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Ann Thorac Surg 2001;72:321
© 2001 The Society of Thoracic Surgeons
e-mail: tuncozgur{at}gantep.edu.tr
To the Editor
We read with great interest the article by Rendina and associates [1]. As they indicated, sleeve resection of the pulmonary artery has not yet achieved acceptance in lung cancer. However, it is fortunate that long-term survival in their study was similar with that reported for standard resection.
In January 2000, we performed a bronchovascular sleeve right upper lobectomy together with lymph node dissection in a patient with squamous cell lung carcinoma who was a 67-year-old male. Computed tomography scan of the thorax showed a mass-like density between 2 and 5 cm in the right upper lobe bronchi. Invasion of the right intermedier bronchi was also observed but there was no radiological evidence of metastasis to the other lung regions and lymph nodes. Sleeve resection was performed due to the invasion of tumor into the intermedier bronchi and pulmonary artery. Postoperative histopathological evaluation of the hilar and mediastinal lymph nodes revealed no evidence of metastasis. However, tumor invasion involving the intima of the pulmonary artery was determined in the resected lung. On the basis of these findings, cancer was staged as II-B according to the new staging system [2]. On the perfusion scan of the lung, which was performed 1 week after the surgery, a total perfusion defect was determined on the right side. Therefore, a completion pneumonectomy had to be done 1 month after the first operation. This histopathological evaluation of the resected lung after secondary surgery revealed an expected thrombosis formation in the anastomosis line of the pulmonary artery. However, it also revealed that there were numerous micro-metastasis in the right middle and lower lobes despite no radiological evidence of metastasis in the above-mentioned locations. During the past 8 months, the patient remained clinically stable with no evidence of tumor recurrence. It seems like an unexpected complication provided a better chance for the longer survival through a secondary surgery.
Of course, it is not fair to make a conclusion against Rendina and his associates depending on one case. Long-term results in their series are encouraging. We also believe that bronchial sleeve resection is an oncologically adequate operation and can be performed safely if the tumor invasion is limited to the perivascular layer of the pulmonary artery. In the cases of non-small cell lung cancer with intravascular invasion of the pulmonary artery, metastasis to the lower and middle lobes may occur. Therefore, we believe that pneumonectomy may be the accurate choice of surgery in such cases.
References
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