Imaging of postoperative complications following surgery for lung cancer

Imaging findings of the postoperative chest: What the radiologist should know

Thoracic surgical procedures are increasing in recent years, and there are different types of lung resections. Postsurgical complications vary depending on the type of resection and the time elapsed, with imaging techniques being key in the postoperative follow-up. Multidisciplinary management of these patients throughout the perioperative period is essential to ensure an optimal surgical outcome. This pictorial review will review the different thoracic surgical techniques, normal postoperative findings and postsurgical complications.

The postoperative chest in lung cancer

Most of the complications following lung cancer surgery occur in the early postoperative period and can result in significant morbidity and mortality. Delayed complications can also occur. Diagnosing these complications can be challenging because clinical manifestations are non-specific. Imaging plays an important role in detecting these complications in a timely manner and facilitates prompt interventions. Hence, it is important to have knowledge of the expected anatomical alterations following lung cancer surgeries, and the spectrum of post-surgical complications and their respective imaging findings to avoid misinterpretations or delay in diagnosis.

Efficacy of preoperative white blood cell count and lymphocyte/monocyte ratio in predicting post-lobectomy pneumonia

Background

This study aims to examine preoperative white blood cell count and lymphocyte/monocyte ratio and to investigate foreknown risk factors for pneumonia following lobectomy.

Methods

Between January 2005 and May 2018, a total of 152 patients (135 males, 17 females; mean age: 61.9±7.5 years; range, 45 to 73 years) who underwent right lower lobectomy for non-small cell lung cancer were retrospectively analyzed. Data including age, sex, preoperative white blood cell count and lymphocyte/monocyte ratio, smoking, preexisting chronic diseases, body mass index, stage of lung cancer, the use of neoadjuvant chemotherapy, type of surgery, operation duration, blood transfusion, and postoperative intensive care unit admission were recorded.

Results

Twenty-five (16.4%) patients developed postoperative pneumonia. Older patients presenting with elevated levels of preoperative white blood cell count and lymphocyte/monocyte ratio, excessive tobacco consumption, prolonged operation duration, history of a chronic disease, a body mass index over 30 kg/m2, advanced lung cancer, neoadjuvant chemotherapy, and intensive care unit admission after surgery were at high risk for postoperative pneumonia. There was no significant difference in sex, type of surgery (thoracotomy versus thoracoscopy), and the use of blood products. In predicting the development of postoperative pneumonia, lymphocyte/monocyte ratio had 85.% sensitivity and 87.5% specificity, while white blood cell count had 72.5% sensitivity and 77.5% specificity.

Conclusion

Preoperative white blood cell count and lymphocyte/ monocyte ratio provide supporting evidence in predicting pneumonia following lobectomy contributing to the existing risk identification criteria.

Postoperative cavitating infarction following lobectomy: the importance of variant pulmonary anatomy

A 75-year-old woman was admitted to hospital with haemoptysis, fever and shortness of breath. She had undergone a right video-assisted thoracoscopic surgery upper lobectomy for an apical lung cancer 4 weeks earlier, and had been treated with antibiotics for 1 week prior to admission for a suspected postoperative lung abscess. Review of preoperative imaging found that she possessed a lobar pulmonary artery variant, with postoperative imaging confirming that the right lower lobe segmental pulmonary artery had been divided alongside the upper lobe vessels. The diagnosis of a lung abscess was thus revised to a cavitating pulmonary infarct. There are numerous variations of the pulmonary vasculature, all of which have the potential to cause a range of serious vascular complications if not appreciated preoperatively. Measures to mitigate the risk of complications resulting from vascular anomalies should be considered by both radiologists and surgeons, with effective lines of communication essential to safe working.

Contralateral pulmonary resection using selective bronchial blockade in postpneumonectomy patients

BACKGROUND

Pulmonary resection is occasionally performed in postpneumonectomy patients with contralateral lung lesions, such as metachronous or metastatic lung cancer. Careful intraoperative respiratory management is essential in such patients. This study evaluated the respiratory management of postpneumonectomy patients who underwent contralateral pulmonary resection with selective bronchial blockade of the lobe or segment to be resected.

METHODS

We retrospectively analyzed the surgical findings and safety of surgery in six patients who underwent contralateral pulmonary resection with selective bronchial blockade after pneumonectomy for non-small cell lung cancer (NSCLC).

RESULTS

The percutaneous oxygen saturation did not decrease in any of the patients during bronchial blockade under high oxygen concentration. The median blockade time was 57.5 minutes. The operative field was tolerable secured under conditions of partial lung collapse, and partial pulmonary resection was performed as planned. Postoperatively, one patient developed acute respiratory distress syndrome due to acute exacerbation of interstitial pneumonia; however, no patients died within one month postoperatively. Two patients underwent pulmonary resection in order to obtain adequate tissue specimens to evaluate the biomarkers of multiple lung metastases. On histopathology, one patient tested positive for anaplastic lymphoma kinase (ALK) and was subsequently administered an ALK inhibitor, which prolonged survival.

CONCLUSIONS

In all patients, intraoperative respiratory condition under partial lung collapse remained stable, and all partial pulmonary resections were safely performed. However, surgical indications should be carefully reviewed preoperatively in patients with interstitial pneumonia.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: Contralateral partial pulmonary resection was performed using selective bronchial blockade in postpneumonectomy patients. Percutaneous oxygen saturation did not decrease during the bronchial blockade under high oxygen concentration, and the operative field was tolerable secured under conditions of partial lung collapse.

WHAT THIS STUDY ADDS

Oxygen concentration can be set to the minimum level, sufficient to maintain oxygenation, during contralateral partial pulmonary resection with selective bronchial blockade.

Imaging in Cardio-oncology: An Overview of an Emerging Medical Discipline

The world of cardio-oncology is an evolving field involving the assessment of cardiovascular disease in patients suffering from cancer. Cancer and cardiovascular diseases are the two leading causes of morbidity and mortality in the developed world. Globally, cancer is diagnosed in 12.7 million patients annually, and cancer incidence is projected to increase by 40% in high-income countries from 2008 to 2030. Chemotherapy is the main treatment for most cancers and improves survival, but is associated with significant cardiotoxicity. In recent years, the introduction of new biological anti-cancer treatments in addition to "classic" chemotherapy has further improved survival, but has also introduced new cardiovascular side effects beyond "pure" myocardial damage. The increasing number of patients with cancer and cancer survivors, and the growing complexity of cancer treatment and cardiovascular side effects, call for teamwork including cardiologists with specific training and expertise working in teams with oncologists, hematologists, and others. The purpose of this review was to describe the clinical background and importance of cardio-oncology, with an emphasis on the use of imaging in this clinical setting.

A case report with COVID-19 during perioperative period of lobectomy

RATIONALE

Currently, COVID-19 has made a significant impact on many countries in the world. However, there have been no reported cases of pulmonary lobectomy with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) infection. We are the first to report such a case.

PATIENT CONCERNS

We report a 63-year-old Wuhan male patient with smoking history of 40 cigarettes per day for 40 years. He sought medical consultation for right lower lung nodules found by CT scan.

DIAGNOSES AND INTERVENTIONS

The patient's postoperative pathological diagnosis was squamous cell carcinoma of the right lower lung. On the fourth day after the operation, the real-time reverse transcription polymerase chain reaction test showed a positive result. After the operation, we routinely give symptomatic treatments such as anti-infection, nebulization and oxygen inhalation. We also change antibiotics several times depending on the patient's condition.

OUTCOMES

The patient's condition continued to deteriorate. On the fifth day after surgery, the patient died despite medical treatment.

LESSONS

We are the first to report the diagnosis and treatment process of patients with COVID-19 during perioperative period of lobectomy. It provides a case for the postoperative management of such patients.

Reoperation for hemostasis within 24 hours can get a better short-term outcome when indicated after lung cancer surgery

Background

Postoperative hemorrhage after lung cancer surgery is a potentially fatal complication. This study aimed to investigate the indications and timing of reoperation for postoperative hemorrhage after lung cancer surgery.

Methods

We identified all patients who underwent lung resection and mediastinal lymph node dissection for lung cancer between October 2001 and September 2015 at Sichuan Cancer Hospital, identifying 57 who had undergone reoperation for hemostasis. The records of these 57 patients were reviewed and analyzed.

Results

The most common postoperative hemorrhage site was the separation surface of the original pleural adhesions (29.8%). The median time interval between the initial operation and reoperation was 12 hours (range, 2-432 hours), and most patients (77.2%) underwent reoperation within 24 hours. The overall morbidity and mortality rates of reoperation were 50.9% and 5.3%, respectively. The morbidity rates of the early reoperation group (≤24 hours) and the late reoperation group were 43.2% and 77.0%, respectively, which were significantly different (P=0.033). The mortality rates of the early reoperation group and the late reoperation group were 0 and 23.1%, respectively, which were also significantly different (P=0.010).

Conclusions

Once indications of reoperation for postoperative hemorrhage after lung cancer surgery are identified, reoperation within 24 hours after the initial operation can get a better short-term outcome.

Left Lung Torsion: Complication of Lobar Resection for an Early Stage Lung Adenocarcinoma

Lobar torsion is a fatal but fortunately rare occurrence following lung resection. Early clinical signs and radiographic features may be nonspecific resulting in diagnostic delay. A high index of suspicion is vital for early diagnosis and intervention to avoid further parenchymal necrosis and deadly gangrene. We report a case of left lower lobe torsion in a 76-year-old female following elective upper lobectomy for underlying lung adenocarcinoma. Diagnosis was made following highly suggestive radiographic findings prompting bronchoscopy and revision thoracotomy. An emergency detorsion failed to restore lung viability and was followed by completion pneumonectomy. The patient recovered and was discharged on the seventh postoperative day.