J Thorac Cardiovasc Surg 1995;109:597-599
© 1995 Mosby, Inc.
Surgical management for metachronous bronchogenic cancer occurring after pneumonectomy
Gilbert Massard, MD,
Jean-Marie Wihlm, MD,
Georges Morand, MD
Department of Thoracic Surgery
University Hospital of Strasbourg
F-67091 Strasbourg, France
To the Editor:
It is with greatest interest that we perused the outstanding report on resection of metachronous bronchogenic cancers on single lungs, which has been published by Dr. Westermann and colleagues. 
1 We would like to share our experience, although it is less extensive, inasmuch as we dealt with only four similar patients during the past 7 years.
All four patients were men, with ages ranging from 51 to 61 years (Table I), and had strong smoking histories. Pneumonectomy had been done because of squamous cell cancer: stage I in one patient and stage II in three patients. One of them had undergone postoperative radiotherapy because of in situ carcinoma involvement of the resection margin. The second cancers were follow-up diagnoses at an interval ranging from 12 to 71 months. The staging procedure (computed tomographic [CT] scan of head, chest, and abdomen; abdominal ultrasonography, and technetium bone scan) did not reveal distant metastases. Postoperative forced expiratory volume in 1 second (FEV1 ) was predicted to exceed 1 L in all patients. Three patients were operated on through a median sternotomy: a regular middle lobectomy was done in two and a segmental resection of the lingula in one. The fourth patient underwent a wedge resection through a short muscle-sparing lateral thoracotomy. In this particular case, we were able to block the right upper lobe bronchus with a balloon catheter positioned under bronchoscopic guidance. Only two patients had a smooth postoperative outcome. Two others, both operated on through a median sternotomy, had respiratory failure and required transient tracheostomy. Their discharge from the hospital was delayed until postoperative days 27 and 65, respectively.
On January 1, 1994, two patients were alive and well at 5 and 67 months after operation A third patient died 5 months after resection of the lingula with brain metastases. The fourth patient had a third malignancy in the right upper lobe 10 months after middle lobectomy and received focal radiotherapy; he remained in complete remission until his death from an unrelated cause 29 months after operation (Table II).
We may consider that all four patients had metachronous cancer, because their tumors occurred at least 6 months after treatment of a first lesion 2 However, only one of them had a tissue diagnosis that was different from the first cancer. We have to admit that the distinction from a single metastasis is nearly impossible. Preoperative work-up was limited to screening for distant metastases. In our standard staging described previously, 3 we perform mediastinoscopy only when mediastinal CT scanning reveals contralateral adenomegaly. None of the patients in the present series underwent mediastinoscopy. Perhaps it should be considered routinely in these particular cases, in which mediastinal dissection during the procedure is necessarily shortened and incomplete in cases of an anterior approach.
It is generally admitted that surgical resection is the best treatment option for metachronous bronchogenic cancer 2,4 However, whenever the first cancer has been resected with a pneumonectomy, the second procedure will carry the challenge of an operation on a single lung, whose function has to recover entirely in the immediate postoperative period. Two factors directly interfere with the postoperative respiratory function: the extent of resection and the parietal restriction effect of thoracotomy. Our general guideline is to plan a resection that leaves an FEV1 of at least 1 L after operation. Therefore we would not propose operation to a patient with an FEV1 less than 1.2 L. The resection should be as economic as possible and should probably be restricted to patients with T1 lesions. We considered that a middle lobectomy or a lingular resection was the permitted maximum; we were thus able to resect a small T2 lesion (Fig. 1).
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Fig. 1. Chest CT scan in patient seen with a right middle lobe mass 34 months after left pneumonectomy. Pronounced retrosternal shift of middle lobe because of anterior transmediastinal herniation is observed.
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To decrease as far as possible postoperative parietal restriction, the accurate choice of surgical approach is of paramount importance, and we entirely suscribe to the authors' choice of sternotomy or muscle-sparing lateral thoracotomy. Quite obviously, a standard posterolateral thoracotomy should be avoided. In our first three patients, we elected a median sternotomy, which is renowned to convey fewer respiratory side effects and decreased postoperative pain. 5 Furthermore, these three patients had lesions located in the middle lobe or lingula, which had switched into a retrosternal position by transmediastinal herniation after pneumonectomy (Fig. 1). This approach has been discussed in a case report published previously by our group. 6 We were disappointed with unpredictable cases of postoperative respiratory failure that complicated the outcome of two patients.
A muscle-sparing lateral thoracotomy is an elegant alternative for posteriorly located lesions; this incision needs to be just large enough to permit easy insertion of the palpating hand and stapling devices The ideal way would be video-assisted thoracoscopic surgical resection, because the thoracotomy would be limited to some stab wounds. However, the peroperative need for pneumothorax and immobility of the lung would require the use of cardiopulmonary bypass and would add another factor of morbidity. We demonstrated that lobar exclusion with a bronchial blocker is feasible during a limited-access thoracotomy; this would probably be insufficient for adequate exposure for a video-assisted thoracoscopic surgical procedure.
Surgical resection is the most satisfactory treatment option for bronchogenic cancer. It may be done successfully after pneumonectomy in patients who are seen with T1 second primary cancer and may yield significant long-term survival. However, the operative risk is considerable in these patients and should therefore be balanced with the less satisfactory treatment of focal radiotherapy, which is a valuable alternative in high-risk patients.
Again, we would like to compliment Dr. Westermann and his colleagues for their excellent results.
12/8/57777
References
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