Middle Lobectomy After Pneumonectomy
Jorge Quiroga, MD,
José María G Prim, MD,
Milagros Moldes, MD,
Ramiro Ledo, MD
Thoracic Surgery Service, Santiago University Hospital, Santiago de Compostela, Spain
Jorge Quiroga, MD, Tel: +34 981 951 178, Fax: +34 981 950 454, Email: quirojo{at}hotmail.com, Thoracic Surgery Service, Santiago University Hospital, Choupana St. s/n. 15706, Santiago de Compostela, A Coruña, Spain.
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ABSTRACT
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A 59-year-old man underwent a successful middle lobectomy to treat metastasis from a pulmonary adenocarcinoma resected previously by left pneumonectomy.
Key Words: Adenocarcinoma • Carcinoma • Bronchogenic • Pneumonectomy
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INTRODUCTION
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Patients who have undergone pneumonectomy for bronchogenic carcinoma may develop a new primary or metastatic lung cancer. Surgery after pneumonectomy is usually limited by poor lung function, the presence of distant metastases, or by the misconception that a previous pneumonectomy is an absolute contraindication to additional lung resections.1 However, certain patients may benefit from further surgical resection, with an acceptable risk of morbidity and mortality.2 The risk-benefit relationship depends on meticulous selection within this particular group of patients, never forgetting that the aim of surgery is to increase survival with an acceptable quality of life.
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CASE REPORT
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Follow-up computed tomography in a 59-year-old man who had undergone pneumonectomy for pulmonary adenocarcinoma (pT2N0M0-G3) 21 months previously showed a new right lung mass. On admission, he was asymptomatic. Thoracoabdominal computed tomography indicated a pulmonary mass of 4 x 3 cm in the middle lobe, with no mediastinal or hilar lymph node enlargement (Figure 1A
). Fluorine-18-fluorodeoxyglucose positron-emission tomography revealed a focus of hypermetabolism in the middle lobe, with no other foci of pathological uptake (Figure 1B). The results of respiratory function tests are given in Table 1. Bronchoscopy was not performed due to poor patient collaboration. With a diagnosis of histologically undefined pulmonary mass, a right thoracotomy was performed. An anatomic middle lobectomy was carried out to ensure complete resection. The patient was extubated at the end of the procedure. No postoperative complications were observed, and he was discharged after 7 days. Histopathology showed metastasis of a poorly differentiated adenocarcinoma of pulmonary origin. The immunohistochemical pattern was consistent with the contralateral lung carcinoma. After 9 months of follow-up, the patient was asymptomatic and had no signs of locoregional or distant recurrence.
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Figure 1. (A) Computed tomography showing the middle lobe mass. (B) Positron-emission tomography showing hypermetabolism of the mass, with a maximum standard uptake value of 17.3.
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DISCUSSION
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Patients with bronchogenic carcinoma treated by surgery have a 1% to 5% per year risk of developing a second primary lung carcinoma or pulmonary recurrence.1,3 Poor lung function tests in patients with single-lung lesions are often the main cause of inoperability. Some surgeons consider that major resections are contraindicated in these patients;3 however, middle lobe resection should be considered a special case due to minimal functional and vascular repercussions.
Ventilation must be of high frequency and a low tidal volume, with intermittent periods of apnea to reduce the barotrauma and tissue damage caused by handling a hyperinflated lung, which could lead to edema, contusion, and atelectasis. Postoperative pain control and intensive physiotherapy are of particular importance. An epidural catheter for patient-controlled analgesia, thoracotomy without rib cutting, an intercostal muscle flap, and transcostal closure helps to reduce postoperative pain and thus the probability of developing respiratory complications. Surgical risk is high in these patients, particularly in those undergoing major resections. Survival of 20 months after right upper lobectomy on a single lung has been reported.4 Donington and colleagues1 found increased morbidity and mortality in patients with more than one wedge resection. The greater the volume of lung tissue excised, the higher the morbidity and mortality, related principally to the reduction in respiratory function and to cardiac overload caused by changes in the pulmonary circulation. Limited lung resections must therefore be the standard in these cases, as long as complete resection of the lesion can be guaranteed, even for metachronous tumors, as this offers the best risk-benefit balance.
Survival after resection on a single lung is different in metachronous tumor and lung metastasis. In metachronous tumors, actuarial survival of 50% can be achieved at 5 years, whereas in patients with resected lung metastases, 5-year survival does not exceed 15%.1 However, serious difficulties are often encountered when attempting to establish the differential diagnosis. If the preoperative diagnosis is uncertain, surgery becomes an important therapeutic option to be considered.
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REFERENCES
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- Donington JS, Miller DL, Rowland CC, Deschamps C, Allen MS, Trastek VF, et al. Subsequent pulmonary resection for bronchogenic carcinoma after pneumonectomy. Ann Thorac Surg 2002; 74:154–9.[Abstract/Free Full Text]
- Terzi A, Lonardoni A, Scanagatta P, Pergher S, Bonadiman C, Calabró F. Lung resection for bronchogenic carcinoma after pneumonectomy: a safe and worthwhile procedure. Eur J Cardiothorac Surg 2004;25:456–9.[Abstract/Free Full Text]
- Wood DE. Pulmonary resection after pneumonectomy [Review]. Thorac Surg Clin 2004;14:173–82.[Medline]
- Barker JA, Yahr WZ, Krieger BP. Right upper lobectomy twenty years after left pneumonectomy. Preoperative evaluation and follow-up. Chest 1990;97:248–50.[Abstract/Free Full Text]
Asian Cardiovasc Thorac Ann 2009;
17:300-301
© 2009 by SAGE Publications
DOI: 10.1177/0218492309104745
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ABSTRACT
INTRODUCTION
