Complete Pathologic Response of Squamous Cell Carcinoma Abutting an Internal Mammary Bypass Graft

We present a case of an advanced squamous cell carcinoma encroaching on patient’s left internal mammary artery bypass graft. Tumor board consensus was to proceed with 2 cycles neoadjuvant chemotherapy followed by resection. Intraoperatively, the could not be safely dissected from adjacent pleura, but frozen sections were negative for malignant transformation. Final pathologic examination showed complete response chemotherapy, and surveillance imaging is now recurrence 5 years postoperatively. Although neoplasms invading into vasculature can post technical challenges during operation, therapy downstage these tumors make resection feasible without added morbidity. Lung (SCC) pose in treatment, given its typically more stage at diagnosis characteristically central location. SCC associated up 30% shorter median survival compared other non–small lung cancers. Administration therapy, most commonly combined radiation improve resectability locally tumors, especially invasion critical surrounding structures. upper lobe impinging (LIMA) graft that successfully treated while sparing LIMA bypass. A 76-year-old former smoker (60 pack-years) history 3-vessel coronary grafting (CABG) presented our clinic multiple weeks persistent cough, hemoptysis, weight loss. Clinical unremarkable. Chest computed tomography (CT), however, revealed mass borderline enlarged mediastinal hilar lymph nodes. Positron emission scan hypermetabolism mass, nodes, distal paratracheal node. Endobronchial ultrasound transbronchial biopsy confirmed nondiagnostic subcarinal Mediastinoscopy sampling levels 2R/L, 4R/L, 7 nodes metastatic disease. Thus, tumor clinically staged as IIIA (T3 N1). Operative planning complicated fact abutted patent Coronary CT angiography proximal compression neoplasm flow (Figure). would have provided best rate setting, induction alone, risks irradiating He underwent carboplatin nab-paclitaxel minimal adverse effects. The demonstrated excellent clinical reduction size 9.1 × 5.5 cm 6.0 3.2 change solid lesion primarily cystic cavity. In joint operation involving both thoracic cardiac surgeons, patient redo sternotomy lobectomy, regional lymphadenectomy, total pulmonary decortication. Preoperative catheterization completely dependent through Vein mapping performed, legs prepared venous needed obtained. Percutaneous access femoral vein also rapidly initiate cardiopulmonary bypass, which offloading heart protective against myocardial ischemia, although we cool additional protection. During dissection, adherent pleura fully freed. Frozen this pleural margin cancer, so decision made leave behind small edge rather than compromise integrity remainder postoperative hospital course overall unremarkable, discharged day 5. (ypT0 N0) no residual primary (0% viable cells) 16 After resection, serial screenings been continues follow-up oncology service surveillance. cancer remains leading cause cancer-related death world. However, advances are dynamically changing landscape treatment. Platinum-based doublet like received has traditionally considered standard care SCC.1Socinski M.A. Obasaju C. Gandara D. et al.Current emergent options cancer.J Thorac Oncol. 2018; 13: 165-183Abstract Full Text PDF PubMed Google Scholar rates low chemotherapy. review trials (including platinum-based trials) found between 0% 16%.2Hellmann M.D. Chaft J.E. William W.N. al.Pathologic after resectable cancers: proposal use “major response” surrogate endpoint.Lancet 2014; 15: e42-e50Abstract Scopus (309) Our patient, who had carboplatin, exception, norm, exception may long. Neoadjuvant immunotherapy recently shown great promise treating cancer. Early assessing addition pembrolizumab or atezolizumab 45% 50%.3Shen Wang J. Wu al.Neoadjuvant treatment IIB-IIIB carcinoma.J Dis. 2021; 1760-1768Crossref (27) Scholar,4Shu C.A. Gainor J.F. Awad M.M. patients non-small-cell cancer: open-label, multicentre, single-arm, phase trial.Lancet 2020; 21: 786-795Abstract (284) Immunotherapy soon replace because studies suggested does survival5Krantz S.B. Mitzman B. Lutfi W. chemoradiation shows advantage alone patients.Ann Surg. 105: 1008-1016Abstract (24) worse outcomes.6Martinez-Meehan Dhupar R. al.Factors cancer.Clin Cancer. 349-356Abstract (9) These innovations potential outcomes all improving cancers risk factors, such CABG complicate presence adhesive prior series, undergoing twice likely hemorrhage (6.8% vs 3.5%; P = .009), those trended toward increased complications.7Akcam T.I. Samancilar O. Yazgan S. al.Lung surgery graft: multicentre study.Heart Circ. 30: 454-460Abstract (2) Left lesions prove challenging, their proximity grafts, series suggest accomplished. (n 27) morbidity short-term deaths resection; two-thirds early-stage (16/27 1 3/27 2), only 3 27 chemotherapy.8Wei Broussard Bryant A. Linsky P. Minnich D.J. Cerfolio R.J. lobectomy grafting.J Cardiovasc 2015; 150: 531-535Abstract contrast, raising concern possible need Fortunately, specimens border transformation, allowing us spare preserve existing conclusion, whereas often manifested disease, improvements show downstaging outcomes. crucial when invade where poses high morbidity, intraoperative should strongly circumstances avoid excessive dissection