Completion pneumonectomy for lung cancer

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1 Journal of BUON 7: , Zerbinis Medical Publications. Printed in Greece ORIGINAL ARTICLE Completion pneumonectomy for lung cancer N. Baltayiannis, D. Anagnostopoulos, N. Bolanos, L. Tsourelis Department of Thoracic Surgery, Metaxa Cancer Hospital, Piraeus, Greece Summary Purpose: Completion pneumonectomy is a trully challenging operation associated with increased mortality and morbidity. The aim of this study was to present a series of 18 patients who underwent completion pneumonectomy for lung cancer during a 15-year period and to evaluate the postoperative outcomes and long-term results. and methods: Between January 1985 and December 2000,18 patients underwent completion pneumonectomy for lung cancer; 10 for local recurrence,6 for second primary lung tumor and 2 for lung tumors in patients who had previously been operated on for benign disease. Results: No intraoperative deaths occurred. Postoperative mortality and morbidity were 11.11% and 33.33%, respectively. The median operational time was minutes. The mean blood loss during the procedure was 1.042,5 ml. The complication rate was 33.33%. The 5-year survival was 18.75% for all patients. The 5-year survival was 25% for the local recurrence group and 50% for the primary lung cancer group. The 5-year survival of the patients in the second primary tumor group has not been reached yet. Conclusion: Completion pneumonectomy can be performed with an acceptable operative mortality rate and offers a second chance for cure to patients with lung cancer. Although complications are common,they can successfully be managed with proper understanding of them. Key words: completion pneumonectomy, local recurrence, lung cancer, second primary tumor Introduction The first successful pneumonectomy was performed in 1933 by E. A. Graham [1]. Since then, pulmonary resection,whether pneumonectomy, lobectomy, or more limited procedures, has become an important therapeutic option in the management of primary lung cancer. In modern-day surgery, operative mortality for resectional surgery of the lung is under 5% for lobectomy and under 10% for pneumonectomy [2]. Received ; Accepted Author and address for correspondence: Nikolaos Baltayiannis,MD 14,Sokratous Street Alimos Athens Greece Tel: Fax: Sequential unilateral pulmonary resection leading to pneumonectomy is uncommon. The last pulmonary resection in the sequence has been termed completion pneumonectomy [3]. Completion pneumonectomy refers to an operation intended to remove what is left of a partially resected lung during previous surgery. When compared to standard pneumonectomy, it is a more challenging technical procedure with reported increased operative mortality and morbidity [4]. Although the first paper on indications and techniques of reoperation for bronchogenic carcinoma was published in 1954, the first comprehensive analysis of the rationale, indications, and results of completion pneumonectomy was that of McGovern and colleagues from Mayo Clinic in 1988 [5,6]. Since then, many reports have been published to examine the risk and outcome of this technique. In most series the procedure could be performed with acceptable mortality, although it had a higher morbidity. The aim of this study was to present a series of 18

2 236 patients who underwent completion pneumonectomy in our department during a 15-year period and to evaluate the postoperative outcomes and long-term results. and methods Between January 1985 and December 2000,we performed 18 completion pneumonectomies for lung cancer; 10 for recurrent bronchogenic carcinoma,6 for second primary bronchogenic carcinoma, and 2 for primary lung cancer in patients previously operated on for benign disease (arteriovenous fistula and echinococcosis). The ratio of completion pneumonectomies to standard pneumonectomies was around 2.8% during the same period. There were 16 male and 2 female patients, with an average age of 54 years (range years). Right completion pneumonectomy was done in 12 patients and left completion pneumonectomy in 6 patients. To be eligible for completion pneumonectomy, postoperative forced expiratory volume in 1 second (FEV1), estimated with spirometry and lung perfusion scan, had to be more than 1000 ml; arterial blood gasses sampled on resting and after exercise had to be within normal range. The metastatic spread was ruled out with total body computed tomographic scan, technetium bone scan, and abdominal ultrasound. We do not perform preoperative mediastinoscopy routinely, because we consider that homolateral stage IIIa disease is amenable to curative resection. Mediastinoscopy is performed when computed tomographic scan findings are suggestive of contralateral mediastinal node involvement; this was not the case in any patient of this series. Table 1. Indications for initial surgical procedure Indication n(%) Primary lung cancer 16 (88. 9) Benign disease Arteriovenous fistula 1 (5. 6) Pulmonary hydatid cyst 1 (5. 6) Total 18 (100) Table 2. TNM classification of the patients with primary lung cancer in the first operation (n=16) Classification T1N0M0 1 T2N0M0 2 T1N1M0 1 T2N1M0 2 T2N2M0 2 T3N0M0 2 T3N1M0 3 T2N3M0 2 Second procedure-completion pneumonectomy Completion pneumonectomy was performed, in all cases, for lung cancer (Table 4). First procedure Indications for initial surgical procedure were benign diseases in 2 patients (arteriovenous fistula and pulmonary hydatid cyst) and malignant disease in 16 patients (primary lung cancer, Table 1). TNM classification of the patients with primary lung cancer was T1N0M0 in 1 patient, T2N0M0 in 2 patients, T1N1M0 in 1 patient, T2N1M0 in 2 patients, T2N2M0 in 2 patients, T3N0M0 in 2 patients, T3N1M0 in 3 patients, T2N3M0 in 2 patients and T4N0M0 in 1 patient (Table 2). The initial surgical procedure was a right upper lobectomy in 7 patients, a right lower bilobectomy in 5 patients, a left upper lobectomy in 2 patients, a left lower lobectomy in 2 patients, a left segmental resection in 1 patient and a left partial (wedge) resection in 1 patient (Table 3). Table 3. Type of first operation (n=18) Type of operation n(%) Right upper lobectomy 7 (39) Right lower lobectomy 5 (27.8) Left upper lobectomy 2 (11.1) Left lower lobectomy 2 (11.1) Left segmentectomy 1 (5.6) Left partial (wedge) resection 1 (5.6) Table 4. Indications for completion pneumonectomy (n=18) Indication n(%) Local recurrence 10 (55.6) Second primary tumor 6 (3.3 ) Primary lung cancer 2 (11.1)

3 237 Local recurrence Local recurrence was defined as a second lung malignancy with the same histological features and the same anatomic site, occurring within 2 years of the first procedure. Bronchial stump recurrence was regarded as a local recurrence regardless of the time interval [4,9]. According to these criteria completion pneumonectomies were performed for a local recurrence of the first malignancy in 10 cases. Among those patients, 6 had adenocarcinoma, 3 squamous-cell carcinoma and 1 large-cell carcinoma. TNM classification at initial operation were T2N0M0 in 1 patient, T1N1M0 in 1 patient, T2N1M0 in 2 patients, T2N2M0 in 2 patients and T3N0M0, T3N1M0, T2N3M0, and T4N0M0 in 1 patient each. The mean interval between the first and second procedure was 30.9 months (range months). Second primary tumor Second primary tumor was defined as a second malignant tumor when the cell type was of different histology or when a tumor with the same cell type occurred in a different anatomic site more than 2 years from the first malignancy in the absence of residual tumor after the first operation [10]. According to these criteria completion pneumonectomies were performed for a second primary lung cancer in 6 cases. Among those patients the initial histological classification were adenocarcinoma in 3 patients, large-cell carcinoma in 1 patient and squamous-cell carcinoma in 2 patients. TNM classification at initial operation were T1N0M0, T2N0M0, T3N0M0, T2N3M0 in 1 patient each, and T3N1M0 in 2 patients. Histological classification at the second operation (completion pneumonectomy) were adenocarcinoma in 2 patients and squamous-cell carcinoma in 4 patients. TNM classification at the second operation were T2N0M0 in 2 patients,t3n0m0 in 3 patients, and T3N1M0 in 1 patient. The mean interval between the first and second operation was 40.2 months(range months). Surgical technique The first task of the surgeon was to carefully read the surgical report on the patient s previous operation. All procedures were done by reopening of the previously used thoracotomy incision. In 11 (61.11%) cases, the 5th or 6th rib had to be removed to provide easier access to the pleural space. Twelve (66.66%) completion pneumonectomies were performed on the right side and six (33.33%) on the left side. Excessive bleeding from the chest wall was prevented by mobilization of the lung through the intrapleural plane. This part of operation was particularly difficult when the first procedure had been done extrapleurally. Once the lung was freed, the hilum was avoided and the pulmonary blood vessels were ligated intrapericardially. The bronchial stump was kept short, and excessive peribronchial dissection was avoided to preserve vascularization. Bronchial closure was done with staplers in 16 (88.88%) cases and with interrupted sutures (absorbable 3-0 polygalactin vicryl sutures) in 2 (11.11%) cases. The bronchus was transected as close to the tracheal bifurcation as possible and the stump was covered with pleural tissue in 3 (16.66%) cases and with pericardial flap in 15 (83.33%) cases to reinforce the line of bronchial closure (Figure 1). Before closure of thoracotomy, fibrin glues and hemostatic agents were generously applied over the raw surfaces to control the hemorrhage (leakage). The space was drained by a clamped chest tube, which was left in place for equilibration and removed 48 hours after the operation. Survival Five-year overall survival was calculated from the date of the completion pneumonectomy. Primary lung cancer in patients with initial benign disease Two patients had a completion pneumonectomy for squamous-cell carcinoma ptnm T1N0M0 and T2N0M0 respectively that occurred 14 and 32 years after initial segmentectomy and after initial wedge resection for echinococcosis and arteriovenous fistula, respectively. Figure 1. The bronchial stump was covered with flap of pleura to reinforce the line of closure.

4 238 Results The median duration of the surgical procedure was minutes (range 170 to 260 minutes, Figure 2). The median blood loss perioperatively was 1,042.5 ml (range 570 to 1,850 ml). Intraoperative blood loss exceeded 1,000 ml in 9 (50%) patients, who were transfused with 4 units of packed red cells (Figure 3). Intraoperative complications Dense pleural and perihilar adhesions were encountered in 16 (88.88%) patients, and intrapericardial dissection was used in all patients. According to the surgeon s report, only 3 (16.66%) resections were performed without any particular difficulties. We encountered intraoperative injury of great vessels in 2 (11.1%) patients (pulmonary vein, azygos vein), both of which were immediately controlled. There were no intraoperative deaths (Table 5). Postoperative complications The mortality rate during the immediate postoperative period was 11.11% (2 patients). There were 1 lethal pulmonary embolism and 1 lethal myocardial infarction. Four (22.22%) patients experienced postoperative complications. One patient had secondary bleeding with intrapleural clotting (hemothorax). The patient was managed conservatively. One patient developed a bronchopleural fistula which was managed with muscle flap closure. One patient had pulmonary edema and one patient had supraventricular tachycardia; both were managed successfully (Table 5). The mean hospital stay was 18 days (range 8-32 days). Follow-up Follow-up was complete for all 16 patients who survived completion pneumonectomy. The mean followup period of the patients was 3.5 years and ranged from 6 months to 14.5 years. The 5-year survival was 18.75% for all 16 patients (Figure 4). We also analyzed survival with regard to the indications. The 5-year survival was 25% for the local recurrence group and 50% for the primary lung cancer group (Figure 5). The 5-year survival of the patients in the second primary tumor group has not yet been reached (Figure 6). minutes) Discussion Completion pneumonectomy, which has been defined as an operation removing the remnant of a previously partially resected lung, has the reputation of a technical challenge with increased operative risk [11]. The range of indications for completion pneumonectomy covers both benign and malignant diseases [6,12]. Figure 2. Operative time. loss (ml) Figure 3. Intraoperative blood loss. Table 5. Complications with completion pneumonectomy (n=8) Complication, n Intraoperative complications Death 0 Injury of pulmonary vein 1 Injury of azygos vein 1 Postoperative complications Death 2 Pulmonary embolism 1 Myocardial infarction 1 Hemothorax 1 Bronchopleural fistula 1 Pulmonary edema 1 Supraventricular tachycardia 1 Mortality % Morbidity %

5 239 Figure 4. 5-year survival of all the patients with completion pneumonectomy Figure 5. 5-year survival for the local recurrence and the primary lung cancer groups survi Figure 6. 5-year survival for the second primary lung cancer group. Iterative lung resection for benign disease is required when superinfection occurs in a destroyed lung, such as relapsing bronchiectases after lobectomy, or complications of conservative cancer treatment (bronchostenosis after sleeve lobectomy, radionecrosis). Indications for malignancies include primary bronchogenic cancer after lobectomy for benign disease, metachronous bronchogenic cancer, and resectable local recurrence. With respect to the increasing frequency of primary bronchogenic carcinoma, metachronous cancers, which occur in 5% to 10% of patients with a previous cancer operation, may be expected as the most frequent indication in the coming years [13,14]. Completion pneumonectomy is a challenging procedure that poses a great stress on surgeons not only intraoperatively but also preoperatively and postoperatively. The surgeon must be too careful in deciding whether the operation is indeed indicated, whether the gain in survival and quality of life outweighs the risks involved, and whether other therapeutic options are available [15]. Therefore we subscribe to Deslauriers who recommends that this type of operation should be performed only by experienced thoracic surgeons [11,16]. We opened the chest a space above or below the previous incision, to avoid the major adhesions to the space of thoracotomy. We routinely covered the bronchial stump with adjacent tissues and left a chest tube connected to a balanced drainage system for 48 hours [17]. Median operative blood loss was 1,042.5 ml in this series, which is comparable to the 1500 ml reported by Gregoire et al. [12], to the 1000 ml reported by Massard et al. [18] and to the 805 ml reported by Fujimoto et al. [19]. The mean operative time was minutes in this series, which is comparable to the 210 minutes reported by Regnard et al. [20]. Operative mortality after completion pneumonectomy is increased almost twofold with reference to standard pneumonectomy (11.11% versus 6.8%) [21]. Our mortality rate agrees with previously published data [3,6,12,22]. Complications after completion pneumonectomy are common. The complication rate in our study was 22.22%,which is comparable to those reported previously (18-46%) [4,6,12,18,19,23]. Bronchopleural fistula occurred in 1 patient (5.5%). This rate is similar to those of previous reports (0-13%) [4,6,12,18,19,23]. Contralateral pneumothorax may potentially be a life-threatening complication. The possibility of such an occurrence would be higher because mechanical ventilation is frequently and for a longer time used for respiratory failure after pneumonectomy. We must carefully check contralateral pneumothorax by means of daily chest roentgenography [19]. Chylothorax develops in 0.2 to 0.5% of cardiovascular and thoracic operations, and its occurrence after

6 240 pneumonectomy is rare [24]. We must, however, pay attention to the excessive and rapid filling of the pospneumonectomy space in the early postoperative period, which may be due to bleeding,infection, and chylothorax [25]. Chylothorax should be treated early by means of a surgical intervention because it can easily deteriorate the hemodynamic and respiratory state of a patient after pneumonectomy [19,25]. Fortunately, there were neither intraoperative nor postoperative contralateral pneumothorax nor chylothorax in our study. In our series we found an overall 5-year survival of 18.75% after completion pneumonectomy among all the patients with lung cancer. This low survival compared with the rate of 23 to 44.5 reported previously was probably related to the inclusion of patients with malignancy only [4,18,20,26]. with completion pneumonectomy for benign disease were excluded from this study. The 5-year survival was 25% for the local recurrence group and 50% for the primary lung cancer group. The survival of the patients in the second primary tumor group has not reached 5 years. For patients with local recurrence the 5-year survival was comparable to the 24% reported by Gregoire et al. [12]. Since the original report from the Mayo Clinic in 1988 [6], many publications have confirmed that, in selected patients, completion pneumonectomy can be done with an acceptable risk and that the operative mortality for lung cancer patients is only slightly higher than modern standards for standard pneumonectomy [4,8,12,18-20,27]. The planning for completion pneumonectomy must, however, be done very meticulously, and the surgeon must decide if the operation is indeed indicated and whether the patient has enough reserve to tolerate it. Major technical difficulties in operations exist in the dissection of the pleural adhesions, which sometimes needs to be done through the extrapleural plane. Most importantly, the surgeon must know if he or she has the skills and experience necessary to perform the operation successfully [28]. References 1. Graham EA, Singer JJ. Successful removal of entire lung for carcinoma of the bronchus. JAMA 1933; 101: Ginsberg RJ, Hill LD, Eagan RT et al. Modern thirty-day operative mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 1983; 86: Dartevelle P, Khalife J. Surgical approach to local recurrence and second primary lesion. In: Delarue NC, Eschapasse H (eds): International Trends in General Thoracic Surgery (Vol 1). Philadelphia, WB Saunders, 1985, pp: Al-Kattan K, Goldstraw P. Completion pneumonectomy: indications and outcome. J Thorac Cardiovasc Surg 1995; 110: Beattie EJ, Davis C, O Kane C et al. Surgical intervention in recurrent bronchogenic carcinoma. 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