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Ann Thorac Surg 1998;66:309-310
© 1998 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, European Institute of Oncology, via Ripamonti 435, 20141 Milan, Italy
b Department of Thoracic Surgery, Institut Mutualiste Montsouris, Paris, France
e-mail: lspaggia{at}ieo.it
To the Editor
We thank Dr Dieter for his comment, and we are very glad that our article [1] continues to arouse interest. We fully agree with Dr Dieter that operation in a single-lung patient after pneumonectomy can be performed for thoracic and extrathoracic disease; obviously, these patients have a higher operative risk than the normal population (ie, double-lung). This is mainly because of the need for single-lung ventilation, the limited respiratory capacity, and the presence of several associated cardiovascular diseases. However, we believe that operations in single-lung patients for metachronous or synchronous lung cancer have technical and oncologic problems that make this type of operation completely different from that performed for extrapulmonary disease. In fact, in this last case (eg, cardiac, vascular, or abdominal operation) the single lung is not involved in the operation and its function remains unchanged.
Cancer operation on a single lung is rare [1], and this is due to both functional and oncologic reasons: (1) The residual functionality of the cardiorespiratory system after pneumonectomy often does not allow resection on the residual lung. (2) The localization and the stage of the neoplasm allows only rarely a wedge resection (or multiple wedge resections), which is the gold standard operation in this setting [1]. (3) Finally, pneumologists and oncologists frequently do not believe that these patients can be still treated by surgical resection, and thus some patients are excluded from a second chance of cure.
We take this opportunity to emphasize some technical and oncologic aspects of this infrequent operation. From a technical point of view, we believe that (1) a short posterolateral thoracotomy without fracture of the ribs to avoid postoperative pain is the best approach even for the middle lobe [2]. (2) Being a salvage cancer operation, video-assisted thoracic surgical resection is generally not indicated [2]. (3) The single lung should be manipulated carefully with the aim to avoid lung contusions that may make worse the limited respiratory reserve. (4) When the neoplasm is centrally located, a segmentectomy with femorofemoral cardiopulmonary bypass without cardiac arrest should be considered [3]; an upper lobe T1 lesion can be easily removed through a recently developed transmanubrial approach without any functional consequences [4]. (4) Finally, lobectomy (apart from middle lobectomy) should be indicated only in highly selected patients [1, 5].
From an oncologic point of view, the best indication is a solitary metachronous neoplasm in the residual lung, even though multiple (but few and peripheral) metachronous lesions do not contraindicate operation. Because of the poorer prognosis of N2 patients at the time of pneumonectomy, the presence of a metachronous localization in the residual lung should suggest "a wait and observe" attitude for 1 or 2 months and then a restaging to exclude a rapidly evolving disease; in our reported series, all patients had N1 disease [1].
The presence of a synchronous contralateral coin lesion in a patient requiring pneumonectomy is an interesting situation that might indicate a further primary lung cancer or an isolated metastatic localization. In this situation, only the presence of a different histology might suggest a synchronous primary lung cancer that might better benefit from operation. Because of the impossibility to distinguish the primitive or metastatic nature of the lesion in the case of the same histology, we believe that in motivated and young patients with a low cardiorespiratory risk, pneumonectomy should be performed first, followed 3 to 4 weeks later by resection on the residual lung. This attitude finds justification in the following remarks: the patient might have a minimal N2 disease that could contraindicate contralateral resection; pneumonectomy might not be technically or oncologically feasible, and thus the side of the pneumonectomy should be explored first; and finally, a pneumonectomy after a contralateral thoracotomy and resection, even though limited, might increase the risk of postoperative cardiorespiratory complications.
Finally, to complete our discussion about this subject, we have recently published our experience regarding a limited number of patients operated on for recurrences in a single lung after pneumonectomy for metastases [6]. This very aggressive operation should be performed only in highly selected patients, but it might lead to important results in term of survival [5] and thus it deserves attention (Fig 1).
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This article has been cited by other articles:
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  L. Spaggiari, P. Solli, and G. Veronesi Single lung resection of second primary after pneumonectomy for lung cancer Ann. Thorac. Surg., April 1, 2003; 75(4): 1358 - 1358. [Full Text] [PDF]
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