Surgical treatment of locally advanced T4 non-small cell lung cancer with mechanical circulatory support

T4 non-small cell lung cancer (NSCLC) is a very heterogeneous group of locally advanced neoplasm greater than 7 cm or characterized by at the least one of the following: one or more satellite tumor nodules in a different ipsilateral lobe or by the invasion of the trachea, carina, heart, great vessels, vertebral body, oesophagus, or mediastinum. Because of the location and invasion of surrounding structures, controversy exists in surgical resection of T4 tumours which are usually considered unresectable and incurable. For a long time, a radical or extended resection of these tumours, needing a removal of tissues beyond the physical boundaries of a standard lobectomy or pneumonectomy, has been considered as an obstacle. At the same time the introduction of more advanced surgical techniques, often including the use of extracorporeal life support (ECLS), has allowed to extend the limits of conventional surgery increasing the rate of a complete surgical resection. Thanks to increasing experience gained during lung transplantation, more surgeons are now using such methods to obtain a good oxygenation and hemodynamic support during complex resections of the locally advanced tumours. The aim of this paper was to perform a critical review of the state of art of surgical treatment for T4 NSCLC with ECLS. Concerning the two different categories of T4 (tumors reaches heart and great vessels or tumors presenting with carina extension) which more often may need ECLS, we analysed indications, choice of suitable extracorporeal device, short- and long-term results.