Importance of the multidisciplinary approach in the surgical treatment of giant mediastinal neoplasms: a case series

Introduction

Background

Oncologic diseases often make physician deal with complex clinical situations requiring interaction between several specialists. In the last decades, multidisciplinary team (MDT) meetings have been supported in literature as a standard of care in order to offer the best treatment strategies. Indeed, the cooperation of specialists with different backgrounds, skills and clinical experience allow to customize the best therapeutic and diagnostic pathway (1,2). As well, MDT meetings [defined also as tumor boards (TB)] ensure several advantages in oncologic patients’ management, such as overall survival improvement, better staging accuracy and global adherence to guidelines (3-6). Being also suggested by lung cancer treatment guidelines, MDT meetings showed to improve the patients’ access to surgery, radiotherapy and chemotherapy (7,8). Despite this, the models of TB are very different across all health services and it seems not easy to standardize their capability (9).

Rationale and knowledge gap

We previously emphasized how MDT meetings succeed in tailor surgical plan. Indeed, the collaboration of different expertise makes possible to deal with challenging or apparently impossible surgical interventions (10,11). The difficulty is often related to the mediastinal involvement of primary neoplasia so that cooperation and planning of surgical steps become crucial (12,13).

Objective

In this paper, we aimed to emphasize the essential role of cooperation between different surgical specialist (overall cardio-thoracic and vascular surgeons) in order to customize the most appropriate strategy.

Methods

We report a retrospective, single-center case series of four patients affected by primary mediastinal tumor with huge extension to adjacent critical structures. All these cases were discussed into the MDT meetings in order to plan the correct procedure. Our MDT comprises oncologists, cardio-thoracic, vascular and plastic surgeons, pulmonologists, diagnostic and interventional radiologists, anesthesiologist and pathologists. It is scheduled weekly, on Monday. It is committed to lung cancer and mediastinal tumors. We usually discuss every oncologic case. We often perform our surgical procedures together with vascular and plastic surgeons. In this paper, we focalized on the most particular cases we dealt with (main characteristics are listed in Table 1). The surgical steps are synthesized with a brief schema for every case. We present this case series in accordance with the AME Case Series reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-23/rc).

Case presentation

Case #1

A 70-year-old man presented in outpatient setting (never smoker and without significant comorbidities). Because of fever onset he underwent chest X-ray examination that showed minimal left pleural effusion. Medical therapy was indicated with a new chest X-ray examination at 10 days which showed slight increase in left pleural effusion. So, the patient underwent contrast-enhanced chest computed tomography (CT) scan that revealed the presence of voluminous thymic neoformation (8 cm × 3.5 cm × 11 cm) with close relationship with the superior vena cava (SVC), right pulmonary artery (PA) and right atrium. The patient performed a positron emission tomography (PET)-CT scan with 18-fluorodeoxyglucose (18-FDG) with detection of unique uptake from the thymic lesion [maximum standard uptake value (SUVmax), 3.3]. A CT guided biopsy yielded a type A thymoma diagnosis (Figure 1). During our MDT meeting we discussed about the histologic data with our pathologist and the interventional radiologist who performed the biopsy. They both assessed the reliability of the specimen. We preferred to avoid a surgical biopsy because of the risk of tumor seeding (14).

Figure 1 Case #1 pre-surgical computed tomography scan.

So, after MDT discussion, the patient was candidated to upfront surgical resection. We performed a median sternotomy. The surgical exploration confirmed the adhesion of the tumor to right atrium, SVC with extension to both anonymous veins, ascending aorta and right PA. The neoplasia was accurately separated from all these structures except of right phrenic nerve, SVC and left anonymous vein because of clear signs of infiltration. Therefore, the right phrenic nerve was cut. Then, we dissected the SVC and performed an end-to-end anastomosis between the two caval stump and an end-to-side anastomosis with the left brachiocephalic trunk, using a polytetrafluoroethylene (PTFE) prosthesis (15). All these surgical steps were carried out with vascular surgeon cooperation.

Case No. 1 schema: after median sternotomy, right phrenic nerve, SVC and left anonymous vein infiltration were found. Right phrenic nerve was cut and a prosthetic vascular anastomosis between SVC and anonymous vein stump was sewn.

After surgery, the patient was transferred to intensive care unit (ICU) and then to sub-intensive geriatric unit to assure perioperative monitoring and a faster recovery. The final histological examination reported a type-B3 Thymoma, with a single metastatic peritumoral lymph-node and microscopic infiltration of fat mediastinal tissues and right atrial resection margin [stage III according to Masaoka-Koga, pT4 pN1 pMx according to Tumour, Node, Metastasis (TNM) VIII ed.].

The case was discussed again at our MDT meeting and an adjuvant radio-chemotherapy was indicated (16). Later the patient underwent radiotherapy on two single bone metastases, occurred 4 years after the operation, and on a small mediastinal malignancy relapse, occurred 5 years after the operation. Nowadays (6 years after the operation) the patient is still alive and in good clinical conditions with last oncologic follow-up being at September 2023. The vascular anastomosis is still patent on control CT scan.

Case #2

A 52-year-old patient—affected by type 1 neurofibromatosis, obesity and chronic ischemic heart disease—was discussed to our weekly scheduled MDT meeting. He had already undergone a surgical removal of a malignant peripheral nerve sheath tumor of the left sternocleidomastoid muscle with subsequent radiotherapy. The last CT and magnetic resonance scans showed relapse of malignancy with evidence of a 7 cm ×7 cm solid lesion implicating: multifragmentary fracture of the left clavicle sternal extremity; infiltration of the left pectoral muscle median insertion; extension to antero-superior mediastinum that caused encasement of the left jugular and left subclavian veins with associated neoplastic thrombosis (Figure 2) that extended to the cranial portion of the SVC.

Figure 2 Case #2 pre-surgical computed tomography scan.

After MDT evaluation the patient was candidate to a radical surgery. We performed a left hemi-clamshell approach. We carried out the neoplasm excision en bloc with left clavicle, first left rib, left sternal hemi-manubrium and left anonymous vein. Before that we extract the neoplastic thrombus via a longitudinal cavotomy (after clamping the SVC next to the atrium and caval tributaries). We rebuilt the thoracic wall using a Teflon prosthesis and a titanium bar attached between the second left rib’s anterior arch and the contralateral one. Then the plastic surgeons performed a vertical rectus abdominis myocutaneous flap (VRAM flap) based on the right superior epigastric pedicle (the right internal mammary artery was saved).

Case No. 2 schema: after a left hemi-clamshell incision, left clavicle, first left rib, left sternal hemi-manubrium and left anonymous vein infiltration were confirmed. Neoplasm excision with the infiltrated structures was performed. Thoracic wall reconstruction was carried out via a Teflon prosthesis, titanium bar and VRAM flap placement.

After surgery, the patient was transferred to ICU where a tracheostomy was performed in order to supply the low muscle exertion due to surgical demolition and obesity. After that he was sent to sub-intensive geriatric unit to assure perioperative monitoring and a faster recovery. The post-operative course was complicated by occurrence of purulent collection of soft tissues at the left pectoral level that was successfully treated with percutaneous drainage and antibiotic drugs. Finally, the patient was discharge to a respiratory rehabilitation center. The final histology assessed a completed microscopic resection (R0). After that the patient started a biologic therapy with pazopanib that he maintained until the exitus (22 months after the operation).

Case #3

A 41-year-old woman presented to the emergency department for dyspnea. A contrast-enhanced chest CT scan was performed showing a huge anterior mediastinal mass adherent to SVC, pulmonary vessels, aortic arch and pericardium and causing compression of trachea and principal bronchial branches. Histological examinations yielded a monophasic synovial sarcoma diagnosis (the biopsy was performed via an anterior mediastinotomy at another hospital). First the patient underwent a chemotherapy treatment (epirubicin/ifosfamide) for 4 months. The control CT scan did not demonstrate any significant decrease in the mass dimension (Figure 3).

Figure 3 Case #3 pre-surgical computed tomography scan.

After MDT discussion, the patient was candidated to a cytoreductive debulking intervention. A right hemi-clamshell incision was performed with a left antero-lateral thoracotomy in addition to control the mediastinal neurovascular structures. The tumor encased right phrenic nerve for one third of the course and left phrenic nerve for two thirds. The anterior SVC wall was removed because of neoplastic infiltration and then reconstructed with a patch. When the neoplasia was entirely removed, plastic surgeons with proven expertise with neural anastomosis reassembled phrenic nerve fibers. The right phrenic nerve was reconstructed with a 10-cm orthotopic graft belonging to the residual left phrenic nerve. At the end, a Teflon prosthesis was fixed to the sternum and to the second rib. Thoracic wall was stabilized by a titanium bar fastened to the anterior arch of both the second ribs (Figure 4).

Figure 4 Case #3 post-surgical computed tomography scan.

Case No. 3 schema: after a right hemi-clamshell incision and a left antero-lateral thoracotomy, bilateral phrenic nerve and anterior SVC wall infiltration were found. Neoplasm excision with phrenic nerves portion and SVC wall infiltrated were performed. Right phrenic nerve was reconstructed with orthotopic graft by residual left phrenic nerve stump and SVC wall was repaired. Thoracic wall was reconstructed via a Teflon prosthesis and titanium bar placement.

Forty-eight hours after the procedure, the patient removed the orotracheal tube and was tracheostomized. Firstly, we keep the mechanical ventilation to supply diaphragm initial paralysis. With regular exercise of auxiliary respiration muscles, there was a progressive improvement in respiratory function evidenced by serial arterial blood gases and confirmed by echographic M-mode scan which evaluated diaphragmatic movement in condition of maximal inspiration and expiration.

After a rehabilitation path, 5 months after surgery, tracheostomy was finally removed. Later the patient underwent radiotherapy for sternal oncologic relapse (1 year after the operation). Then, after further MDT evaluation, she was assigned to percutaneous ablation and stereotactic body radiation therapy of two different lung metastases (2 and 3 years after the operation). Then she started chemotherapy until the exitus (4 years after the operation).

Case #4

A 23-year-old patient presented to our outpatient ward. She had recently received a myasthenia gravis (MG) diagnosis. After that she underwent a thorax CT scan that showed a huge anterior mediastinal lesion adherent to SVC, left PA and vein, aortic arch and pericardium and causing compression of left jugular, subclavian and anonymous vein (Figure 5). Histological examinations yielded a type B3 thymoma diagnosis (the biopsy was performed via an anterior mediastinotomy at another hospital). First the patient underwent a chemotherapy treatment (cisplatin, doxorubicin and cyclophosphamide, three cycles). The CT scan control demonstrated a low response to the treatment, with partial rehabilitation of anonymous vein lumen. So, the case was presented to our MDT meeting and the patient was candidated to a radical surgical intervention.

Figure 5 Case #4 pre-surgical computed tomography scan.

A left hemi-clamshell incision was performed. The surgical exploration confirmed the thymic neoplasm infiltrating the mediastinal structures as well as CT scan reported, including left phrenic nerve. First, we performed a pericardiotomy to confirm the possible separation of the tumor from the ascending aorta, common trunk of the PA and myocardium. After visualization of the right phrenic nerve—not infiltrated by the tumor—and ligation of jugular and subclavian vein, clamping of the SVC was performed below the infiltrated tract. We cleaved the tumor from the SVC and collected a vascular suturing by continuous of Prolene 4/0 to restore the caval circulation. We finally carried out a left pneumonectomy en bloc with thymic tumor and retrosternal fat. We used bovine pericardium and a Teflon prosthesis to reconstruct the pericardium.

Case No. 4 schema: after a left hemi-clamshell incision, a pericardiotomy was performed to assess cleavage of ascending aorta, pulmonary trunk and myocardium. SVC wall and left phrenic nerve infiltration were found. SVC repair, left phrenic nerve cut, thymectomy and left pneumonectomy was carried out. Pericardium was reconstructed with bovine pericardium and Teflon prosthesis.

Then the patient was tracheostomized in order to supply the low muscle exertion due to MG. The post-operative course was complicated by right jugular vein thrombosis successfully treated with oral anticoagulant therapy (Figure 6).

Figure 6 Case #4 post-surgical computed tomography scan.

With regular exercise of respiration muscles, there was a progressive improvement in respiratory function evidenced by arterial blood analysis. Finally, the patient was discharge to a respiratory and neurologic rehabilitation center. The final histological examination confirmed a type B3 Thymoma (stage IVb according to Masaoka-Koga, pT4 pN1 pMx according to TNM VIII ed.). Later the patient underwent adjuvant radiotherapy and nowadays she lives in good clinical conditions, without sign of malignancy relapse (1 year after the operation).

Ethical consideration

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for the publication of this case series and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Key findings

We reported a case series of four patients affected by different primary tumors with huge mediastinal and vascular involvement. Every patient was discussed at our MDT meeting where surgical indications were established. Our MDT consists of surgeons, oncologists, diagnostic and interventional radiologists, radiotherapists, pulmonologists, anesthesiologist and pathologists. Sharing with other colleagues these borderline cases in our meeting and planning surgical interventions with other surgeons, allowed us to customize the more appropriate treatment (17,18). We usually have a further assessment of the case in our MDT after surgical treatment. The effort of our colleagues, above all the radiotherapist, is essential because they often handle the following diagnostic and therapeutic step, for adjuvant therapy or follow-up. The patients usually report a good overall satisfaction of our approach that helped them to feel the real focus of our work.

Strengths and limitations

Our paper recognizes as main limitation the very small sample size that is also due to the peculiar characteristics of such clinical cases. These cases are not standardized and also very heterogeneous for age, histology and comorbidities.

Comparison with similar researches

Some reports in literature emphasized how cooperation among surgeons is of paramount importance (see Table 2). Starting form a two-surgeon approach, multidisciplinary surgery proved safety, efficiency and was able to offset low or mid-volume of operations performed in a single center (19). Also, in the pediatric setting multidisciplinary surgery yielded low complication rates and optimal surgical outcomes (20,21). Furthermore, multidisciplinary planning is cornerstone of surgical treatment of sarcomas, in particular the ones involving the abdomen and the pelvic region. In these cases, the collaboration between different specialities allowed surgeons to perform very challenging operations (22). For what regards lung cancer, collaboration with spine-committed orthopedic is also important when primary tumor invades thoracic vertebrae (23). Above all others, vascular surgeons play a very significant role. They are often involved in cancer operations requiring critical vascular dissection or reconstruction. Some authors highlighted the importance of preoperative planning together in a multidisciplinary context rather than call for a vascular surgeon as rescue emergency treatment (24). Indeed, our group has a deep working link with vascular surgeon that are always included into our pre-surgical discussion. Furthermore, we work every day in the same ward at the hospital and this encourages our routine comparison and information sharing.

Explanations of findings

Cooperation among different surgery specialities is of paramount importance when it comes to deal with challenging oncologic patients.

Implications and actions needed

As long as multidisciplinary approaches are becoming the standard of care, the sharing of surgical expertise and preoperative planning should become a milestone of TB. Further and larger reports are needed in order to clearly define and establish the basic role of various surgical specialists into the multidisciplinary oncologic debate. It could be very interesting to build a management collaborative protocol aiming to deal with complex mediastinal neoplasms.

Conclusions

This report emphasizes how multidisciplinary surgical approach gives the chance to deal with very challenging oncologic situations. The sharing of expertise, preoperative planning and collaboration of different specialities is milestone of surgical treatment of borderline cases. These peculiar indications should be discussed into a TB considering the tumor histology, neoadjuvant treatment, age, comorbidities, life expectancy and patient’s will.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-23/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-23/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-23/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for the publication of this case series and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

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

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