Cancer resection on the residual lung after pneumonectomy for bronchogenic carcinoma

Contralateral Pulmonary Resection after Pneumonectomy

Background

Contralateral pulmonary resection after pneumonectomy presents considerable challenges, and few reports in the literature have described this procedure.

Methods

We retrospectively reviewed the medical records of all patients who underwent contralateral lung resection following pneumonectomy for any reason at our institution between November 1994 and December 2020.

Results

Thirteen patients (9 men and 4 women) were included in this study. The median age was 57 years (range, 35-77 years), and the median preoperative forced expiratory volume in 1 second was 1.64 L (range, 1.17-2.12 L). Contralateral pulmonary resection was performed at a median interval of 44 months after pneumonectomy (range, 6-564 months). Surgical procedures varied among the patients: 10 underwent single wedge resection, 2 were treated with double wedge resection, and 1 underwent lobectomy. Diagnoses at the time of contralateral lung resection included lung cancer in 7 patients, lung metastasis from other cancers in 3 patients, and tuberculosis in 3 patients. Complications were observed in 4 patients (36%), including acute kidney injury, pneumothorax following chest tube removal, pneumonia, and prolonged air leak. No cases of operative mortality were noted.

Conclusion

In carefully selected patients, contralateral pulmonary resection after pneumonectomy can be accomplished with acceptable operative morbidity and mortality.

Survival after wedge resection versus lobectomy for stage IA second primary NSCLC with previous lung cancer-directed surgery

Background

The surgical procedure for early-stage second primary non-small cell lung cancer (SP-NSCLC) remains controversial, especially for patients with previous lung cancer-directed surgery. This study aims to compare the survival after wedge resection and lobectomy for these patients.

Methods

Stage IA SP-NSCLC patients with clear clinical information were searched from the Surveillance, Epidemiology, and End Results (SEER) database. The Cox proportional hazard model, the competing risk model, and the Kaplan–Meier survival curve were used to describe the survival difference between wedge resection and lobectomy. A 1:1 propensity score matching (PSM) method was also performed to reduce the potential impact of confounding factors between the two groups.

Results

Of the 320 eligible stage IA SP-NSCLC patients included in this study, 238 (74.4%) patients underwent wedge resection and 82 (25.6%) patients received lobectomy. The 5-year overall survival (OS) was 61.3% with wedge resection and was 66.1% with lobectomy. Both before and after PSM, wedge resection showed similar OS and lung cancer-specific mortality as lobectomy in the entire cohort. Additionally, in all subgroup analyses, wedge resection demonstrated equivalent survival to lobectomy. However, in the female, sublobectomy for the first primary lung cancer, and interval ≤ 24 months subgroups, wedge resection displayed a higher lung cancer-specific mortality than lobectomy (fine-gray test, all p < 0.05).

Conclusion

Overall, wedge resection is comparable to lobectomy in OS for stage IA SP-NSCLC patients with previous lung cancer-directed surgery. Therefore, we believe that wedge resection may be sufficient for these patients, although, in some cases, wedge resection has a higher lung cancer-specific mortality rate than lobectomy.

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.

The European experience

Traditionally, pulmonary lobectomy has always been considered as the gold standard for the treatment of early stage non-small cell lung cancer (NSCLC); limited resections have been proposed in case of "compromised" patients, with relevant comorbidities. In the last years, the interest in anatomical segmentectomies among surgeons has been progressively growing, even for patients fit for lobectomy, in selected cases. In this article we debate the current trends in the treatment of early stage NSCLC around Europe.

Therapeutic options following pneumonectomy in non-small cell lung cancer

INTRODUCTION

Pneumonectomy can be considered the most appropriate treatment for lung cancer that cannot be removed by lesser resection on.

AREAS COVERED

Therapeutic options following pneumonectomy may be required at least in 3 different scenarios: 1) an early approach due to acute surgical complications 2) a late approach due to chronic surgical complications 3) an integrated radio-chemotherapeutic adjuvant approach for advanced stages. In this review we focused on these three settings with particular emphasis to surgical approach as well as to alternative options. Expert commentary: Pneumonectomy itself does not preclude postoperative additional treatments, if needed, to maximize oncological results and to manage potential short or long term complications. However, as pneumonectomy puts a significant physiological stress on the respiratory and circulatory systems, the benefits and risks of pneumonectomy should be compared with those of alternative, non-resectional treatment modalities.

Computed tomography-guided percutaneous microwave ablation of early stage non-small cell lung cancer in a pneumonectomy patient

A squamous cell lung cancer patient was treated with pneumonectomy. A recurrent lung cancer (adenocarcinoma) was found 45 months later and successfully biopsied and treated with microwave ablation. After 18 months of follow up, no evidence of tumor recurrence was observed.

Efficacy and Safety of Stereotactic Ablative Radiotherapy in Patients with Previous Pneumonectomy

Background

Thoracic surgery for a newly diagnosed primary lung tumor following a previous pneumonectomy is rarely indicated. Stereotactic ablative radiotherapy (SABR) might represent a curative option. This report focuses on outcomes, toxicity and quality of life (QoL) after SABR.

Methods

Nine patients were treated with SABR between 2004 and 2011; median time since surgery was 8.4 years. In 4 cases, a histological confirmation was possible with bronchoscopy. In 5 cases, the clinical proof of malignancy was based on radiological criteria. Forced expiratory volume in 1 second (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) were tested in all patients. A SABR biologically equivalent dose of >100 Gy was prescribed in all cases. QoL questionnaire forms were administered before SABR and during follow-up.

Results

Median follow-up was 41.8 months. We did not observe grade >3 acute toxicity, and concerning late toxicity, we registered 2 cases. QoL was decreased during the first 12 months of follow-up, followed by a progressive improvement after this time. One patient had a local relapse at 7.4 years; 1 developed a new nodule at 5.5 years, associated with metastases; and 1 developed a new nodule without any systemic disease at 3 years. There were 2 cancer-related deaths (18.2%) at 3 and 12 months after progression.

Conclusions

Data support efficacy and safety of SABR in patients with a new primary lung cancer following previous pneumonectomy, with acceptable acute, late toxicity profile and without significant impairment of QoL. Our results were comparable to those in the literature.

Stereotactic body radiation therapy for a new lung cancer arising after pneumonectomy: dosimetric evaluation and pulmonary toxicity

OBJECTIVE

To evaluate the tolerance of stereotactic body radiation therapy (SBRT) for the treatment of secondary lung tumours in patients who underwent previous pneumonectomy.

METHODS

12 patients were retrospectively analysed. The median maximum tumour diameter was 2.1 cm (1-4.5 cm). The median planning target volume was 20.7 cm(3) (2.4-101.2 cm(3)). Five patients were treated with a single fraction of 26 Gy and seven patients with fractionated schemes (3 × 10 Gy, 4 × 10 Gy, 4 × 12 Gy). Lung toxicity, correlated with volume (V) of lung receiving >5, >10 and >20 Gy, local control and survival rate were assessed. Median follow-up was 28 months.

RESULTS

None of the patients experienced pulmonary toxicity > grade 2 at the median dosimetric lung parameters of V5, V10 and V20 of 23.1% (range 10.7-56.7%), 7.3% (2.2-27.2%) and 2.7% (0.7-10.9%), respectively. No patients required oxygen or had deterioration of the performance status during follow-up if not as a result of clinical progression of disease. The local control probability at 2 years was 64.5%, and the overall survival at 2 years was 80%.

CONCLUSION

SBRT appears to be a safe and effective modality for treating patients with a second lung tumour after pneumonectomy.

ADVANCES IN KNOWLEDGE

Our results and similar literature results show that when keeping V5, V10 V20 <50%, <20% and <7%, respectively, the risk of significant lung toxicity is acceptable. Our experience also shows that biologically effective dose 10 >100 Gy, necessary for high local control rate, can be reached while complying with the dose constraints for most patients.

Outcomes of pulmonary resection in single-lung patients

BACKGROUND

After pneumonectomy, the development of a new lung cancer or a recurrence in the residual lung is a challenge. Surgery often is considered contraindicated. The goal of our study is to assess the morbidity and mortality of lung resection on a single lung.

METHODS

All patients who underwent lung resection after pneumonectomy from January 1996 through December 2012 were reviewed.

RESULTS

There were 12 patients (10 men and 2 women). Mean age was 71 years (range, 54-81 years). Mean preoperative FEV1 was 1,470 ml (52%) and preoperative FVC 2,153 ml (61,5%). Subsequent pulmonary resection was performed after a median follow-up of 34,5 months. Wedge resection was performed in all patients. Diagnosis was pulmonary mestastatic lung cancer in 2 patients, metachronous lung cancer in 6, metastatic extrathoracic cancer in 3 and benign nodule in one. Complications occurred in 4 patients (33,4%) while operative mortality was nil.

CONCLUSIONS

Lung resection on a single lung is a safe procedure associated with acceptable morbidity and mortality. Careful patient selection is very important.

Accelerated radiotherapy and concurrent chemotherapy for patients with contralateral central or mediastinal lung cancer relapse after pneumonectomy

BACKGROUND

Treatment options are very limited for patients with lung cancer who experience contralateral central or mediastinal relapse following pneumonectomy. We present results of an accelerated salvage chemoradiotherapy regimen.

METHODS

Patients with localized contralateral central intrapulmonary or mediastinal relapse after pneumonectomy were offered combined chemoradiotherapy including concurrent weekly cisplatin (25 mg/m(2)) and accelerated radiotherapy [accelerated fractionated (AF), 60 Gy, 8×2 Gy per week] to reduce time for repopulation. Based on 4D-CT-planning, patients were irradiated using multifield intensity-modulated radiotherapy (IMRT) or helical tomotherapy.

RESULTS

Between 10/2011 and 12/2012, seven patients were treated. Initial stages were IIB/IIIA/IIIB: 3/1/3; histopathological subtypes scc/adeno/large cell: 4/1/2. Tumour relapses were located in mediastinal nodal stations in five patients with endobronchial tumour in three patients. The remaining patients had contralateral central tumour relapses. All patients received 60 Gy (AF), six patients received concurrent chemotherapy. Median dose to the remaining contralateral lung, esophagus, and spinal cord was 6.8 (3.3-11.4), 8.0 (5.1-15.5), and 7.6 (2.8-31.2) Gy, respectively. With a median follow-up of 29 [17-32] months, no esophageal or pulmonary toxicity exceeding grade 2 [Common terminology criteria for adverse events (CTC-AE) v. 3] was observed. Median survival was 17.2 months, local in-field control at 12 months 80%. Only two local recurrences were observed, both in combination with out-field metastases.

CONCLUSIONS

This intensified accelerated chemoradiotherapy schedule was safely applicable and offers a curative chance in these pretreated frail lung cancer patients.

[Lung cancer surgery in a single-lung]

INTRODUCTION

The diagnosis of a second lung cancer in a patient with a previous medical history of lung cancer is no longer a rarity. Also, it is possible to observe a new location in a patient who underwent pneumonectomy in the past. Surgery remains the best treatment. Our objective was to overview this subject.

PATIENTS AND METHODS

Among 5611 patients operated in our institution, 186 (3.3%) had metachronous cancer and 17 had previous pneumonectomy (0.7% of pneumonectomies and 0.2% of NSCLC treated in our department). The procedure was diagnostic and therapeutic in 88% of cases (n=15).

RESULTS

There were 16 males and 1 female, mean age was 62.5-years. All were smokers (11 were former smokers) and 6 had other medical history. Mean FEV was 52% (range 35-95%). Types of resection were 2 lobectomies, 4 segmentectomies, and 11 wedge resections. There were no postoperative deaths, but two complications. Histological subtype of the first and second cancer was the same in 11 patients. All patients were pN0 after second surgery. The long-term survival (median 33 months) was 35.3% at 5-years and 14.1% at 10-years. Two patients treated with pneumonectomy for their first cancer were pN2. Patients who underwent upper right lobectomy for treatment of their second cancer survived longer than 5-years.

CONCLUSION

Surgical resection for lung cancer on single-lung is associated with acceptable morbidity and mortality. Prolonged survival can be achieved in selected patients.

Radiotherapy for a second primary lung cancer arising post-pneumonectomy: planning considerations and clinical outcomes

BACKGROUND

Second primary non-small cell lung cancer (SPLC) is a significant cause of death amongst lung cancer survivors. As subsequent surgery is seldom feasible post-pneumonectomy, we studied the long-term clinical outcomes achieved with curative radiotherapy using modern delivery techniques.

METHODS

Retrospective review of an institutional database between 2003-2011 identified 27 patients who had received curative radiotherapy for SPLC arising post-pneumonectomy. Treatments included; stereotactic ablative radiotherapy (SABR, n=20, dose 54-60 Gy in 3-8 fractions), hypofractionated radiotherapy (HFR, n=6, dose 39-60 Gy in 12-23 fractions) and conventional radiotherapy (RT, n=1, 60 Gy in 30 fractions). Clinical follow-up with a CT scan at 3, 6 and 12 months, then yearly was performed. Toxicities were scored using the common toxicity criteria for adverse events (version 4.0).

RESULTS

The median overall survival was 39 months (95% CI, 33-44 months). After a median follow-up of 52 months (95% CI, 37-67 months), any recurrence was observed in four (15%) patients. Actuarial 3-year rates of local, regional and distant recurrences were 8% (95% CI, 0-21 months), 10% (95% CI, 0-23%) and 9% (95% CI, 0-20%), respectively. Patients receiving HFR or RT all had centrally located tumors. Of the patients treated with HFR delivered 12 fractions, 75% (3/4) developed grade 3 or higher radiation pneumonitis (RP), including one probable grade 5 toxicity. Of those receiving RT or HFR in 13 or more fractions no (0/3) grade 3 or worse RP was observed, despite such treatment being used for larger tumors and resulting in worse lung dose-volume histogram metrics. All the patients who developed RP had radiotherapy plans, which prioritized the sparing of central structures over lung sparing. No non-RP grade 3 or higher toxicities were observed.

CONCLUSIONS

Curative radiotherapy is an effective treatment for SPLC arising post-pneumonectomy. For larger central tumors, our data suggests that plans should prioritize reducing lung doses above the sparing of central structures.

Video-assisted thoracoscopic management for emphysema associated with contralateral destroyed lung

BACKGROUND

Surgery can be quite challenging in condition that contralateral lung has no function. We report 3 cases of emphysema associated with contralateral destroyed lung managed with the use of video-assisted thoracic surgery (VATS).

METHODS

From December 2007 to December 2008, 3 patients of emphysema associated with contralateral destroyed lung were operated on by VATS. There were two pulmonary wedge resections and mechanical pleurodesises for pneumothorax and one lung volume reduction surgery (LVRS) for worsening dyspnea. Their records were reviewed retrospectively.

RESULTS

No postoperative mortality was observed. One case for pneumothorax experienced prolonged postoperative air leakage. Of all the three cases, two cases for pneumothorax had no recurrence and one case for worsening dyspnea had improved lung function.

CONCLUSIONS

VATS for emphysema associated with contralateral destroyed lung is feasible in selected patients.

Right lower lobectomy eight years after left pneumonectomy for a second primary lung cancer

Lobectomy for second primary lung cancer in a patient with previous pneumonectomy is seldom done because most such patients either have inadequate pulmonary reserve or metastatic disease at other sites. This is different than when this type of surgery is done for benign disease where the lobe to be resected is already non functional. We report a case where successful right lower lobectomy for a second primary lung cancer was carried out in a 53 year old man who had had a left pneumonectomy eight years before. We conclude that, although this type of approach can be worthwhile, surgeons must be cautious and selective before doing so.

Surgical treatment for metachronous second primary lung cancer after radical resection of primary lung cancer

PURPOSE

We retrospectively reviewed our experience of surgical resection for second primary lung cancer (SPLC) in our institute. And to clarify whether periodic follow-up after resection of first primary lung cancer (FPLC) is associated with earlier detection of SPLC.

METHODS

From January 2003 to March 2011, a total of 386 patients underwent surgical resection for primary lung cancer in our institute. Of these patients, 21 (5.4%) with SPLC were observed during follow-up after surgery. Radiation therapy was selected instead of surgical resection in 7 patients to preserve respiratory function. The other14 patients are reviewed in this paper.

RESULTS

Histological types were different between FPLC and SPLC in only one patient(FPLC: adenosquamous carcinoma, SPLC: squamous cell carcinoma). The average SPLC tumor size (18±8 mm) was smaller (P = 0.07) than the average FPLC tumor size (26±14 mm). Recurrence was not observed in these patients.The follow-up period after resection of SPLC was 31±30 (5-94) months. During followup, 2 patients died of de novo malignancies, and the other 12 patients were alive without recurrence.

CONCLUSION

Systematic and periodic long-term follow-up after FPLC probably resulted in earlier detection of SPLC and yielded this good prognosis.

Percutaneous cryoablation for pulmonary nodules in the residual lung after pneumonectomy: report of two cases

Lung cancers in the residual lungs of patients who have undergone pneumonectomies are often unresectable, primarily because of the risks of overt pulmonary function losses. Percutaneous cryoablation of lung tumors is a potentially minimally invasive technique that has recently been used in the treatment of lung cancers and metastatic lung tumors. Here, we present two patients who had previously undergone pneumonectomies, in whom lung cancers in the residual lungs were treated by cryoablation. In both patients, the procedures were performed safely without any complications, such as airway bleeding, hemothoraces, or pneumothoraces. The changes in pulmonary functions after the procedures were minimal: % vital capacity (-1% and -4%), and %FEV(1) (-1% and +10%) in the first and second patients, respectively. The performance statuses were maintained at zero in both patients after cryoablation. In the first patient, local control has been maintained for 4 years. In the second patient, local control was maintained for 2 years until the patient died of distant metastases. This is, to our knowledge, the first reported case of lung cryoablation in residual lungs of patients who have previously undergone pneumonectomies. Application of percutaneous cryoablation may represent a new treatment option for lung tumors in patients who have previously undergone pneumonectomies.

[Surgical treatment of pulmonary lesions in a single lung]

We performed surgery on 4 patients who had previously undergone left pneumonectomy and presented a second pulmonary lesion (3 lung cancers; 1 metastasis from colon cancer). Patients were aged between 52 and 79 years; 3 were men. Wedge resection was performed in 3 patients and segmentectomy in the other. Preoperative forced expiratory volumes in the first second were 1940 mL (72%), 576 mL (29%), 1390 mL (63%), and 2370 mL (63%). There was no perioperative mortality; 1 patient presented an air leak for 7 days. Two patients were alive and disease-free at 12 and 15 months, and 2 died from causes unrelated to the tumor at 52 and 183 months. There was no deterioration in the quality of life. In selected cases, patients with a second tumor in a single lung can be treated surgically with little or no mortality and with a prolonged survival.

[Pulmonary metastasectomy after pneumonectomy]

INTRODUCTION, OBJECTIVES: Authors of two thoracic surgical departments from the above named hospitals discuss their practices of pulmonary metastasectomy after pneumonectomy for malignant disease.

MATERIAL AND METHODS

Six patients were operated after pneumonectomy for metastatic spread in the residual lung. The average age of the three male and three female patients was 52.5 years. The applied preoperative diagnostical methods were the following: chest-x-ray, CT scan, MRI, PET-CT scan, perfusion lung scintigraphy, bronchological examinations, functional respiratory tests, ECG, cardiac echo, arterial blood gases (ABGs) and other laboratory analyses. Patient selection for operation was based on strict oncological and cardiorespiratory criteria. Finally, the authors describe the applied operative technique; atypical mechanical resection with stapler.

RESULTS

Mean length of postoperative intensive care was between 3 to 7 days, while that of hospitalization altogether was 13 to 18 days (average 15.2 days). Ventilation needed for one patient for 5 days approximately. Two of the six patients' survival was 18 and 25 months after pulmonary metastasectomy. Four patients are still alive, their average postoperative survival is 33.5 months. They are followed up regularly and their quality of life is satisfactory.

CONCLUSIONS

The key factors that determine the successful outcome of metastasectomies are careful and personalized evaluation of the patients, their condition and fitness for thoracotomy, stabile cardiopulmonary functions and the capacity of the residual lung. Multidisciplinary teamwork involving anaesthetists and intensive care specialists along with surgeons using the quick atypical resection technique are the key elements to improved survival of these patients.

Pulmonary radiofrequency ablation in a single lung patient

Recurrence in the contralateral lung of patients who have undergone pneumonectomy for lung cancer is often not surgically treatable. Percutaneous radiofrequency ablation (RFA) of tumours is an emerging minimally invasive technique which has recently been used in the treatment of lung cancer. The case history is presented of a patient who had previously undergone pneumonectomy in whom recurrence of lung cancer was treated by RFA. The procedure was performed under CT guidance and was uneventful. At follow up 9 months later the tumour appeared to have ablated. To our knowledge, no similar case has previously been reported in the literature.

Pneumothorax after pneumonectomy: surgery with successful double lobe ventilation

Contralateral pneumothorax is potentially lethal in patients who have undergone pneumonectomy. There are few reports about the diagnosis and treatment of this situation. This is a report of our experience with selective lobar ventilation of the middle and lower lobes using a guidewire and a bronchial blocker in the right upper bronchus of a patient who had previously undergone left pneumonectomy.

Pulmonary resection after pneumonectomy

Patients who have a lung cancer in the residual lung after pneumonectomy should not be automatically excluded for surgical consideration. These patients should be carefully staged and evaluated physiologically. The most important initial differentiation is to distinguish a true second primary lung cancer from metastatic recurrent lung cancer. Meticulous staging with chest CT, PET, brain MRI, and mediastinoscopy should be able to successfully exclude metastatic disease, multifocal disease, or locally advanced tumors. Only patients who have stage I disease are candidates for this type of extended resection. Ideally, these patients should have small peripheral tumors that can be encompassed with a low-volume wedge resection. More extended resections, such as segmentectomy or right middle lobectomy, may be considered in some patients but seem to bear a higher operative morbidity and mortality. The need for an upper or lower lobectomy after contralateral pneumonectomy is probably an absolute contraindication to surgical resection. To tolerate pulmonary resection after pneumonectomy, and to obtain the desired survival benefit, patients should have a good to excellent performance status, no serious comorbidities, and a ppoFEV1 greater than 1.0 L/second. In these highly selected patients, pulmonary resection after pneumonectomy can be accomplished with an acceptable operative morbidity and mortality and, in true cases of metachronous second primary lung cancers, may achieve a 5-year survival rate of up to 50%.

Subsequent pulmonary resection for bronchogenic carcinoma after pneumonectomy

BACKGROUND

Patients who have undergone a pneumonectomy for bronchogenic carcinoma are at risk of cancer in the contralateral lung. Little information exists regarding the outcome of subsequent lung operation for lung cancer after pneumonectomy.

METHODS

The records of all patients who underwent lung resection after pneumonectomy for lung cancer from January 1980 through July 2001 were reviewed.

RESULTS

There were 24 patients (18 men and 6 women). Median age was 64 years (range, 43 to 84 years). Median preoperative forced expiratory volume in 1 second was 1.47 L (range, 0.66 to 2.55 L). Subsequent pulmonary resection was performed 2 to 213 months after pneumonectomy (median, 23 months). Wedge excision was performed in 20 patients, segmentectomy in 3, and lobectomy in 1. Diagnosis was a metachronous lung cancer in 14 patients and metastatic lung cancer in 10. Complications occurred in 11 patients (44.0%), and 2 died (operative mortality, 8.3%). Median hospitalization was 7 days (range, 2 to 72 days). Follow-up was complete in all patients and ranged between 6 and 140 months (median, 37 months). Overall 1-, 3-, and 5-year survivals were 87%, 61%, and 40%, respectively. Five-year survival of patients undergoing resection for a metachronous lung cancer (50%) was better than the survival of patients who underwent resection for metastatic cancer (14%; p = 0.14). Five-year survival after a solitary wedge excision was 46% compared with 25% after a more extensive resection (p = 0.54).

CONCLUSIONS

Limited pulmonary resection of the contralateral lung after pneumonectomy is associated with acceptable morbidity and mortality. Long-term survival is possible, especially in patients with a metachronous cancer. Solitary wedge excision is the treatment of choice.

Curative radiotherapy for a second primary lung cancer arising after pneumonectomy -- techniques and results

BACKGROUND AND PURPOSE

Only limited data exist on the outcome of curative radiotherapy in patients who develop a second primary lung tumour after pneumonectomy. The treatment of eight such patients is described.

MATERIALS AND METHODS

The case records of patients who underwent curative radiotherapy for stage I non-small cell lung cancer after a previous pneumonectomy were reviewed. Treatment was delivered using 3D external radiotherapy to a dose of 50-70 Gy, in once-daily fractions of 2-2.5 Gy. An endobronchial brachytherapy boost was used in three patients. Original treatments were re-planned in an attempt to minimize the volume of irradiated lung.

RESULTS

A complete remission was achieved in five (of six) evaluable patients, but two patients subsequently developed a local relapse. All patients survived for a minimum of 1 year after treatment. Only one patient developed significant (grade 2) radiation pneumonitis. When treatments were re-planned to optimize beam arrangements, and when customized blocks were used, the mean lung volume receiving > or = 20 Gy (calculated for 70 Gy) decreased from 24.6+/-4.1 (range, 18-31%) to 17.3+/-5.1% (range, 12-26%). Similarly, the radiation conformity index improved from 0.44+/-0.11 to 0.61+/-0.06.

CONCLUSIONS

Involved-field radiotherapy can be curative in patients who develop a new lung tumour after pneumonectomy. Recent advances in defining target volumes, treatment planning and delivery are likely to improve upon these results.

Surgical management of metachronous bronchial carcinoma

OBJECTIVE

To assess the results of surgery for the treatment of metachronous bronchial carcinoma.

METHODS

From 1985 to 1999, 38 patients were operated on for a metachronous lung carcinoma, accordingly to the criteria of Martini. All tumors were staged using the new International Classification System revised in 1997.

RESULTS

Diagnosis of the second cancer was done at radiological follow-up in 30 asymptomatic patients. Seventeen metachronous locations were ipsilateral. Histology of the metachronous lesion was the same as that of the first tumour in 23 patients (60%). The first resection was a lobectomy (n=35), a pneumonectomy (n=2) and a carinal resection (n=1). The second one was a wedge resection (n=7), a segmentectomy (n=3), a lingulectomy (n=2), a lobectomy (n=9), a bilobectomy (n=1), and a pneumonectomy (n=16). There were five in-hospital deaths (13%). Completion pneumonectomy was performed in 15 patients, with one postoperative death (7%). The overall estimated 5 and 10-years actuarial survival rates from the treatment of the first cancer were 70 and 47% respectively. The 5-year survival rate after the treatment of the second cancer was 32% (median survival: 31 months), including the operative mortality. Survival was negatively affected by a resection interval of less than 2 years and the performance of atypical lung sparing pulmonary resection for the treatment of the second cancer.

CONCLUSIONS

Good long-term results are achievable by the means of a second pulmonary resection in selected patients with metachronous lung cancer. Optimal cancer operations should be applied whenever functionally possible.

Surgery for second lung cancers

PURPOSE

To evaluate the outcomes of patients surgically treated for their second primary lung cancer.

METHOD

In a computerized surgical registry of > 800 consecutive patients treated for primary pulmonary carcinoma since 1980, 37 patients presented with a second lung cancer. These patients were analyzed regarding their original treatment, preoperative evaluation, operative procedures, and long-term follow-up.

RESULTS

Three fifths of the patients were female, and 57% were > or = 65 years old at the time of their second operation. One patient originally had two synchronous tumors; another patient had three metachronous neoplasms. The interval between surgeries ranged from 5 to 239 months. In 31 patients, treatment for their original tumor was surgical resection alone. Lobectomy was the most common operation for the original tumor, and 78% were stage I. When the second tumor was diagnosed, 25 patients (68%) were asymptomatic. Eight patients (22%) were current smokers, and 29 patients (78%) were former smokers. The most common operation for the second tumor was a lobectomy. Surgical mortality was 5.4%. Nineteen patients (51%) survived 2 years, and 9 patients (24%) survived > or = 5 years. Eleven patients (30%) were still alive at last follow-up, 3 to 198 months postoperatively, and only 13 patients (34%) had died of their cancer.

CONCLUSION

Surgical treatment of second primary pulmonary neoplasms can be performed in selected patients with acceptable long-term survival.

Completion right lower lobectomy for recurrence after left pneumonectomy for metastases

Resection of pulmonary recurrences on the residual lung after pneumonectomy for metastases is exceptional. A 37-year-old woman was submitted to left extended pleuro-pneumonectomy after left leg amputation for fibrosarcoma. At 43 months later, a wedge resection on the right lower lobe was performed followed 32 months later by a further wedge resection in the same lobe. A completion right lower lobectomy for a new recurrence was performed 17 months after the last pulmonary resection. The patient did not develop postoperative complications. She is still alive and free of disease 10 years and 9 months after pneumonectomy and 36 months after completion lobectomy on the residual lung. In highly selected patients, aggressive surgery for metastases on the residual lung can be successfully performed and it can improve survival.