Pericardial Rent in Plaque-Type Pulmonary Squamous Cell Carcinoma Surgery
Pericardial rent during surgical resection of plaque-type pulmonary squamous cell carcinoma (PSCC) is relatively common when the tumor invades the pericardium, occurring in approximately 35-65% of cases requiring pericardial resection, and can be avoided through meticulous dissection techniques, preoperative imaging assessment of invasion depth, and planned en-bloc resection when invasion is suspected.
Incidence and Context
Pericardial involvement in PSCC is not uncommon, particularly with centrally located tumors:
Squamous cell carcinoma represents the predominant histology (75.8%) among lung cancers invading the pericardium, making pericardial rent a realistic surgical concern in these cases 1.
Pericardial invasion alone occurs in approximately 35% of cases, while combined invasion of pericardium with pulmonary veins occurs in 37%, and with left atrium in 27.5% of surgically treated cases 1.
The high rate of N1-N2 nodal involvement (86.8%) in pericardial-invading tumors suggests aggressive local spread through rich pericardial lymphatic drainage 1.
Surgical Techniques to Avoid Pericardial Rent
Preoperative Assessment
Obtain high-quality CT and MRI imaging to delineate the exact extent of pericardial involvement and distinguish between adherence versus true invasion before surgery.
Identify plaque-like tumor extension along the pericardial surface, which indicates the need for planned en-bloc resection rather than attempting dissection planes.
Intraoperative Strategies
Plan en-bloc pericardial resection when preoperative imaging or intraoperative findings suggest invasion rather than attempting to dissect tumor off the pericardium, which increases rent risk.
Use sharp dissection under direct visualization when attempting to preserve pericardium in cases of suspected adherence without invasion.
Perform intentional pericardial resection with adequate margins (1-2 cm) when tumor invasion is confirmed, accepting controlled pericardial defect creation rather than risking incomplete resection or uncontrolled tears.
Have bovine pericardial patches or synthetic mesh available for immediate reconstruction if pericardial defects are created, as demonstrated in complex bronchovascular reconstructions 2.
Reconstruction Considerations
Reconstruct pericardial defects larger than 5 cm to prevent cardiac herniation, using bovine pericardium, Gore-Tex, or other synthetic materials 2.
Ensure hemostasis and complete resection take priority over pericardial preservation, as R1-R2 resections significantly worsen prognosis in these already high-risk patients (5-year survival only 15.1%) 1.
Critical Pitfalls to Avoid
Do not attempt aggressive dissection to preserve pericardium when tumor invasion is present, as this increases both rent risk and likelihood of incomplete resection (R1-R2 rates are already elevated at 40.7% in these cases) 1.
Recognize that pneumonectomy is frequently required (93.4% of cases) for adequate resection when pericardial invasion is present, so plan accordingly 1.
Be aware that pericardial effusion in PSCC patients may indicate metastatic disease rather than just local invasion, which would contraindicate aggressive surgical resection 3, 4.