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Ann Thorac Surg 1996;62:1598-1602
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Cancer Resection on the Residual Lung After Pneumonectomy for Bronchogenic Carcinoma

Departments of Thoracic Surgery, Anesthesiology, and Intensive Care, Institut Mutualiste Montsouris, Paris, France

Accepted for publication June 24, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Addendum References

 
Background. After pneumonectomy for bronchogenic carcinoma, the residual lung may be the site of a new lung cancer or metastatic spread.

Methods. From 1989 to 1995, 13 patients with carcinoma on the residual lung after pneumonectomy for lung cancer were operated on. Three segmentectomies and 7 simple wedge resections were performed, 2 patients had multiple wedge resections, and 1 patient had an exploratory thoracotomy. Nine patients had a primary metachronous bronchogenic carcinoma, 3 had metastases from bronchogenic carcinoma, and no definite conclusion was reached in 1 case.

Results. No postoperative mortality was observed. Four patients had postoperative complications. The mean postoperative hospital stay was 14 days. Seven patients are alive, including 5 patients without evidence of disease. Six patients died of their disease, all with pulmonary recurrences. The overall median survival was 19 months, with a probability of survival at 3 years (Kaplan-Meier) of 46% (95% confidence interval, 22% to 73%).

Conclusions. Limited pulmonary resection for lung cancer after pneumonectomy for bronchogenic carcinoma is feasible with very low morbidity. In highly selected patients, surgical resection might prolong survival.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Addendum References

 
After pulmonary resection for lung cancer, the remaining parenchyma may be the site of a second primary cancer, with an incidence ranging from 2% to 5% every year [1], or metastatic spread without evidence of extrathoracic disease. Although operation is considered the best treatment option for resectable lung tumors [1], some centers consider contralateral pneumonectomy a contraindication to further pulmonary resection for lung cancer [2]. Furthermore, both oncologic and cardiopulmonary physiologic principles make operation a therapeutic option in only a small proportion of patients. For these reasons, operation on a single lung is infrequently reported in the treatment of synchronous or metachronous lung malignancies, and, to the best of our knowledge, only 47 patients who underwent oncologic operations on the remaining lung after pneumonectomy for bronchogenic carcinoma have been reported to date (Table 1) [1, 3–15]. Therefore, it appeared of interest to report our relatively large and homogeneous series of 13 consecutive patients who underwent oncologic operation with curative intent on the residual lung after pneumonectomy for non–small cell lung cancer.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Addendum References

First Resection
In 12 patients the first resection was a pneumonectomy; only 1 patient (patient 8) had a left upper lobectomy for pulmonary adenocarcinoma, followed 37 months later by left completion pneumonectomy (Table 2). An extended pneumonectomy was performed in 5 patients (see Table 2). Only 1 patient received induction chemotherapy; by contrast, 7 patients received adjuvant radiotherapy and only 1 underwent combined postoperative chemotherapy and radiotherapy. At the time of pneumonectomy, the histology was adenocarcinoma in 3 patients, squamous cell carcinoma in 8, undifferentiated large cell carcinoma in 1, and cystoadenocarcinoma in the last patient. Concerning the pathologic staging after pneumonectomy, there were 4 stage I, 2 stage II, 4 stage IIIA, and 3 stage IIIB. In 4 cases there were no lymph nodes involvement, whereas N1 disease was diagnosed in the remaining 9 cases. Interestingly, not a single patient had pathologic N2 disease (see Table 2). In 11 patients the postoperative course was uneventful; patient 9 had postoperative bleeding that required reintervention, and patient 2 had a pyothorax with bronchial fistula that was treated by open window and subsequent thoracoplasty and myoplasty procedures.

Bronchoscopy was performed in all patients to exclude proximal bronchial tumoral involvement that might necessitate more than a segmentectomy. Cardiorespiratory criteria were (1) preoperative forced expiratory volume in 1 second greater than 40% and predicted postoperative forced expiratory volume in 1 second not less than 30% of theoretical values, (2) perfusion defect(s) limited to the area of the planned lung resection on systematic perfusion lung scan, and (3) absence of echocardiographic signs of pulmonary hypertension. Eventual additional diagnostic tests (eg, right heart catheterization, exercise testing) were performed on a case-by-case basis. Postoperative analgesia protocol included systematic patient-controlled systemic analgesia [15] by morphine for 1 to 3 days (1.5 mg/mL; refractory period, 10 minutes; maximum quantity at 4 hours, 20 mg), associated with paracetamol (4 g/day).

Statistical Methods
Overall survival probabilities were calculated by the Kaplan-Meier method [16] with the date of operation on the single lung as the starting date. Rothman's formula [17] was used to calculate 95% confidence intervals.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Addendum References

 
All malignancies were metachronous, with a median interval between operations of 38 months (see Table 2).

Bronchocopy was normal in all but 1 patient who had an invasion of a segmental bronchus. The tumor was completely resected through a segmentectomy.

The thoracic approach was a posterolateral thoracotomy in all patients. The type of intervention performed was segmentectomy in 3 patients and single wedge resection in 7 patients; patients 11 and 12 underwent multiple wedge resection. Resection was complete in 11 patients. Resection proved microscopically incomplete in patient 12, whereas no resection was performed in patient 7 because intraoperative findings required right lower lobectomy. Patient 9 had a wedge resection associated with dissection of an isolated mediastinal lymph node metastasis (N2) (diameter, 10 mm; in paraaortic mediastinal nodal station number 6 [18]) that was not detected by preoperative thoracic computed tomographic scan. Tumor type was adenocarcinoma in 5 patients, squamous cell carcinoma in 6, large cell carcinoma in 1, and metastatic cystoadenocarcinoma in 1 (see Table 2). Because the histologic type was different (when compared with that at pneumonectomy), patients 1, 4, 8, and 9 were considered to have a second primary bronchogenic carcinoma. A second primary lung cancer was also considered in patients 5, 6, 7, 10, and 13, according to the criteria of Martini and Melamed [3]. In 1 patient (patient 12) the first TNM and the interval between operations suggest a second primary tumor; by contrast, the first histology and the triple localization give evidence of a metastatic spread. Patient 11 had metastases of pulmonary cystoadenocarcinoma, whereas patients 2 and 3 probably had a metastasis of their primary lung cancer.

All patients could be extubated at the end of operation, and none required respiratory support postoperatively. No postoperative mortality was observed. Nine patients (69%) had an uneventful postoperative course. Four complications (31%) were observed: one hemorrhage that required reintervention, one pulmonary edema that was successfully treated without mechanical ventilation, and two prolonged air leaks requiring prolonged suction drainage. The mean postoperative hospital stay was 14 days, ranging from 6 to 25 days.

None of the patients had development of severe chronic respiratory insufficiency after the operation, and all performed daily activities. To date, 7 patients (53.8%) are still alive, including 5 patients (38.5%) without evidence of disease and 2 patients with evolving pulmonary disease. Six patients (46.2%) died of their disease (see Table 2): 5 patients had isolated pulmonary recurrences, whereas 1 patient had both pulmonary and hepatic recurrences. Patient 7 died 15 months after exploratory thoracotomy, whereas the patient with incomplete (R1) resection died 4 months after operation on the residual lung. Finally, the patient with N2 disease died 9 months postoperatively (see Table 2).

The overall median survival was 19 months (range, 4 to 36 months). The probability of survival after operation on the residual lung in patients with "classic" primary bronchogenic carcinoma is shown in Figure 1 (patient 11 with cystadenocarcinoma, a known slowly evolving disease, was not included in the curve). The 3-year probability of survival is 46% (95% confidence interval, 22% to 73%).

View larger version (11K): [in this window] [in a new window]   Fig 1. . Probability of survival (Kaplan-Meier) after operation on residual lung for bronchogenic carcinoma. Patient 11 was not considered in the estimated survival. Vertical bar at 3 years indicates 95% confidence interval (CI).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Addendum References

We did not observe any postoperative mortality in our series, thus contrasting with the overall 14.9% mortality rate reported in the literature (see Table 1). Analyzing the patients who died in the postoperative course, we found that 71% of them had undergone lobectomy or "extended" segmentectomy (eg, bisegmentectomy, segmentectomy plus wedge resection). Successful lobectomy after pneumonectomy has been reported, especially in the treatment of young patients with benign diseases, whereas in older patients with second lung cancer after pneumonectomy, it should probably be contraindicated [21]. Besides, extended segmentectomy or multiple wedge resections should be also regarded with particular attention. In fact, during operation on the residual lung, the parenchymal manipulations or contusions next to wedge resections might worsen the limited respiratory reserve of these patients. Thus, wedge resection or a single segmentectomy should be considered the "gold standard" procedures on a single lung.

However, from an oncologic point of view, segmentectomy or wedge resection for stage I lung cancer is associated with a significantly greater risk of locoregional recurrence when compared with lobectomy [22], but overall survival rates do not seem to be significantly reduced by limited resections, and 3- and 5-year disease-free survival rates of about 75% and 55%, respectively, can be observed after limited resection [22]. Accordingly, all patients who died in our series had locoregional recurrences at the time of death, but the observed median survival is among the highest reported values (see Table 1), with a 3-year probability of survival of 46% (see Fig 1), and 5 of 13 patients are alive and free of disease (see Table 2). Therefore, when considering both technical and oncologic aspects, we believe that limited resections provide the patients with the best risk-benefit ratio in this setting.

Finally, preoperative patient selection is obviously critical not only regarding the functional and oncologic consequences of the planned resection, but also regarding the staging of both first and new lung cancers. First, it may appear questionable to perform a high-risk surgical procedure in patients with previous stage IIIA or IIIB disease. In fact, we consider previous N2 disease a contraindication to further surgical treatment; by contrast, previous T3 or T4 tumors should not be considered an absolute contraindication to further resection, provided that the first resection has been complete and that a significant disease-free interval has been observed (see Table 2). Second, preoperative staging of the second lung tumor must be especially careful. Any suspected N2 disease on high-resolution computed tomographic scan should be objectively documented by mediastinoscopy, keeping in mind that this approach can be hazardous in these patients who present postpneumonectomy mediastinal shift and laterotracheal fibrosis on the side of the first resection with lymph node dissection and eventual postoperative radiotherapy. In the future, positron emission tomography scanning might become an extremely useful test to safely identify "true" N2 disease in this setting. Therefore, we have decided to operate, after having excluded patients with proved or highly suspected N2 disease, we do not perform systematic mediastinal lymphadenectomy that adds significant morbidity without providing significant survival benefit.

Thus, our experience supports the view that, in highly selected patients, limited radical resection of second lung cancer after pneumonectomy for bronchogenic carcinoma can be successfully performed with very low morbidity and mortality, and is therefore likely to offer a chance of cure and prolonged survival.

	Addendum

Top Footnotes Abstract Introduction Material and Methods Results Comment Addendum References

 
From January to May 1996, 3 additional patients underwent operation for non–small cell lung cancer arising on the residual lung after pneumonectomy for bronchogenic carcinoma. All 3 patients had undergone pneumonectomy for stage II disease 144, 3, and 3 months before operation on the single lung (2 patients had synchronous lung cancer). A 61-year-old man had an incomplete resection because of unsuspected mediastinal lymphangitis, whereas the other patients (66- and 70-year-old men) underwent radical simple wedge resection for T1 tumors. The postoperative hospital stays ranged from 9 to 12 days, and no complications occurred. These data further comfirm that in highly selected patients, limited resections on a single lung can be performed with very low morbidity and mortality.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Addendum References

 
Address reprint requests to Dr Grunenwald, Service de Chirurgie Thoracique, Institut Mutualiste Montsouris Choisy, 6, Place de Port-au-Prince, 75013 Paris, France.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Addendum References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lorenzo Spaggiari Dominique Grunenwald Pierre Baldeyrou Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Spaggiari, L. Articles by Tric, L. Search for Related Content PubMed PubMed Citation Articles by Spaggiari, L. Articles by Tric, L.