A successful case of complete surgical resection via left upper and right lower lobectomy for bilateral lung metastases of a perivascular epithelioid cell tumor in the colon: a case report

Background

Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal neoplasms with malignant potential. No effective treatment other than surgical resection has been established for lung metastases of PEComas. We describe a patient who underwent complete surgical resection via bilateral lobectomy involving a two-step procedure for lung metastases 8 years after undergoing radical surgery for a colonic PEComa.

Case presentation

A 53-year-old woman underwent partial colectomy for a PEComa in the transverse colon 8 years ago. She presented with an abnormal chest shadow during a health examination. Chest computed tomography (CT) revealed a solid nodule 2 cm in diameter located centrally in the right lower lobe and a solid nodule 3 cm in diameter located centrally in the left upper lobe. Positron emission tomography revealed 18F-fluorodeoxyglucose uptake in these nodules. These nodules were suspected to be metastatic tumors of the colonic PEComa and were considered for complete surgical resection. Segmentectomy could not be performed because of the anatomical location of the tumors straddling the segments; therefore, bilateral lobectomy was required for complete surgical resection. Therefore, we performed two-step lobectomy safely with the expectation of pulmonary function recovery. Microscopically, the tumors were diagnosed as lung metastases of the PEComa. One year after the last surgery, no recurrence was detected, and the patient’s pulmonary function improved.

Conclusions

This case indicates that even if multiple lung metastases of a PEComa require bilateral lobectomy, complete resection with a two-step surgery may be considered.

Single lung resection: The limits of the possible. Clinical report

INTRODUCTION

Single lung resection remains a challenge due to the preservation of the respiratory reserve. This report presents that case of a female patient with bilateral fibrotic-cavitary pulmonary tuberculosis complicated with empyema on the right lung. Only 3.5 lung segments were left after a multistage surgery.

PRESENTATION OF CASE

The first stage included draining of empyema and transsternal transmediastinal right main bronchus occlusion. Then, upper lobectomy with partial S6 resection of the left lung, followed by pleuropneumonectomy was performed. At a follow-up of two years and 10 months, patient's condition was good.

DISCUSSION

Although single lung surgery has been possible over half a century ago, it remains a high-risk intervention.

CONCLUSION

With the removal of the non-functioning parenchyma and elimination of the air/vascular shunt, single lung resection volume exceeding lobectomy is possible, which may improve cardiorespiratory function.

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.

VATS Right Upper Lobe Anterior Segmentectomy in Post Left Pneumonectomy: Technique

Lung resection following pneumonectomy for recurrent lung cancer is a challenging scenario. Peri-operative airway management and choice of surgical procedure are issues to be addressed by both the anesthesiologists and thoracic surgeons. We hereby report a case of anterior segmentectomy of the right upper for recurrent lung cancer, in a patient who had previously underwent pneumonectomy for primary lung cancer one year earlier. A modified conventional tracheal intubation and unique surgical techniques were applied for video-assisted thoracoscopic surgery (VATS) anterior segmentectomy of the right upper lobe in a patient with a notable mediastinal shift (following contralateral pneumonectomy), resulting in a good recovery and clinical outcome. The clinical experience is summarized in detail in this article.

Feasibility of Spontaneous Ventilation in Secondary Contralateral Thoracic Surgery

Background

A secondary contralateral thoracic surgery is a challenging procedure and is rarely indicated. We retrospectively compared the perioperative values to find out whether video-assisted thoracoscopic surgery under spontaneous ventilation is feasible for this surgery.

Material/Methods

Patients were retrospectively collected from January 1, 2015 to December 30, 2018 who underwent secondary contralateral video-assisted thoracoscopic surgeries with mechanical ventilation (MV-VATS group) or spontaneous ventilation (SV-VATS group). A propensity score-matching analysis was used to counterbalance the discrepancies. The primary outcome measures were the values of respiratory mechanics and hemodynamics, and the secondary outcome measures were postoperative recovery and complications.

Results

In the SV-VATS group, the operation and anesthesia times were shorter (P=0.008 and P=0.020, respectively). The peak respiratory pressure value was lower (P<0.001), and there was less use of analgesic drugs during the operation (P<0.001). The vital signs and oxygenation were stable during the operation and in post-anesthesia care unit. The extubation time of laryngeal mask airway, chest-tube duration, and postoperative hospital stay were shorter in the SV-VATS group (P=0.015, P=0.000, P=0.003, respectively), but the duration of intensive care unit stay, the postoperative clinical complications, and chest radiography results were not significantly different between the 2 groups (P>0.05). In the SV-VATS group, postoperative leukocyte count (P<0.001) and neutrophil ratio (P=0.001) were lower and the postoperative value of PaCO₂ was slightly higher (P=0.026).

Conclusions

VATS under spontaneous ventilation might be an alternative approach for patients who undergo a secondary contralateral thoracic surgery with intraoperative stable vital signs, and does not increase postoperative complications.

Thoracoscopic partial lung resection following pneumonectomy: a report of three cases

Background

The prognosis of patients who undergo unilateral pneumonectomy and subsequently develop a contralateral pulmonary tumor can be improved by tumor resection. Thus, surgery is a treatment option if the patient’s pulmonary function and performance status are satisfactory. To date, there have been only few cases reporting thoracoscopic lung resection for pulmonary tumor after contralateral pneumonectomy because of the difficulty in respiratory management during surgery. Thoracoscopic surgery requires the maintenance of the operative field to allow the lung to collapse, and in partial lung resection we need to identify tumor localization. The identification of a tumor lesion just inferior to the pleura is easy; however, the identification of a tumor lesion in the deep parts is difficult. The tumor in the deep part of the lung segments can be easily located if the tumor-affected lobe is allowed to completely collapse. Therefore, ventilation technique should be modified according to the tumor localization.

Case presentation

Here, we report three cases of thoracoscopic partial lung resections for pulmonary tumors that developed after contralateral pneumonectomy. Intermittent manual ventilation using a tracheal tube was performed in two cases with a lesion just inferior of the pleura. The tumors in both patients were resected using automatic suturing devices while arresting manual ventilation. The affected lobe was allowed to collapse using a bronchial blocker in one of the cases with a lesion in the deep part. Furthermore, she had contralateral pneumothorax with bullae on the right upper and lower lobes of the lung. The tumor in the deep part of the lung segment and ruptured bullae were easily located and resected using automatic suturing devices. The hemodynamic status of the patients was stable, and the intra- and postoperative courses were uneventful.

Conclusions

Our cases demonstrate that thoracoscopic lung resection after contralateral pneumonectomy can be performed if intermittent manual ventilation is utilized when the tumor is located just inferior to the pleura and if selective double ventilation using an intrabronchial blocker is utilized when the tumor is located in the deep part.

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.