocarcinoma 9 T3N2M0-IIIB .... two-step surgical 220 2000 SVC reconstruction, bronchus sleeve,PA sleeve T4N2M0-IIIB 9 M 56 Squamous cell carcinoma 6 T4N3M0-IIIC Gemcitabine +Cisplatin mid-sternal incision 240 1500 SVC reconstruction, bronchus sleeve T4N3M0-IIIC 10 M 69 Squamous cell carcinoma 5 T4N2M0-IIIB .... mid-sternal incision 200 1000 SVC reconstruction ,Carina reconstruction,bronchus sleeve, PA sleeve T4N2M0-IIIB 11 M 72 Squamous cell carcinoma 7 T3N2M0-IIIB Gemcitabine,Etoposide +cisplatin,Radiotherapy Posterior lateral thoracotomy 150 300 SVC reconstruction ,bronchus sleeve, PA plasty T4N2M0-IIIB 12 M 32 Adenocarcinoma 21 T4N2M0-IIIB .... two-step surgical 240 2000 SVC reconstruction, bronchus sleeve T4N2M0-IIIB 13 M 56 Adenocarcinoma 6.4 T4N2M0-IIIB .... Posterior lateral thoracotomy 210 1500 SVC reconstruction ,Carina plasty,Right middle bronchus and left principal bronchus reconstruction, PA sleeve T4N2M0-IIIB 14 F 58 Squamous cell carcinoma 6.6 T4N2M0-IIIB Paclitaxel + Cisplatin, Radiotherapy mid-sternal incision 270 4000 SVC reconstruction, bronchus sleeve T4N0M0-IIIA 15 M 54 Squamous cell carcinoma 9.5 T4N2M0-IIIB Docetaxel + cisplatin two-step surgical 230 700 SVC reconstruction, bronchus sleeve,PA sleeve T4N2M0-IIIB SVC = superior vena cava;PA = pulmonary artery Preoperative Evaluation and Treatment All patients underwent preoperative examinations to exclude distant metastasis and confirm the locally advanced nature of the tumors, including the contrast-enhanced brain magnetic resonance imaging, whole-body bone scan, and contrast-enhanced chest and abdominal CT scans. The contrast-enhanced chest CT revealed that all the tumors were located in the right upper lobe. Besides, the hilar structures and superior vena cava (SVC) were invaded either by direct tumor extension or by enlarged invasive lymph nodes, resulting in the near-complete obliteration of the fat space between the bronchus and major vessels (Fig. 1 A). The azygos vein appeared tortuous, narrowed, or even absent in some patients. The invaded SVC became narrow or even obstructed; however, the proximal segment of the SVC leading to the right atrium was normal in all patients on CT scans. Despite the tumor extension, both the pulmonary artery trunk and the middle to lower segments were free from tumor involvement. Bronchoscopy revealed the neoplasms were near to the the carina in 3 patinents and located at the right upper lobar orifice in 4 patients. Besides, the bronchus mucous were thick in 4 patients, and the bronchus were narrow in 3 patients. Totally, 8 patients were diagnosed as adenocarcinoma and 7 patients were comfirmed with squamous cell carcinoma by the cytologic examination from bronchoscopies or CT-guided transthoracic needle biopsies, conducted either at our hospital or other institutions. The preoperative clinical stages were T3N2M0-IIIB (4 patients), T4N2M0-IIIB (10 patients), and T4N3M0-IIIC (1 patient). Among them, 9 patients received neoadjuvant treatments including chemotherapy (8 patients), radiotherapy (2 patients), or targeted therapy (1 case). Unfortunately, the specific neoadjuvant regimens for the other 6 patients were unclear. Reevaluations were performed before surgery by a multidisciplinary team (MDT) to exclude contraindications following neoadjuvant therapy.(Table 1 ) Statistical Analysis Continuous variables were reported as either means with standard deviations or medians with interquartile ranges, depending on their distribution, as assessed by the Shapiro–Wilk normality test. Categorical variables were reported as percentages. To assess mortality rates in patients undergoing complete resection, overall survival (OS) analysis was conducted by the Kaplan–Meier method, and the OS was defined as the time from the surgery to death from any cause or last follow-up, whichever occurred first. All statistical analyses were conducted using R Studio, version 4.2.2 (The R Project for Statistical Computing). Surgical manipulations and procedures from two typical cases In our center, surgical approaches to the tumor primarily include a right posterolateral incision in the fourth intercostal space and a two-step approach, which involves an initial median sternotomy followed by a posterolateral incision[ 4 ]. The principal objective is to ensure the safety of the surgery while achieving complete tumor resection and facilitating the reconstruction of the SVC, PA, or bronchus. Typical case 1 (Fig. 1 ), diagnosed with lung adenocarcinoma, presented with severe cough and facial and neck swelling. After undergoing neoadjuvant therapy (chemotherapy, immunotherapy, and radiotherapy) at another hospital, the patient was then admitted to our department. The chest CT revealed a large mass about 10.0 cm located in the superior lobe of the right lung, invading the SVC and causing a significant narrowing (Fig. 1 A) as well as the right pulmonary trunk (Fig. 1 B). In addition, the bronchoscopy indicated that the tumor was occluding the right upper lobar bronchus. Given that the tumor had invaded the SVC, PA, and right upper lobe bronchus, the patient required a double sleeve resection of the right upper lobe and PA, along with reconstruction of the SVC. The procedure was particularly challenging due to the tumor’s location at the hilum and its invasion into critical hilar structures, including the SVC, azygos vein, tracheobronchial angle, and PA trunk, making exposure and control of these structures difficult. Based on our previous experience, a two-step surgical approach was undertaken. The patient was initially positioned supine, and general anesthesia was administered using a double-lumen endobronchial tube. An extracorporeal venous shunt was then established, connecting the right internal jugular vein to the right femoral vein before surgery (Fig. 2 ). Following the establishment of the extracorporeal venous shunt, the patient underwent a median sternotomy, during which the left brachiocephalic vein was mobilized, transected, and reconnected to the right atrial appendage using a 10-mm GORE-TEX® vascular graft (W.L. Gore and Associates, AZ, USA) with running 4 − 0 polypropylene sutures (Fig. 3 A). After reconstructing the left brachiocephalic vein to the right atrial appendage, the right brachiocephalic vein was addressed. If it proved difficult to mobilize and expose the right brachiocephalic vein, a neck incision above the right clavicle was made to improve the surgical field and anatomical clarity, followed by dissection of the right brachiocephalic vein. Opening the pericardium facilitated the exposure of the SVC root, and the PA trunk behind the SVC was safely mobilized intrapericardially (Fig. 3 B). The SVC was then isolated, clamped, and resected. A 14-mm diameter ringed PTFE graft was interposed between the right brachiocephalic vein and the SVC root using running 4 − 0 polypropylene sutures (Fig. 3 A). Dissection of the right mediastinal lymph nodes (stations 2 and 4) was also performed. The median sternotomy incision was closed in a standard manner. Subsequently, the patient was repositioned to the left lateral decubitus position and underwent a right posterolateral thoracotomy through the fourth intercostal space. Since the invaded SVC had been transected and the mediastinal side of the tumor freed via median sternotomy, the tumor’s mobility was increased, facilitating the exposure of the hilum structure. The PA trunk, already encircled intrapericardially, could be clamped safely and easily (Fig. 3 B). The tumor resection involved double sleeve resection of the bronchus and pulmonary artery. An anastomosis between the right main bronchus and the cut end of the middle lobe bronchus was performed using interrupted 3 − 0 Vicryl sutures (Ethicon, USA). The right PA trunk and right intermediate PA were reconstructed using running 4 − 0 polypropylene sutures (Fig. 4 ). Margins of the bronchus, SVC, and PA were examined under frozen section to ensure tumor-free borders. Radical mediastinal lymph node dissection was performed, including stations 2, 4, 7, 9, and 10. The posterolateral thoracotomy incision was then closed in a standard manner. Typical case 2 (Fig. 5), diagnosed with lung squamous cell carcinoma and presenting with hemoptysis, was admitted to our department after receiving neoadjuvant therapy (chemotherapy plus immunotherapy). Chest CT revealed invasion of the SVC by the tumor and swollen mediastinal lymph nodes (Fig. 5). However, the PA appeared to be normal. Bronchoscopy showed the open of right superior lobar bronchial was invaded by the neoplasm. Thus, the patient required sleeve resection of the right superior lobe and SVC resection and reconstruction. Given the tumor’s relatively small size and partial SVC invasion, the surgical approach was through a right posterolateral incision in the fourth intercostal space after general anesthesia and the establishment of an extracorporeal venous shunt. The procedure began with the release of the hilum and exposure of critical hilar structures: the SVC, azygos vein, PA trunk, and superior pulmonary vein. The pericardium was opened behind the phrenic nerve, facilitating the encircling of the PA trunk beneath the SVC, and allowing safe encirclement of the proximal segment of the SVC intrapericardially. Subsequently, the distal end of the SVC was freed, and the invaded section was clamped and resected. A ringed PTFE graft with a diameter of 14 mm was used for SVC reconstruction with continuous sutures of 4 − 0 polypropylene. The next step was the sleeve resection of the right superior lobe and en bloc removal of the involved lobe. Airway conduit anastomosis between the right main bronchus and the intermediate bronchus was performed using end-to-end 4 − 0 interrupted absorbable sutures for the back wall and interrupted sutures for the front wall. Radical mediastinal lymph node dissection was completed prior to all these reconstructions, including stations 2, 4, 7, 9, and 10. Finally, the posterolateral thoracotomy incision was closed in a standard fashion. Results Complete resection was conducted in all 15 cases. All patients underwent SVC resection and reconstruction using a ringed PTFE graft with a diameter of 14 mm. The surgical approach varied: mid-sternal incision in 4 patients, right posterior lateral thoracotomy in 6 patients, and a two-step surgical procedure in 5 patients. Among them, 7 patients received simultaneous SVC reconstruction and double sleeve resection (bronchus and PA), 3 patients had SVC reconstruction and double sleeve resection (bronchus and PA) with carina reconstruction, 4 patients underwent SVC reconstruction and bronchus sleeve resection, and 1 patient had SVC reconstruction and PA plasty. Systemic lymphadenectomy was performed on all patients. The mean tumor size was 8.9 ± 0.84cm, the mean operative time was 295 ± 91.92 minutes, and the mean operative blood loss was 950 ± 353.55 ml. Pathological histology revealed that 7 patients were confirmed with adenocarcinoma and 8 patients with squamous carcinoma. As for the pathological TNM stage, 1 patient was clarified as T4N0M0-IIIA, 12 patients were T4N2M0-IIIB, and 2 patients were T4N3M0-IIIC. (Table 1 ) Postoperative outcomes and follow-up Subcutaneous injection heparin was administered to the patient with PTFE replacement (10,000 IU/day for 5 days) and then oral warfarin taking were last for long-term management to maintain an international normalized ratio (INR) within the range of 1.5-2.0. The mean ICU stay was 3 ± 2.82 days and the mean length of hospital stay was 16 ± 4.24 days. There was no postoperative mortality. The postoperative course was uneventful for 9 patients. 2 patients (2/15) developed atrial fibrillation on the second and fourth postoperative day, respectively, and both restored sinus rhythm with medical intervention. 1 patient (1/15) developed an acute lung infection due to Acinetobacter baumannii and recovered well after effective anti-infective treatment. Prolonged air leak (> 7 days) occurred in 1 patient (1/15) and it was resolved with low-pressure suction on the 13th postoperative day. ARDS and acute heart failure occurred in 1 patient (1/15), which were effectively resolved by non-invasive ventilation, enhancement of cardiac contractility, appropriate reduction of systolic blood pressure, and diuresis to reduce blood volume load. Another patient (1/15) developed postpneumonectomy edema on the second postoperative day and was cured with glucocorticoids, diuresis, anti-infective treatment, and non-invasive ventilation by the 11th postoperative day. Complete follow-up information was obtained for all patients. The vessels, including the PTFE graft, remained patent demonstrated by postoperative CT (Fig. 6 ). The median follow-up time was 29 months (range, 3–64 months), and the OS rates at 1, 3 and 5 years was 80%, 28.6% and 28.6%, respectively (Kaplan-Meier) (Fig. 7 ) (Table 2 ). Table 2 Postoperative outcome and follow up Patient No Postoperative Complications ICU/Hospital Stay (days) Anticoagulation Outcome 1 No 1/13 Warfarin Alive at 18 months 2 No 1/17 Warfarin Alive at 26 months 3 No 4/60 Warfarin Alive at 37 months 4 Atrial fibrillation 6/29 Warfarin died at 14 months 5 Infection 4/23 Warfarin died at 9 months 6 ARDS and Acute heart failure 9/22 Warfarin died at 25 months 7 No 4/16 Warfarin died at 64 months 8 Prolonged air leak 6/20 Warfarin died at 3 months 9 Atrial fibrillation 9/47 Warfarin died at 32 months 10 No 8/62 Warfarin died at 10 months 11 No 8/41 Warfarin died at 17 months 12 Postpneumonectomy edema 6/31 Warfarin died at 15 months 13 No 5/18 Warfarin died at 13 months 14 No 15/36 Warfarin died at 24 months 15 No 5/19 Warfarin Alive at 40 months Comment Lung cancers invading the SVC with mediastinal lymph node metastasis were traditionally considered as contraindication for surgery, and the PACIFIC treatment strategy (concurrent chemoradiotherapy followed by sequential Durvalumab immunotherapy) is recommended by the NCCN guidelines [ 5 , 6 ]. However, evidence has shown that certain patients may benefit significantly from extended surgery if radical resection can be achieved[ 7 ]. Simultaneous sleeve resection of the bronchus and pulmonary artery, along with reconstruction of the superior vena cava for locally advanced NSCLC, is technically challenging and complex, thus it has been performed occasionally and relatively rarely reported in the literatures. Solli et al.[ 8 ] described a 68-year-old woman with a limited pT4N1 lung adenocarcinoma who underwent double prosthetic replacement of the PA and SVC, along with sleeve lobectomy; Daxing Zhu et al.[ 9 ] performed a double sleeve lobectomy and SVC resection for a 65-year-old NSCLC patient with a persistent left SVC; Yifeng Sun and colleagues[ 7 ] reported four locally advanced NSCLC patients who received triple reconstruction of the PA, SVC, and bronchus. In general, it could be concluded that reconstruction of the PA, SVC, and bronchus for locally advanced NSCLC is a technical challenge for thoracic surgeons but is safe and practicable for selected patients, suggesting that certain patients could experience improved clinical outcomes if radical resection is achieved. One of the clinical significances of this surgical method is to preserve the pulmonary function, which improves the quality of life compared to pneumonectomy. It has been reported that pneumonectomy is one of the worst prognostic factors for locally advanced NSCLC with SVC involvement. Furthermore, patients who undergo pneumonectomy or bilobectomy have poorer overall survival and disease-free survival compared to those who undergo lobectomies [ 10 , 11 ]. As patients with malignant superior vena cava syndrome (SVCS) usually require urgent treatment due to a high potential risk of early mortality, another practical significance of this surgical method is the relief of SVC obstruction, which may be beneficial for subsequent anti-tumor therapy[ 12 ]. Actually, Surgery for locally advanced lung cancer has always been subject to controversy all the time[ 13 ]. However, many studies have reported that extended resection for locally advanced lung cancer can achieve clinical benefits. Spaggiari and colleagues[ 14 ] have reported that extended pneumonectomy with partial resection of the left atrium for advanced lung cancer is a feasible procedure with low postoperative morbidity and mortality, leading to excellent local control of the disease. Qinghua Zhou[ 15 ] reported that carinal resection and reconstruction combined with heart and great vessel plasty is technically feasible in treating locally advanced non-small cell lung cancer involving the carina, heart, and great vessels. According to previous studies, for certain locally advanced NSCLC patients with extended resections had a favorable clinical outcomes compared to inoperable patients with a median survival time of 12 months[ 16 ]. Yaron Shargall[ 17 ] reported their 15-year single-center experience with surgical resection of the superior vena cava for NSCLC and found that the patients’ overall survival rates at 1- and 3-year were 68% and 57%, and the disease-free survival rates was 55% and 27%, respectively. Sekine and colleagues[ 18 ] reported on a 74-year-old male diagnosised with pT4N2M0-IIIB stage squamous cell carcinoma had a disease-free survival (DFS) longer than 3 years after underwenting triple reconstruction of the pulmonary artery, superior vena cava, and bronchus. Multiple modality therapy can remarkably increase the survival rate and improve the prognosis and quality of life in these patients. Additionally, it has been reported that patients with N2 disease who underwent induction therapy experienced survival comparable to that of patients with N1-0 disease[ 17 ]. For patients with resectable stage N2 NSCLC, the 5-year survival rate was 30.5% for those who received surgical intervention, compared to 22.2% with chemotherapy and 27% with radiotherapy alone[ 19 ]. Therefore, for certain patients with locally advanced NSCLC, surgical intervention, as an essential component of multimodality therapeutic approaches, can offer a significant survival benefit. Although technically challenging, sleeve resection of the bronchus, PA, and reconstruction of the SVC are safe and practicable for indicated locally advanced NSCLC patients. Key points of these procedures include examining all margins via frozen section and interposing vascularized tissue to protect the anastomosis[ 20 ]. To perform the surgery safely and achieve en bloc resection of the tumor, the surgical approach is crucial. Based on our previous experience, approaches such as posterior lateral incision, median sternotomy, and a two-step approach which offers more advantages than the traditional hemi-clamshell approach[ 4 ], are all viable options. The specific surgery approach depends mainly on the tumor size, the extent of invasion of the hilar structure, and the ease of PA and SVC control. If the tumor is large and invades the SVC and hilar structure obviously (Fig. 1 ), it is extremely difficult to expose these structures through a posterior lateral incision, especially when the tumor is densely adherent to the anterior chest wall. In such cases, freeing the PA and SVC safely is nearly impossible without excellent exposure. Therefore, a two-step approach is suitable to perform this surgery safely and achieve R0 resection as far as possible. Specifically, first, the left brachiocephalic vein is freed and reconnected to the right atrial appendage via median sternotomy, and the reconnected PTFE graft between the left brachiocephalic vein and the right atrial appendage helps increase the return of intracranial venous blood and relieve pressure when the SVC is clamped. Second, the right brachiocephalic vein is freed easily, and the proximal segment of the SVC can be encircled intrapericardially, allowing for safe SVC resection and reconstruction. Third, opening the pericardium at this point facilitates the easy exposure and control of the PA trunk behind the SVC. After SVC reconstruction and PA trunk control, the median sternotomy is closed, and the patient is placed in the left lateral decubitus position to perform a right posterolateral thoracotomy through the fourth intercostal space. This allows for sleeve resection of the right upper lobe, PA or both, and systematic dissection of the right mediastinal lymph nodes. Previous studies have proven that if the tumor is relatively small and the SVC and hilar structure are moderately invaded, a right posterolateral thoracotomy can be selected, [ 7 , 18 ] It is usually necessary to open the pericardium to facilitate the easy exposure and safe encirclement of the PA trunk behind the SVC. Sleeve resection of the right upper lobe, PA or both, and SVC reconstruction can then be routinely accomplished. Considering that the SVC will be clamped during resection and reconstruction, which increases central venous pressure and obstructs intracranial venous blood return, our routine practice is to create an extracorporeal venous shunt connecting the right internal jugular vein to the right femoral vein before surgery (Fig. 2 ). This shunt effectively reduces central venous pressure when the SVC is clamped, minimizing the risk of cerebral edema. Conclusions Sleeve resection of the bronchus, PA, and SVS reconstruction for locally advanced non-small cell lung cancer is technically feasible and safe, which could offer a significant survival benefit for carefully selected patients. Declarations Ethics approval and consent to participate： Approved by Ethics Committee of West China Hospital of Sichuan University, Approval number: 2024-1015. Consent for publication： Every human participant gave permission to use their medical records in this study. Availability of data and materials： No datasets were generated or analysed during the current study. Competing interests: The authors declare no competing interests. Funding: No Funding Authors' contributions: Kaili Huang and Pengfei Li wrote the main manuscript text. Qiang Wu and Wen Li prepared figures 1-7. Xiaojun Tang and Qinghua Zhou designed this topic. All authors reviewed the manuscript. References Lee DS, Flores RM. Superior vena caval resection in lung cancer. Thorac Surg Clin. 2014;24(4):441–7. Kusumoto H, Shintani Y, Funaki S, et al. Combined resection of great vessels or the heart for non-small lung cancer. Ann Thorac Cardiovasc Surg. 2015;21(4):332–7. Dartevelle PG, Mitilian D, Fadel E. Extended surgery for t4 lung cancer: A 30 years' experience. Gen Thorac Cardiovasc Surg. 2017;65(6):321–8. Deng HY, Qin CL, Qiu XM, Tang XJ, Zhu DX, Zhou Q. A two-step surgical approach combining sternotomy and subsequent thoracotomy for locally advanced lung cancers requiring both right upper lung resection and superior vena cava reconstruction. J Thorac Dis. 2018;10(8):4831–7. Tanaka Y, Hokka D, Ogawa H, et al. Surgery for malignant lesions of the chest which extensively involved the mediastinum, lung, and heart. Gen Thorac Cardiovasc Surg. 2017;65(7):365–73. Ettinger DS, Wood DE, Aisner DL, et al. Non-small cell lung cancer, version 3.2022, nccn clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2022;20(5):497–530. Sun Y, Zheng H, Chen Q, et al. Triple plasty of bronchus, pulmonary artery, and superior vena cava for non-small cell lung cancer. Ann Thorac Surg. 2013;95(2):420–4. Solli P, Spaggiari L, Grasso F, Pastorino U. Double prosthetic replacement of pulmonary artery and superior vena cava and sleeve lobectomy for lung cancer. Eur J Cardiothorac Surg. 2001;20(5):1045–8. Zhu D, Qiu X, Zhou Q. Combined double sleeve lobectomy and superior vena cava resection for non-small cell lung cancer with persistent left superior vena cava. Zhongguo Fei Ai Za Zhi. 2015;18(11):718–20. Spaggiari L, Magdeleinat P, Kondo H, et al. Results of superior vena cava resection for lung cancer. Analysis of prognostic factors. Lung Cancer. 2004;44(3):339–46. Spaggiari L, Thomas P, Magdeleinat P, et al. Superior vena cava resection with prosthetic replacement for non-small cell lung cancer: Long-term results of a multicentric study. Eur J Cardiothorac Surg. 2002;21(6):1080–6. Cao S, Zou Y, Lyu T, et al. Safety and efficacy of stent graft implantation for malignant superior vena cava syndrome. Heart Surg Forum. 2021;24(6):E952–7. Spaggiari L, Leo F, Veronesi G, et al. Superior vena cava resection for lung and mediastinal malignancies: A single-center experience with 70 cases. Ann Thorac Surg. 2007;83(1):223–9. discussion 229–230. Spaggiari L, M DA, Veronesi G, et al. Extended pneumonectomy with partial resection of the left atrium, without cardiopulmonary bypass, for lung cancer. Ann Thorac Surg. 2005;79(1):234–40. Zhou Q, Liu B, Yang J, et al. [carinal resection and reconstruction combined with heart and great vessel plasty in the treatment of locally advanced non-small cell lung cancer]. Zhongguo Fei Ai Za Zhi. 2006;9(1):2–8. Hotta K, Kiura K, Fujiwara Y, et al. Role of survival post-progression in phase iii trials of systemic chemotherapy in advanced non-small-cell lung cancer: A systematic review. PLoS ONE. 2011;6(11):e26646. Shargall Y, de Perrot M, Keshavjee S, et al. 15 years single center experience with surgical resection of the superior vena cava for non-small cell lung cancer. Lung Cancer. 2004;45(3):357–63. Sekine Y, Yasufuku K, Motohashi S, Fujisawa T. Triple reconstruction of pulmonary artery, superior vena cava and bronchus for lung cancer. Interact Cardiovasc Thorac Surg. 2006;5(4):509–10. Bakir M, Fraser S, Routledge T, Scarci M. Is surgery indicated in patients with stage iiia lung cancer and mediastinal nodal involvement? Interact Cardiovasc Thorac Surg. 2011;13(3):303–10. Rendina EA, De Giacomo T, Venuta F, Ciccone AM, Coloni GF. Lung conservation techniques: Bronchial sleeve resection and reconstruction of the pulmonary artery. Semin Surg Oncol. 2000;18(2):165–72. Additional Declarations No competing interests reported. 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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-4853915","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":350173805,"identity":"d7bbc867-8a42-4989-b8b8-371fa089833f","order_by":0,"name":"Kai-li Huang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Kai-li","middleName":"","lastName":"Huang","suffix":""},{"id":350173806,"identity":"db71da6f-d2cb-4f36-8571-a86d6d621fdb","order_by":1,"name":"Pengfei Li","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Pengfei","middleName":"","lastName":"Li","suffix":""},{"id":350173807,"identity":"f7cf6936-8043-4e25-9cc1-60f60006c712","order_by":2,"name":"Wu Qiang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Wu","middleName":"","lastName":"Qiang","suffix":""},{"id":350173808,"identity":"0db78c27-9c5c-4bd3-9be2-e81f83070a6f","order_by":3,"name":"Li Wen","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Wen","suffix":""},{"id":350173809,"identity":"b88d7340-2189-459f-8002-f31cb0cb3adb","order_by":4,"name":"Xiaojun Tang","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Xiaojun","middleName":"","lastName":"Tang","suffix":""},{"id":350173810,"identity":"1ec595cc-6624-4909-9eeb-7e25d4cb2b81","order_by":5,"name":"qinghua Zhou","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYDACCQY2ECnHz97Y+PADCVosjCV7DjcbS5CgpSJxw430NgEeYnTw3W5/9uBjm4Sxwc2HbUD9dnK6DQS0SN45kG44s01CTvJ2YtuDAoZkY7MDBLQY3Eg4Js0LtIXvdmK7gQTDgcRthLUktoG0JDbcPNgmwUOclmQ2sJYJNxiJ1CJ5I41NcsY5CWAgJwID2YAIv/DdSH8m8aGsDhiVxx8+/FBhJ0dQCwOqAgNCyjG1jIJRMApGwSjAAgAB6kP+CBfxFwAAAABJRU5ErkJggg==","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"prefix":"","firstName":"qinghua","middleName":"","lastName":"Zhou","suffix":""}],"badges":[],"createdAt":"2024-08-03 15:12:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4853915/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4853915/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":66373434,"identity":"7e4c7e0f-c4ac-48c7-aa82-792ee66816ad","added_by":"auto","created_at":"2024-10-11 05:04:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57146,"visible":true,"origin":"","legend":"\u003cp\u003e1A-B and Fig 5: Superior vena cava (SVC), right pulmonary artery (PA) trunk, and right main bronchus involvement in cancers of right upper lobes. (T=tumor; LN= lymph node)\u003c/p\u003e","description":"","filename":"Figure135.png","url":"https://assets-eu.researchsquare.com/files/rs-4853915/v1/70c107117f0af0bf28bca9b9.png"},{"id":66372668,"identity":"5a11239a-9c86-48cf-9f47-ab317cf32964","added_by":"auto","created_at":"2024-10-11 04:56:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":152715,"visible":true,"origin":"","legend":"\u003cp\u003eAn extracorporeal venous shunt, connecting the right internal jugular vein to the right femoral vein.\u003c/p\u003e","description":"","filename":"Figure222.png","url":"https://assets-eu.researchsquare.com/files/rs-4853915/v1/6c7796df2836ac373d77bc13.png"},{"id":66372669,"identity":"a0b8a4b4-64e7-4c8b-b85c-2b6ef21d06ab","added_by":"auto","created_at":"2024-10-11 04:56:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":218919,"visible":true,"origin":"","legend":"\u003cp\u003eA: Reconstruction of the superior vena cava using a 14-mm diameter ringed PTFE graft (RAA= right atrial appendage). B: The roots of the superior vena cava and the posterior trunk of the right pulmonary artery were exposed within the pericardium, allowing both structures to be clamped when necessary.\u003c/p\u003e","description":"","filename":"Figure322.png","url":"https://assets-eu.researchsquare.com/files/rs-4853915/v1/f3af1643bee439b51f484e38.png"},{"id":66373433,"identity":"6eeb3c14-81f9-47e5-966c-4236a66d25d4","added_by":"auto","created_at":"2024-10-11 05:04:12","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":170965,"visible":true,"origin":"","legend":"\u003cp\u003eSleeve resection of the bronchus and pulmonary Artery.\u003c/p\u003e","description":"","filename":"Figure417.png","url":"https://assets-eu.researchsquare.com/files/rs-4853915/v1/0267273e2e1d24613bfdd822.png"},{"id":66373432,"identity":"dceb1120-3f8f-4255-bc99-d5a621ffba04","added_by":"auto","created_at":"2024-10-11 05:04:12","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":156326,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Figure57.png","url":"https://assets-eu.researchsquare.com/files/rs-4853915/v1/8ef359734ae990c34f90b435.png"},{"id":66372666,"identity":"fb9292db-4628-43c5-9296-3d4cace822a4","added_by":"auto","created_at":"2024-10-11 04:56:12","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":104632,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative CT demonstrated that the vessels remained patent.\u003c/p\u003e","description":"","filename":"Figure66.png","url":"https://assets-eu.researchsquare.com/files/rs-4853915/v1/2fa7425bdbe4ec6a0b9aaf1e.png"},{"id":66372672,"identity":"a6a49bf7-9da5-4870-beae-15ffadee1481","added_by":"auto","created_at":"2024-10-11 04:56:12","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":20257,"visible":true,"origin":"","legend":"\u003cp\u003eOverall survival: Kaplan–Meier curve.\u003c/p\u003e","description":"","filename":"Figure75.png","url":"https://assets-eu.researchsquare.com/files/rs-4853915/v1/8572e94e07d104de259ab6cc.png"},{"id":66373435,"identity":"595ad3fc-34f0-4026-9a82-42be375169ce","added_by":"auto","created_at":"2024-10-11 05:04:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1476490,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4853915/v1/0eca05e7-460f-4e94-8329-4d6b758074c1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sleeve Resection of the Bronchus, Pulmonary Artery, and Superior Vena Cava Reconstruction for Locally Advanced Non-Small Cell Lung Cancer: A Single-Center Retrospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLocally advanced lung cancers invading bronchus, pulmonary artery (PA), and superior vena cava (SVC) present with a unique management challenge in clinical practice[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Most patients are not offered surgical resection due to technical difficulties, concerns about postoperative morbidity and mortality, or minimal survival benefit[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, for certain patients, radical resection might achieve long-term survival[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although double sleeve lobectomies are routine in most thoracic surgical centers, simultaneous SVC resection and reconstruction combined with bronchus sleeve resection, PA sleeve resection, or both, are rarely reported. In this report, we present our preliminary experience with combined extended resection for NSCLC in patients with concomitant involvement of the SVC and bronchus, PA, or both, analyzing technical feasibility and the early and late postoperative outcomes.\u003c/p\u003e"},{"header":"Material and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eBetween 31st January 2014 and 30th December 2023, resection and reconstruction procedures involving the main bronchus, PA, and SVC were performed on 15 patients with NSCLC in our department, including 13 male patients and 2 female patients, with a mean age of 57.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.95 years. Clinical symptoms included SVC obstruction syndrome, persistent dry cough, dyspnea, bloody sputum, and refractory moderate fever. Two patients were found to have a pulmonary mass on physical examination (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\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\u003eMain clinicopathologic data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\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=\"char\" char=\".\" 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 \u003cdiv align=\"char\" char=\".\" 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=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePatient No\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge (y)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHistology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTumor \u003c/p\u003e \u003cp\u003esize (cm)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClinical \u003c/p\u003e \u003cp\u003eTNM\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eInduction\u003c/p\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eApproach\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eOperation time (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBlood loss (mL)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e \u003cp\u003eResection\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eType\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003epTNM\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\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePaclitaxel \u003c/p\u003e \u003cp\u003e +Cisplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003emid-sternal incision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction ,bronchus sleeve, PA sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\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\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eVinorelbine +Cisplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003etwo-step surgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e420\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction ,bronchus sleeve, PA sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\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\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFurmonertinib\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003etwo-step surgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction ,bronchus sleeve, PA sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\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\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePaclitaxel \u003c/p\u003e \u003cp\u003e +Cisplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePosterior lateral thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e6000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction ,bronchus sleeve, PA sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\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\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdenocarcinoma\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\u003eT3N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePemetrexed \u003c/p\u003e \u003cp\u003e +Cisplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePosterior lateral thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction ,Carina reconstruction,bronchus sleeve, PA sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N3M0-IIIC\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\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e....\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePosterior lateral thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e800\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction, PA plasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\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\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT3N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e....\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePosterior lateral thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction, bronchus sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\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\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT3N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e....\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003etwo-step \u003c/p\u003e \u003cp\u003esurgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e220\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction, bronchus sleeve,PA sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSquamous cell carcinoma\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\u003eT4N3M0-IIIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGemcitabine +Cisplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003emid-sternal incision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction, bronchus sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N3M0-IIIC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e....\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003emid-sternal \u003c/p\u003e \u003cp\u003eincision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction ,Carina reconstruction,bronchus sleeve, PA sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT3N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGemcitabine,Etoposide +cisplatin,Radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePosterior lateral thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction ,bronchus sleeve, PA plasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e....\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003etwo-step surgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e2000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction, bronchus sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e....\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePosterior lateral thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e1500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction ,Carina plasty,Right middle bronchus and left principal bronchus reconstruction, PA sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePaclitaxel\u0026thinsp;+\u0026thinsp;Cisplatin, Radiotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003emid-sternal incision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e270\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e4000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction, bronchus sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N0M0-IIIA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSquamous cell carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDocetaxel\u0026thinsp;+\u0026thinsp;cisplatin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003etwo-step surgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSVC reconstruction, bronchus sleeve,PA sleeve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eT4N2M0-IIIB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"12\"\u003eSVC\u0026thinsp;=\u0026thinsp;superior vena cava;PA\u0026thinsp;=\u0026thinsp;pulmonary artery\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePreoperative Evaluation and Treatment\u003c/h2\u003e \u003cp\u003eAll patients underwent preoperative examinations to exclude distant metastasis and confirm the locally advanced nature of the tumors, including the contrast-enhanced brain magnetic resonance imaging, whole-body bone scan, and contrast-enhanced chest and abdominal CT scans. The contrast-enhanced chest CT revealed that all the tumors were located in the right upper lobe. Besides, the hilar structures and superior vena cava (SVC) were invaded either by direct tumor extension or by enlarged invasive lymph nodes, resulting in the near-complete obliteration of the fat space between the bronchus and major vessels (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). The azygos vein appeared tortuous, narrowed, or even absent in some patients. The invaded SVC became narrow or even obstructed; however, the proximal segment of the SVC leading to the right atrium was normal in all patients on CT scans. Despite the tumor extension, both the pulmonary artery trunk and the middle to lower segments were free from tumor involvement. Bronchoscopy revealed the neoplasms were near to the the carina in 3 patinents and located at the right upper lobar orifice in 4 patients. Besides, the bronchus mucous were thick in 4 patients, and the bronchus were narrow in 3 patients. Totally, 8 patients were diagnosed as adenocarcinoma and 7 patients were comfirmed with squamous cell carcinoma by the cytologic examination from bronchoscopies or CT-guided transthoracic needle biopsies, conducted either at our hospital or other institutions. The preoperative clinical stages were T3N2M0-IIIB (4 patients), T4N2M0-IIIB (10 patients), and T4N3M0-IIIC (1 patient). Among them, 9 patients received neoadjuvant treatments including chemotherapy (8 patients), radiotherapy (2 patients), or targeted therapy (1 case). Unfortunately, the specific neoadjuvant regimens for the other 6 patients were unclear. Reevaluations were performed before surgery by a multidisciplinary team (MDT) to exclude contraindications following neoadjuvant therapy.(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were reported as either means with standard deviations or medians with interquartile ranges, depending on their distribution, as assessed by the Shapiro\u0026ndash;Wilk normality test. Categorical variables were reported as percentages.\u003c/p\u003e \u003cp\u003eTo assess mortality rates in patients undergoing complete resection, overall survival (OS) analysis was conducted by the Kaplan\u0026ndash;Meier method, and the OS was defined as the time from the surgery to death from any cause or last follow-up, whichever occurred first. All statistical analyses were conducted using R Studio, version 4.2.2 (The R Project for Statistical Computing).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eSurgical manipulations and procedures from two typical cases\u003c/h2\u003e \u003cp\u003eIn our center, surgical approaches to the tumor primarily include a right posterolateral incision in the fourth intercostal space and a two-step approach, which involves an initial median sternotomy followed by a posterolateral incision[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The principal objective is to ensure the safety of the surgery while achieving complete tumor resection and facilitating the reconstruction of the SVC, PA, or bronchus.\u003c/p\u003e \u003cp\u003eTypical case 1 (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), diagnosed with lung adenocarcinoma, presented with severe cough and facial and neck swelling. After undergoing neoadjuvant therapy (chemotherapy, immunotherapy, and radiotherapy) at another hospital, the patient was then admitted to our department. The chest CT revealed a large mass about 10.0 cm located in the superior lobe of the right lung, invading the SVC and causing a significant narrowing (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA) as well as the right pulmonary trunk (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). In addition, the bronchoscopy indicated that the tumor was occluding the right upper lobar bronchus. Given that the tumor had invaded the SVC, PA, and right upper lobe bronchus, the patient required a double sleeve resection of the right upper lobe and PA, along with reconstruction of the SVC. The procedure was particularly challenging due to the tumor\u0026rsquo;s location at the hilum and its invasion into critical hilar structures, including the SVC, azygos vein, tracheobronchial angle, and PA trunk, making exposure and control of these structures difficult. Based on our previous experience, a two-step surgical approach was undertaken.\u003c/p\u003e \u003cp\u003eThe patient was initially positioned supine, and general anesthesia was administered using a double-lumen endobronchial tube. An extracorporeal venous shunt was then established, connecting the right internal jugular vein to the right femoral vein before surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Following the establishment of the extracorporeal venous shunt, the patient underwent a median sternotomy, during which the left brachiocephalic vein was mobilized, transected, and reconnected to the right atrial appendage using a 10-mm GORE-TEX\u0026reg; vascular graft (W.L. Gore and Associates, AZ, USA) with running 4\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAfter reconstructing the left brachiocephalic vein to the right atrial appendage, the right brachiocephalic vein was addressed. If it proved difficult to mobilize and expose the right brachiocephalic vein, a neck incision above the right clavicle was made to improve the surgical field and anatomical clarity, followed by dissection of the right brachiocephalic vein. Opening the pericardium facilitated the exposure of the SVC root, and the PA trunk behind the SVC was safely mobilized intrapericardially (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). The SVC was then isolated, clamped, and resected. A 14-mm diameter ringed PTFE graft was interposed between the right brachiocephalic vein and the SVC root using running 4\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). Dissection of the right mediastinal lymph nodes (stations 2 and 4) was also performed. The median sternotomy incision was closed in a standard manner.\u003c/p\u003e \u003cp\u003eSubsequently, the patient was repositioned to the left lateral decubitus position and underwent a right posterolateral thoracotomy through the fourth intercostal space. Since the invaded SVC had been transected and the mediastinal side of the tumor freed via median sternotomy, the tumor\u0026rsquo;s mobility was increased, facilitating the exposure of the hilum structure. The PA trunk, already encircled intrapericardially, could be clamped safely and easily (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). The tumor resection involved double sleeve resection of the bronchus and pulmonary artery. An anastomosis between the right main bronchus and the cut end of the middle lobe bronchus was performed using interrupted 3\u0026thinsp;\u0026minus;\u0026thinsp;0 Vicryl sutures (Ethicon, USA). The right PA trunk and right intermediate PA were reconstructed using running 4\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene sutures (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Margins of the bronchus, SVC, and PA were examined under frozen section to ensure tumor-free borders. Radical mediastinal lymph node dissection was performed, including stations 2, 4, 7, 9, and 10. The posterolateral thoracotomy incision was then closed in a standard manner.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTypical case 2 (Fig.\u0026nbsp;5), diagnosed with lung squamous cell carcinoma and presenting with hemoptysis, was admitted to our department after receiving neoadjuvant therapy (chemotherapy plus immunotherapy). Chest CT revealed invasion of the SVC by the tumor and swollen mediastinal lymph nodes (Fig.\u0026nbsp;5). However, the PA appeared to be normal. Bronchoscopy showed the open of right superior lobar bronchial was invaded by the neoplasm. Thus, the patient required sleeve resection of the right superior lobe and SVC resection and reconstruction. Given the tumor\u0026rsquo;s relatively small size and partial SVC invasion, the surgical approach was through a right posterolateral incision in the fourth intercostal space after general anesthesia and the establishment of an extracorporeal venous shunt.\u003c/p\u003e \u003cp\u003eThe procedure began with the release of the hilum and exposure of critical hilar structures: the SVC, azygos vein, PA trunk, and superior pulmonary vein. The pericardium was opened behind the phrenic nerve, facilitating the encircling of the PA trunk beneath the SVC, and allowing safe encirclement of the proximal segment of the SVC intrapericardially. Subsequently, the distal end of the SVC was freed, and the invaded section was clamped and resected. A ringed PTFE graft with a diameter of 14 mm was used for SVC reconstruction with continuous sutures of 4\u0026thinsp;\u0026minus;\u0026thinsp;0 polypropylene.\u003c/p\u003e \u003cp\u003eThe next step was the sleeve resection of the right superior lobe and \u003cem\u003een bloc\u003c/em\u003e removal of the involved lobe. Airway conduit anastomosis between the right main bronchus and the intermediate bronchus was performed using end-to-end 4\u0026thinsp;\u0026minus;\u0026thinsp;0 interrupted absorbable sutures for the back wall and interrupted sutures for the front wall. Radical mediastinal lymph node dissection was completed prior to all these reconstructions, including stations 2, 4, 7, 9, and 10. Finally, the posterolateral thoracotomy incision was closed in a standard fashion.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eComplete resection was conducted in all 15 cases. All patients underwent SVC resection and reconstruction using a ringed PTFE graft with a diameter of 14 mm. The surgical approach varied: mid-sternal incision in 4 patients, right posterior lateral thoracotomy in 6 patients, and a two-step surgical procedure in 5 patients. Among them, 7 patients received simultaneous SVC reconstruction and double sleeve resection (bronchus and PA), 3 patients had SVC reconstruction and double sleeve resection (bronchus and PA) with carina reconstruction, 4 patients underwent SVC reconstruction and bronchus sleeve resection, and 1 patient had SVC reconstruction and PA plasty. Systemic lymphadenectomy was performed on all patients. The mean tumor size was 8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.84cm, the mean operative time was 295\u0026thinsp;\u0026plusmn;\u0026thinsp;91.92 minutes, and the mean operative blood loss was 950\u0026thinsp;\u0026plusmn;\u0026thinsp;353.55 ml. Pathological histology revealed that 7 patients were confirmed with adenocarcinoma and 8 patients with squamous carcinoma. As for the pathological TNM stage, 1 patient was clarified as T4N0M0-IIIA, 12 patients were T4N2M0-IIIB, and 2 patients were T4N3M0-IIIC. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative outcomes and follow-up\u003c/h2\u003e \u003cp\u003eSubcutaneous injection heparin was administered to the patient with PTFE replacement (10,000 IU/day for 5 days) and then oral warfarin taking were last for long-term management to maintain an international normalized ratio (INR) within the range of 1.5-2.0. The mean ICU stay was 3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.82 days and the mean length of hospital stay was 16\u0026thinsp;\u0026plusmn;\u0026thinsp;4.24 days. There was no postoperative mortality. The postoperative course was uneventful for 9 patients. 2 patients (2/15) developed atrial fibrillation on the second and fourth postoperative day, respectively, and both restored sinus rhythm with medical intervention. 1 patient (1/15) developed an acute lung infection due to Acinetobacter baumannii and recovered well after effective anti-infective treatment. Prolonged air leak (\u0026gt;\u0026thinsp;7 days) occurred in 1 patient (1/15) and it was resolved with low-pressure suction on the 13th postoperative day. ARDS and acute heart failure occurred in 1 patient (1/15), which were effectively resolved by non-invasive ventilation, enhancement of cardiac contractility, appropriate reduction of systolic blood pressure, and diuresis to reduce blood volume load. Another patient (1/15) developed postpneumonectomy edema on the second postoperative day and was cured with glucocorticoids, diuresis, anti-infective treatment, and non-invasive ventilation by the 11th postoperative day. Complete follow-up information was obtained for all patients. The vessels, including the PTFE graft, remained patent demonstrated by postoperative CT (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e6\u003c/span\u003e). The median follow-up time was 29 months (range, 3\u0026ndash;64 months), and the OS rates at 1, 3 and 5 years was 80%, 28.6% and 28.6%, respectively (Kaplan-Meier) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e7\u003c/span\u003e) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\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\u003ePostoperative outcome and follow up\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient No\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostoperative Complications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eICU/Hospital\u003c/p\u003e \u003cp\u003eStay (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnticoagulation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOutcome\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\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAlive at 18 months\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\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAlive at 26 months\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\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAlive at 37 months\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\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 14 months\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\u003eInfection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 9 months\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\u003eARDS and Acute heart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9/22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 25 months\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\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4/16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 64 months\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\u003eProlonged air leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 3 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAtrial fibrillation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9/47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 32 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8/62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 10 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8/41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 17 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePostpneumonectomy edema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6/31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 15 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5/18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 13 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15/36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003edied at 24 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5/19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWarfarin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAlive at 40 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eComment\u003c/h2\u003e \u003cp\u003eLung cancers invading the SVC with mediastinal lymph node metastasis were traditionally considered as contraindication for surgery, and the PACIFIC treatment strategy (concurrent chemoradiotherapy followed by sequential Durvalumab immunotherapy) is recommended by the NCCN guidelines [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, evidence has shown that certain patients may benefit significantly from extended surgery if radical resection can be achieved[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Simultaneous sleeve resection of the bronchus and pulmonary artery, along with reconstruction of the superior vena cava for locally advanced NSCLC, is technically challenging and complex, thus it has been performed occasionally and relatively rarely reported in the literatures. Solli et al.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] described a 68-year-old woman with a limited pT4N1 lung adenocarcinoma who underwent double prosthetic replacement of the PA and SVC, along with sleeve lobectomy; Daxing Zhu et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] performed a double sleeve lobectomy and SVC resection for a 65-year-old NSCLC patient with a persistent left SVC; Yifeng Sun and colleagues[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] reported four locally advanced NSCLC patients who received triple reconstruction of the PA, SVC, and bronchus. In general, it could be concluded that reconstruction of the PA, SVC, and bronchus for locally advanced NSCLC is a technical challenge for thoracic surgeons but is safe and practicable for selected patients, suggesting that certain patients could experience improved clinical outcomes if radical resection is achieved.\u003c/p\u003e \u003cp\u003eOne of the clinical significances of this surgical method is to preserve the pulmonary function, which improves the quality of life compared to pneumonectomy. It has been reported that pneumonectomy is one of the worst prognostic factors for locally advanced NSCLC with SVC involvement. Furthermore, patients who undergo pneumonectomy or bilobectomy have poorer overall survival and disease-free survival compared to those who undergo lobectomies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. As patients with malignant superior vena cava syndrome (SVCS) usually require urgent treatment due to a high potential risk of early mortality, another practical significance of this surgical method is the relief of SVC obstruction, which may be beneficial for subsequent anti-tumor therapy[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eActually, Surgery for locally advanced lung cancer has always been subject to controversy all the time[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, many studies have reported that extended resection for locally advanced lung cancer can achieve clinical benefits. Spaggiari and colleagues[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] have reported that extended pneumonectomy with partial resection of the left atrium for advanced lung cancer is a feasible procedure with low postoperative morbidity and mortality, leading to excellent local control of the disease. Qinghua Zhou[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] reported that carinal resection and reconstruction combined with heart and great vessel plasty is technically feasible in treating locally advanced non-small cell lung cancer involving the carina, heart, and great vessels. According to previous studies, for certain locally advanced NSCLC patients with extended resections had a favorable clinical outcomes compared to inoperable patients with a median survival time of 12 months[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Yaron Shargall[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] reported their 15-year single-center experience with surgical resection of the superior vena cava for NSCLC and found that the patients\u0026rsquo; overall survival rates at 1- and 3-year were 68% and 57%, and the disease-free survival rates was 55% and 27%, respectively. Sekine and colleagues[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported on a 74-year-old male diagnosised with pT4N2M0-IIIB stage squamous cell carcinoma had a disease-free survival (DFS) longer than 3 years after underwenting triple reconstruction of the pulmonary artery, superior vena cava, and bronchus. Multiple modality therapy can remarkably increase the survival rate and improve the prognosis and quality of life in these patients. Additionally, it has been reported that patients with N2 disease who underwent induction therapy experienced survival comparable to that of patients with N1-0 disease[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. For patients with resectable stage N2 NSCLC, the 5-year survival rate was 30.5% for those who received surgical intervention, compared to 22.2% with chemotherapy and 27% with radiotherapy alone[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Therefore, for certain patients with locally advanced NSCLC, surgical intervention, as an essential component of multimodality therapeutic approaches, can offer a significant survival benefit.\u003c/p\u003e \u003cp\u003eAlthough technically challenging, sleeve resection of the bronchus, PA, and reconstruction of the SVC are safe and practicable for indicated locally advanced NSCLC patients. Key points of these procedures include examining all margins via frozen section and interposing vascularized tissue to protect the anastomosis[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. To perform the surgery safely and achieve \u003cem\u003een bloc\u003c/em\u003e resection of the tumor, the surgical approach is crucial. Based on our previous experience, approaches such as posterior lateral incision, median sternotomy, and a two-step approach which offers more advantages than the traditional hemi-clamshell approach[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], are all viable options. The specific surgery approach depends mainly on the tumor size, the extent of invasion of the hilar structure, and the ease of PA and SVC control. If the tumor is large and invades the SVC and hilar structure obviously (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), it is extremely difficult to expose these structures through a posterior lateral incision, especially when the tumor is densely adherent to the anterior chest wall. In such cases, freeing the PA and SVC safely is nearly impossible without excellent exposure. Therefore, a two-step approach is suitable to perform this surgery safely and achieve R0 resection as far as possible. Specifically, first, the left brachiocephalic vein is freed and reconnected to the right atrial appendage via median sternotomy, and the reconnected PTFE graft between the left brachiocephalic vein and the right atrial appendage helps increase the return of intracranial venous blood and relieve pressure when the SVC is clamped. Second, the right brachiocephalic vein is freed easily, and the proximal segment of the SVC can be encircled intrapericardially, allowing for safe SVC resection and reconstruction. Third, opening the pericardium at this point facilitates the easy exposure and control of the PA trunk behind the SVC. After SVC reconstruction and PA trunk control, the median sternotomy is closed, and the patient is placed in the left lateral decubitus position to perform a right posterolateral thoracotomy through the fourth intercostal space. This allows for sleeve resection of the right upper lobe, PA or both, and systematic dissection of the right mediastinal lymph nodes. Previous studies have proven that if the tumor is relatively small and the SVC and hilar structure are moderately invaded, a right posterolateral thoracotomy can be selected, [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] It is usually necessary to open the pericardium to facilitate the easy exposure and safe encirclement of the PA trunk behind the SVC. Sleeve resection of the right upper lobe, PA or both, and SVC reconstruction can then be routinely accomplished. Considering that the SVC will be clamped during resection and reconstruction, which increases central venous pressure and obstructs intracranial venous blood return, our routine practice is to create an extracorporeal venous shunt connecting the right internal jugular vein to the right femoral vein before surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This shunt effectively reduces central venous pressure when the SVC is clamped, minimizing the risk of cerebral edema.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSleeve resection of the bronchus, PA, and SVS reconstruction for locally advanced non-small cell lung cancer is technically feasible and safe, which could offer a significant survival benefit for carefully selected patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate：\u003c/p\u003e\n\u003cp\u003eApproved by Ethics Committee of West China Hospital of Sichuan University, Approval number: 2024-1015.\u003c/p\u003e\n\u003cp\u003eConsent for publication：\u003c/p\u003e\n\u003cp\u003eEvery human participant gave permission to use their medical records in this study.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials：\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eNo Funding\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions:\u003c/p\u003e\n\u003cp\u003eKaili Huang and Pengfei Li wrote the main manuscript text. Qiang Wu and Wen Li prepared figures 1-7. Xiaojun Tang and Qinghua Zhou designed this topic. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee DS, Flores RM. Superior vena caval resection in lung cancer. Thorac Surg Clin. 2014;24(4):441\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKusumoto H, Shintani Y, Funaki S, et al. Combined resection of great vessels or the heart for non-small lung cancer. Ann Thorac Cardiovasc Surg. 2015;21(4):332\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDartevelle PG, Mitilian D, Fadel E. Extended surgery for t4 lung cancer: A 30 years' experience. Gen Thorac Cardiovasc Surg. 2017;65(6):321\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeng HY, Qin CL, Qiu XM, Tang XJ, Zhu DX, Zhou Q. 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Ann Thorac Surg. 2005;79(1):234\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou Q, Liu B, Yang J, et al. [carinal resection and reconstruction combined with heart and great vessel plasty in the treatment of locally advanced non-small cell lung cancer]. Zhongguo Fei Ai Za Zhi. 2006;9(1):2\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHotta K, Kiura K, Fujiwara Y, et al. Role of survival post-progression in phase iii trials of systemic chemotherapy in advanced non-small-cell lung cancer: A systematic review. PLoS ONE. 2011;6(11):e26646.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShargall Y, de Perrot M, Keshavjee S, et al. 15 years single center experience with surgical resection of the superior vena cava for non-small cell lung cancer. Lung Cancer. 2004;45(3):357\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSekine Y, Yasufuku K, Motohashi S, Fujisawa T. Triple reconstruction of pulmonary artery, superior vena cava and bronchus for lung cancer. Interact Cardiovasc Thorac Surg. 2006;5(4):509\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBakir M, Fraser S, Routledge T, Scarci M. Is surgery indicated in patients with stage iiia lung cancer and mediastinal nodal involvement? Interact Cardiovasc Thorac Surg. 2011;13(3):303\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRendina EA, De Giacomo T, Venuta F, Ciccone AM, Coloni GF. Lung conservation techniques: Bronchial sleeve resection and reconstruction of the pulmonary artery. Semin Surg Oncol. 2000;18(2):165\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e\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":"NSCLC, superior vena cava (SVC), bronchus sleeve, pulmonary artery (PA) sleeve","lastPublishedDoi":"10.21203/rs.3.rs-4853915/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4853915/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCombined sleeve resection of the bronchus, pulmonary artery (PA), and reconstruction of the superior vena cava (SVC) is occasionally indicated in the treatment of non-small cell lung cancer. However, simultaneous reconstruction of the SVC, sleeve resection of the bronchus and PA for right upper lobe central-type lung cancers presents significant technical challenges for surgeons. In this study, we describe our experience with this surgical procedure and the associated clinical outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFrom 31st January 2014 to 30th December 2023, 15 patients confirmed with non-small cell lung cancer (NSCLC) who underwent SVC resection combined with sleeve resection of the bronchus and/or PA following induction treatment were enrolled in this stuy. The surgical approaches employed included mid-sternal incision in 4 patients (26.7%), right posterolateral thoracotomy in 6 patients (40%), and two-step surgical approach (initially via a mid-sternal incision followed by a right posterolateral thoracotomy) in 5 cases (33.3%). Among these patients, 7 (46.7%) cases underwent simultaneous SVC reconstruction and double sleeve resection (bronchus and PA), 3 (20%) underwent simultaneous SVC reconstruction and double sleeve resection (bronchus and PA) with carina reconstruction, 4 (26.7%) underwent simultaneous SVC reconstruction and bronchus sleeve resection, and 1 (6.7%) underwent SVC reconstruction and PA plasty. Systemic lymphadenectomy was performed in all patients.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll resections were completely resectable (R0). Histological analysis revealed 7 patients (46.7%) were adenocarcinoma and 8 (53.3%) patients were squamous cell carcinoma. Besides, 1 (6.7%) patient was classified as stage pT4N0M0-IIIA, 12 (80%) patients as stage pT4N2M0-IIIB, and 2 (13.3%) patients as stage pT4N3M0-IIIC. No perioperative deaths occurred. The major complication rate was 40% after surgery. The median follow-up duration was 29 months, and the overall survival rates at 1, 3, and 5 years were 80%, 28.6%, and 28.6%, respectively.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eCombined resections of the bronchus, PA and SVC are technically feasible and safe for patients with locally advanced NSCLC. For carefully selected patients, this extended resection surgery may lead to favorable long-term survival.\u003c/p\u003e","manuscriptTitle":"Sleeve Resection of the Bronchus, Pulmonary Artery, and Superior Vena Cava Reconstruction for Locally Advanced Non-Small Cell Lung Cancer: A Single-Center Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-11 04:56:07","doi":"10.21203/rs.3.rs-4853915/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-15T10:08:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-05T16:02:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-04T09:17:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"154803634421865418769159805340938436763","date":"2024-09-04T08:59:23+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-01T13:21:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-01T10:23:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70369040224431302681004252394781930438","date":"2024-08-28T18:39:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224200262726343935111885269838063814732","date":"2024-08-26T13:37:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"142053110097968516915642706068932938631","date":"2024-08-25T22:36:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-25T20:00:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109115283445088012435197599671292484628","date":"2024-08-25T19:12:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267941643827079168042814791782291366924","date":"2024-08-25T16:01:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301330031265210251284473493164104460533","date":"2024-08-25T15:41:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20525624091030291407145885211552275310","date":"2024-08-24T05:28:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-23T15:03:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-13T22:49:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-13T22:48:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2024-08-03T15:10:55+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":"ff9ec36c-d24c-44f4-9cb6-3da0541919ba","owner":[],"postedDate":"October 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-12-24T14:08:07+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-11 04:56:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4853915","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4853915","identity":"rs-4853915","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}