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• W2012974508 abstract "We report a patient with left apical lung carcinoma involving the left subclavian artery with the origin of the vertebral artery who had hypoplasia of the right vertebral artery and the bilateral posterior communicating arteries. After induction chemoradiotherapy, a vein graft was used to create a bypass between the left common carotid artery and the vertebral artery, followed by a successful left upper lobectomy with combined resection of the subclavian artery together with the left vertebral artery. Because anatomic variations of vertebral arteries and cerebral arterial circle are known, preoperative evaluation of the cerebral blood flow should be performed and a relevant reconstruction considered. We report a patient with left apical lung carcinoma involving the left subclavian artery with the origin of the vertebral artery who had hypoplasia of the right vertebral artery and the bilateral posterior communicating arteries. After induction chemoradiotherapy, a vein graft was used to create a bypass between the left common carotid artery and the vertebral artery, followed by a successful left upper lobectomy with combined resection of the subclavian artery together with the left vertebral artery. Because anatomic variations of vertebral arteries and cerebral arterial circle are known, preoperative evaluation of the cerebral blood flow should be performed and a relevant reconstruction considered. Various advances in surgical techniques and chemoradiotherapy have been reported in the treatment of patients with apical lung carcinomas, including those with vascular involvement. Resection of the subclavian artery, including the origin of the vertebral artery, is sometimes required in these patients, and special attention must be given to the anatomic variation of the arteries at the base of the brain because various anomalies of those arteries have been reported. We present a patient who had left apical lung carcinoma involving the left subclavian artery with the origin of vertebral artery and who had hypoplasia of the right vertebral artery and the bilateral posterior communicating arteries. After induction chemoradiotherapy, a bypass operation between the left common carotid artery and the vertebral artery was performed using a vein graft, followed by a successful left upper lobectomy with combined resection of the left subclavian artery, without any surgical or neurologic morbidity. A 60-year-old man underwent resection of an oral carcinoma in situ at a local medical center. Magnetic resonance imaging performed as a preoperative examination incidentally revealed a small mass in the apex of the left lung, which showed an enlargement to 40 mm in diameter in a computed tomography scan at 6 months. The mass involved the left subclavian artery, including the origin of the vertebral artery, which suggested a clinical diagnosis of lung carcinoma (Fig 1). The value of his serum carcinoembryonic antigen was elevated to 51.3 ng/mL. Percutaneous computed tomography-guided fine-needle biopsy established a histologic diagnosis of adenocarcinoma. Positron emission tomography and brain magnetic resonance imaging showed no evidence of mediastinal nodal involvement or distant metastasis, and his clinical stage was judged to be T4 N0 M0. The patient was referred to us, and induction chemoradiotherapy consisting of two cycles of chemotherapy with 80 mg/m2 of cisplatin at day 1 and 20 mg/m2 of vinorelbine on days 1 and 8, combined with 40 Gy of radiation, was performed. Computed tomography imaging after the chemoradiotherapy revealed the size reduction of the tumor to 20 mm in diameter, which still showed vascular involvement. The serum carcinoembryonic antigen level decreased to 5.2 ng/mL. In preparation for combined resection of the origin of the left vertebral artery, we performed cerebral magnetic resonance angiography, which revealed hypoplasia of the right vertebral artery and the bilateral posterior communicating arteries (Fig 2). The blood flow of the basilar arterial system was primarily dependent on the left vertebral artery, and an irreversible cerebral ischemia was anticipated by the resection of the left vertebral artery. The patient was referred to the Department of Neurosurgery, and a bypass was created between the left common carotid artery and the vertebral artery. After a right saphenous vein graft was harvested, a side-to-end anastomosis of the left common carotid artery to the vein graft as well as a side-to-end anastomosis of the left vertebral artery to the vein graft was performed. The proximal part of the left vertebral artery was ligated. Three weeks after the bypass operation, resection of the lung carcinoma was performed with a modification of the anterior approach, as described by Dartevelle and colleagues [1Dartevelle P.G. Chapelier A.R. Macchiarini P. et al.Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet.J Thorac Cardiovasc Surg. 1993; 105: 1025-1034PubMed Google Scholar] and Rusca and colleagues [2Rusca M. Carbognani P. Bobbio P. The modified “hemi-clamshell” approach for tumors of the cervicothoracic junction.Ann Thorac Surg. 2000; 69: 1961-1963Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. Briefly, a collar incision along the superior edge of the left clavicle was connected to a median sternotomy, which was extended to a left anterolateral thoracotomy at the fourth intercostal space. The left half part of the sternum was transected to the second and fourth intercostal spaces, and the first rib was also cut at the midclavicular line. The tumor adhered firmly to the subclavian artery, and a part of the subclavian artery, including the origin of the vertebral artery, was resected. The tumor did not invade the first rib or the brachial plexus. A left upper lobectomy with mediastinal node dissection followed. We did not reconstruct the left subclavian artery because pulse oximetry of the left fingers showed good pulsation during the operation, indicating a sufficient collateral blood flow to the left upper limb. The patient's postoperative course was uneventful, and he kept the full use of his left arm. He left our hospital on day 29 after the operation. Histopathologic examination of the resected specimen revealed no residual viable cancer cells, and the effect of the preoperative chemoradiotherapy was judged to be pathologic complete remission. Cicatricial tissue in the apex of the left upper lobe reached the adventitial layer of the subclavian artery in succession. Many anatomic variations of vertebral arteries and cerebral arterial circle are known [3Matula C. Trattnig S. Tschabitscher M. Day J.D. Koos W.T. The course of the prevertebral segment of the vertebral artery: anatomy and clinical significance.Surg Neurol. 1997; 48: 125-131Abstract Full Text PDF PubMed Google Scholar, 4Krabbe-Hartkamp M.J. Van Der Grond J. De Leeuw F.E. et al.Circle of Willis: morphologic variation on three-dimensional time-of-flight MR angiograms.Radiology. 1998; 207: 103-111PubMed Google Scholar]. Matula and colleagues [3Matula C. Trattnig S. Tschabitscher M. Day J.D. Koos W.T. The course of the prevertebral segment of the vertebral artery: anatomy and clinical significance.Surg Neurol. 1997; 48: 125-131Abstract Full Text PDF PubMed Google Scholar] studied 402 vertebral arteries and found a hypoplastic vertebral artery, defined as a diameter of less than 3.5 mm, in 16 (7.0%), right vertebral artery hypoplasia in 11 (4.8%), and left vertebral artery in 5 (2.2%). The percentage of the cerebral arterial circle with incomplete configuration was 58% in a magnetic resonance angiography study by Krabbe-Hartkamp and colleagues [4Krabbe-Hartkamp M.J. Van Der Grond J. De Leeuw F.E. et al.Circle of Willis: morphologic variation on three-dimensional time-of-flight MR angiograms.Radiology. 1998; 207: 103-111PubMed Google Scholar]. They defined hypoplasia as a vessel with a diameter of smaller than 0.8 mm and reported the percentage of incomplete anterior part of the circle was 26% and an incomplete posterior part was 48% [4Krabbe-Hartkamp M.J. Van Der Grond J. De Leeuw F.E. et al.Circle of Willis: morphologic variation on three-dimensional time-of-flight MR angiograms.Radiology. 1998; 207: 103-111PubMed Google Scholar]. In the present patient, hypoplasia of the right vertebral artery and bilateral posterior communicating arteries was observed, and the blood flow of the basilar arterial system was dependent on the left vertebral artery. Although it appears that combined hypoplasia of the cerebral arterial system, as seen in the present patient, is rare, preoperative evaluation of the cerebral blood flow in patients undergoing resection of the vertebral artery is important because irreversible cerebral ischemia would be anticipated in such cases. For this reason, we routinely obtain cerebral magnetic resonance angiography in patients with apical lung carcinoma where resection of the vertebral artery is expected. On the basis of the obtained picture of the cerebral blood flow, we successfully accomplished a complete resection of the lung carcinoma after the left common carotid artery-vertebral artery bypass procedure using a short vein graft without any surgical or neurologic complications. This report demonstrates a complete resection of apical lung carcinoma with subclavian artery involvement after cerebral blood flow reconstruction." @default.
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• W2012974508 date "2010-07-01" @default.
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• W2012974508 title "Resection of Apical Lung Carcinoma Involving the Vertebral Artery" @default.
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