Three-Port Thoracoscopic Middle Lobectomy in a Patient After Left Pneumonectomy

Guiding Principles in the Management of Synchronous and Metachronous Primary Non-Small Cell Lung Cancer

Multiple lung cancers can be found simultaneously, with incidence ranging from 1% to 8%. Documentation of more than 1 pulmonary lesion can be challenging, because these solid, ground-glass, or mixed-density tumors may represent multicentric malignant disease or intrapulmonary metastases. If mediastinal nodal and distant deposits are excluded, surgery should be contemplated. After surgical treatment of lung cancer, patients should be followed closely for an undetermined period of time. Good clinical judgment is of outmost importance in deciding which individuals will benefit from those surgical interventions and which are candidates for alternate therapies. Every case should be discussed in a multidisciplinary meeting.

Thoracoscopic wedge resection in single-lung patients

Background

The thoracoscopic approach has become a standard procedure in the field of lung resections. However, its advantage in single-lung patients has not yet been well studied. We describe a series of successful thoracoscopic wedge resections in patients presenting with lung cancer after contralateral pneumonectomy.

Methods

Eight patients, with a previous pneumonectomy (5 right and 3 left) for lung cancer, underwent resection for a suspicious neoplasm on the remaining lung. All lesions were detected in the asymptomatic phase during regular follow-up after pneumonectomy based on repeated computer tomography (CT). Only single peripheral lesions less than 2 cm were eligible for wedge resection were eligible for surgery. Video-assisted thoracoscopic, margin-free tumor wedge resections, were performed during apnea windows with the lung in a deflated position.

Results

All patients were treated by a wedge resections smaller than a single segment. Only one patient needed a mini-thoracotomy conversion to accomplish a safe margin-free resection. Median total surgical operative time was 37 minutes. There were no postoperative deaths, while morbidity was 12.5%.

Conclusions

Thoracoscopic surgery represents a feasible surgical option in selected patients after contralateral pneumonectomy, with careful preoperative assessment and using short apnea windows in good collaboration with anesthesiologists. Histological definition, made possible by the surgical-procedure, gives patients the possibility to eventually undergo further targeted therapies. Randomized prospective trials are necessary to assess the best management of peripheral small lung nodules in single-lung patients, in particular to define which patients can benefit from a surgical approach.