J Thorac Cardiovasc Surg 2007;134:1078-1080
© 2007 The American Association for Thoracic Surgery
Right lower lobectomy after right upper lobectomy for multiple metastases in lung cancer of the right lower lobe: Benefit of middle lobe preservation
Hisashi Iwata, MD, PhDa,*,
Takuji Kiryu, MD, PhDb,
Koyo Shirahashi, MDa,
Shinsuke Matsumoto, MDa,
Masafumi Matsui, MDa,
Hirofumi Takemura, MD, PhDa
a Department of General and Cardiothoracic Surgery, Graduate School of Medicine, Gifu University, Gifu, Japan
b Department of Radiology, Graduate School of Medicine, Gifu University, Gifu, Japan.
Received for publication December 29, 2006; revisions received February 13, 2007; accepted for publication February 23, 2007.
* Address for reprints: Hisashi Iwata, MD, PhD, Department of General and Cardiothoracic Surgery, Graduate School of Medicine, Gifu University, 1-1 Yanagido, Gifu City, Gifu 5011194, Japan. (Email: ihisashi{at}gifu-u.ac.jp).
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Drs Matsumoto, Shirahashi, Takemura, Iwata, Kiryu, and Matsui (left to right)
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Postoperative respiratory function is a crucial factor when considering surgical treatment for lung cancer, particularly for relapse or secondary lung cancer. We describe herein a case of lobectomy for multiple metastases in the right lower lobe of the lung with preservation of the middle lobe after initial right upper lobectomy.
Clinical Summary
A 60-year-old woman with lung cancer underwent right upper lobectomy. The tumor specimen was a well-differentiated adenocarcinoma, pathologic stage IA (T1 N0 M0). Multiple slow-growing nodules were noted in the right lower lobe 4 years postoperatively. Recurrent lesions are generally multiple and disseminated, and additional surgical intervention is not usually indicated. However, no nodules were apparent in other lobes during 1 year of follow-up. The patient was therefore referred to our department for surgical treatment. Routine blood biochemistry and coagulation studies yielded normal results and carcinoembryonic antigen level was 2.6 ng/mL. A chest computed tomographic scan from 4 years earlier showed the primary lung cancer as a solid tumor in the right upper lobe (Figure 1, A), compared with the scan of multiple nodules limited to the right lower lobe for the metastases (Figure 1, B). These multiple tumors showed no uptake on a fluorodeoxyglucose positron emission tomographic scan. Transbronchiolar lung biopsy was not performed owing to patient refusal. No extrathoracic metastatic lesions were identified. Preoperative forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1.0) were 2420 mL and 1510 mL, respectively. We evaluated predicted results of completion pnuemonectomy using perfusion scintigraphy and pulmonary artery obstruction testing. Predicted FVC and FEV1.0 after completion pneumonectomy were 1114 mL and 695 mL, respectively. Obstruction of the right pulmonary artery yielded a pressure of 19 mm Hg. Video-assisted right lower lobectomy was performed, preserving the middle lobe. Adhesion of the lower lobe to the chest wall was easily removed by the thoracoscopic view. The middle lobe was also adherent to the chest wall and helped to prevent middle lobe torsion. On final pathologic examination, the specimen from the lower lobe was characteristic of metastatic adenocarcinoma from the previous lung cancer of the right upper lobe (Figure 1, C and D). Postoperative FVC and FEV1.0 were 1570 mL and 1200 mL, respectively. Perfusion scintigraphy showed 391,199 (21.7%) of 1,801,504 counts for the preserved middle lobe (Figure 2). Respiratory function after right upper and lower lobectomies preserved more than half of the original respiratory function.
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Figure 1. A, Chest computed tomographic scan shows a solid, irregular mass in the right upper lobe at primary operation. B, Chest computed tomographic scan shows multiple, slow-growing masses limited to the right lower lobe. C, Tumor of the right upper lobe, characteristic of well-differentiated adenocarcinoma. D, A specimen from the lower lobe shows clear margin between carcinoma and normal tissue, characteristic of metastatic adenocarcinoma from the primary lesion.
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Figure 2. Perfusion scintigraphy of the preserved middle lobe shows a count of 391,199, indicating 21.7% residual respiratory function. Preserved forced vital capacity (FVC), percent vital capacity (VC), and forced expiratory volume in 1 second (FEV1.0) after right upper and lower lobectomy were at 52.7%, 58.2% and 52.5% of original respiratory function. The chest computed tomographic image was taken 1 year after preservation of the middle lobe.
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The postoperative course was uneventful. Chest computed tomographic imaging after 1 year of preservation of the middle lobe showed adequate volume without emphysematous change. After 17 months of follow-up, the patient is doing well with no evidence of disease or requirement for additional oxygen support.
Discussion
Martini and Melamed1
described the properties of metachronous lung cancer such as second cancer in different lobes or lungs but displaying the same histologic features, with neither carcinoma in lymphatics common to both cancer nor extrapulmonary metastasis at the time of diagnosis. However, they also mentioned that bronchial alveolar carcinoma or multinodular growth patterns were arbitrarily excluded because of difficulties in ruling out airborne or intrapulmonary lymphatic dissemination.
The lower lobe specimen displayed characteristics of metastatic adenocarcinoma, given the distinct margin between tumor and normal lung tissue. In addition, multiple tumors were limited to the right lower lobe, suggesting metastases rather than metachronous tumors. We speculated that recurrence was due to transbronchial metastasis during upper lobectomy. From the perspective of management, differentiating between new primary tumors and recurrence is unimportant.2 Angeletti and associates3 showed that aggressive surgical approaches are safe, effective, and warranted in patients with second primary lung cancer or relapse from primary lung cancer. They analyzed 19 patients with metachronous second primary cancer and 7 patients with local relapse. However, right upper and lower lobectomies while preserving the middle lobe were not performed. Gugginoa and colleagues4 described postoperative respiratory insufficiency after completion pneumonectomy in 26.3% of patients with lung cancer and also reported operative mortality rates of 0% to 17.6% for cancer from several institutions. We therefore decided to avoid completion pneumonectomy. Preservation of the middle lobe contributed substantially to postoperative respiratory function (Figure 2).
Conversely, preservation of the middle lobe in the absence of the upper and lower lobes may induce torsion. Various factors appear to be associated with lobar torsion, including complete interlobar fissure, absence of adhesions, a narrow middle lobe hilum, and overzealous mobilization of the lobe.5 In our case, the middle lobe was fixed by adhesions to the chest wall. However, emphysematous changes in the residual middle lobe may be induced owing to volume mismatch in the middle lobe and thoracic cavity during long-term follow-up.
In conclusion, preserving the middle lobe after resection of both upper and lower lobes offers advantages to residual respiratory function, compared with results from completion pneumonectomy.
References
- Martini N, Melamed MR. Multiple primary lung caners. J Thorac Cardiovascular Surg 1975;70:606-612.[Abstract]
- Deschamps C, Palrolero PC, Trastek VF, Payne WS. Multiple primary lung cancers. J Thorac Cardiovasc Surg 1990;99:769-778.[Abstract]
- Angeletti CA, Mussi A, Janni A, Lucchi M, Ribechini A, Chella A, et al. Second primary lung cancer and relapse: treatment and follow-up. Eur J Cardiothorac Surg 1995;9:607-611.[Abstract/Free Full Text]
- Gugginoa G, Doddolia C, Barlesi F, Acri P, Chetaille B, Thomas P, et al. Completion pneumonectomy in cancer patients: experience with 55 cases. Eur J Cardiothorac Surg 2004;25:449-455.[Abstract/Free Full Text]
- Apostolakis E, Koletsis EN, Panagopoulos N, Prokakis C, Dougenis D. Fatal stroke after completion pneumonectomy for torsion of left upper lobe following left lower lobectomy. J Cardiothorac Surg 2006;1:25.[Medline]
