Interactive CardioVascular and Thoracic Surgery 19 (2014) 515–517 doi:10.1093/icvts/ivu144 Advance Access publication 4 June 2014
CASE REPORT – THORACIC
Thoracoscopic lobectomy after bilateral lung transplantation Herbert Decaluwea,b,*, Dirk Van Raemdoncka,b, Geert Verledenb,c and Paul De Leyna,b a b c
Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium Department of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
* Corresponding author. Herestraat 49, 3000 Leuven, Belgium. Tel: +32-163-46820; fax: +32-163-46821; e-mail: [email protected] (H. Decaluwé). Received 3 March 2014; accepted 7 April 2014
Abstract A 61-year-old female patient with a coin lesion in the right upper lobe was referred for surgery. Six years previously she had undergone bilateral lung transplantation through bilateral anterior thoracotomies. Computed tomography and positron emission tomography of the thorax revealed a 19-mm hypermetabolic lesion in the right upper lobe, but no other locoregional or distant disorder. The patient underwent wedge resection by video-assisted thoracic surgery (VATS). Frozen section revealed a large-cell carcinoma. Subsequently, a VATS right upper lobectomy with mediastinal lymph node dissection was performed. Final pathology demonstrated a pT1bN0M0 non-small-cell lung cancer of the right upper lobe. One year after the operation, the patient was alive and disease free. This case report and video illustrate the feasibility of a VATS anatomical resection after lung transplantation.
INTRODUCTION Thoracoscopic lobectomy has become the standard in the surgical treatment of early non-small-cell lung cancer (NSCLC) [1]. Advantages of video-assisted thoracic surgery (VATS) are shorter hospital stay and less morbidity, whereas oncological results are at least equal to those of thoracotomy [1]. Both more extensive resections and procedures after previous thoracic surgery are being reported with increasing frequency [1, 2]. The prevalence of bronchogenic carcinoma after lung transplantation is 2.6%. It is most frequent in the native lung after single-lung transplantation. After bilateral lung transplantation, the prevalence of donor-related bronchogenic carcinoma is around 1% [3].
CASE REPORT A 61-year-old woman was referred with a coin lesion in the right upper lobe. Six years previously she had undergone bilateral lung transplantation for emphysema. The patient stopped smoking 12 years previously. The donor was a 46-year-old female who had died after a subarachnoidal bleed. Smoking history was unknown. Sequential single-lung transplantation was performed through a bilateral anterior thoracotomy. A lesion 15 mm in diameter was found in the right upper lobe on yearly computed tomography (CT). A repeat CT scan 2 months later revealed growth to 19 mm. Positron emission tomography (PET) showed metabolic activity in the nodule only (Fig. 1). Pulmonary function tests are listed in Table 1. Bronchoscopy was negative. The case was discussed at a multidisciplinary board meeting, and a VATS wedge resection, if positive followed by lobectomy, was planned. After placement of an epidural catheter, a bronchoscopicguided double lumen endotracheal tube was placed. The patient
was installed on the left side with the table flexed at the level of the xyphoid. A common three-port access was used with the surgeon and the assistant standing ventral to the patient. We placed a 10-mm camera port at the anterior axillary line at the seventh intercostal space. Lateral to the breast, a 3-cm utility incision was made. The third port was made posterior to the camera port forming a right triangle. After clearance of adhesions between the lung and chest wall, the lesion was visualized in the right upper lobe, close to the fissure between the middle, upper and lower lobe. Frozen section after wedge resection revealed NSCLC. We proceeded with a lobectomy (Video 1). All adhesions between the lung, pericardium and diaphragm and posterior wall were divided. Posteriorly, we freed the sub-carinal space with removal of Position 7 lymph nodes and the secondary carina with Position 11 nodes, delineating the intermediate and upper lobe bronchus. This facilitated the later division of the posterior part of the fissure. The upper lobe vein and truncal artery were divided with a stapler. A stapler was fired on the fissural parenchyma between the upper lobe and the middle lobe, revealing the posterior ascending artery. We created a tunnel towards the secondary carina and opened the fissure between the upper lobe and lower lobe with staplers. The posterior ascending artery and the bronchus were divided and the lobe removed. Next, Position 4 right was cleared. Surgical operating time was 229 min, 179 min from the moment the result of the frozen section was known. Total blood loss was 350 cc. The postoperative course was uneventful, apart from nausea, which ameliorated with reduction of narcotics. The drain was removed on postoperative day 3. The patient went home on Day 8, when the immunosuppressive therapy reached a stable therapeutic drug level. Final pathology showed a lesion of 2.7 cm, poorly differentiated large-cell carcinoma. All lymph nodes were negative.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CASE REPORT
Keywords: Video-assisted thoracic surgery lobectomy • Lung transplant • Non-small-cell lung cancer • Thoracoscopy • Lung cancer
516
H. Decaluwe et al. / Interactive CardioVascular and Thoracic Surgery
Figure 1: (A and B) PET-CT showing an isolated hypermetabolic lesion and (C) the lesion situated in the right upper lobe close to the fissure with the middle and lower lobes. PET: positron emission tomograph.
Table 1: Evolution of lung function before and after thoracoscopic lobectomy in percentage of the measured to expected value Lung function test FEV1% FEV1/ FVC% FVC% DLCO%
Preoperative 3 weeks 3 months 6 months 9 months
83 63
68 68
80 72
77 72
79 65
110 61
84 NA
93 NA
89 NA
102 NA
FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; DLCO: diffusion capacity; FEV1/FVC: Tiffenau index; NA: not available.
A new PET-CT scan 9 months postoperatively revealed no loco regional recurrence or metastatic disease.
DISCUSSION To our knowledge, this is the first reported VATS lobectomy after bilateral lung transplantation.
Video 1: The edited video shows the most important steps of the right upper lobectomy, including subcarinal lymph node dissection, identification of hilar structures and division of upper lobe bronchovascular structures and fissure.
VATS lobectomy is now accepted as the standard surgical treatment modality for early lung cancer [1]. Prior thoracic surgery is not a contraindication to thoracoscopic resections [1, 2]. Adhesiolysis can be easier by VATS compared with thoracotomy because the whole pleural space can be reached and visualized [1]. After lung transplantation, one might expect challenging adhesions at the hilum. The adhesions in this case were less dense than expected. Possibly, this was reduced by the immunosuppressive therapy. Moreover, the target dissection area for a lobectomy was more distal from the hilar anastomoses. By contrast, in a previous case, we had to convert a left thoracoscopic upper
H. Decaluwe et al. / Interactive CardioVascular and Thoracic Surgery
CONCLUSION We report a successful VATS lobectomy in a patient with a pT1bN0M0 NSCLC of the right upper lobe 6 years after bilateral lung transplantation. The patient was disease free at 1 year after treatment. VATS lobectomy has now become the standard treatment in early lung cancer and is feasible after previous thoracic surgery, such as transplantation. Conflict of interest: none declared.
REFERENCES [1] Hanna JM, Berry MF, D’Amico TA. Contraindications of video-assisted thoracoscopic surgical lobectomy and determinants of conversion to open. J Thorac Dis 2013;5:S182–9. [2] Yim AP, Liu HP, Hazelrigg SR, Izzat MB, Fung AL, Boley TM et al. Thoracoscopic operations on reoperated chests. ATS 1998;65:328–30. [3] Yserbyt J, Verleden GM, Dupont LJ, Van Raemdonck DE, Dooms C. Bronchial carcinoma after lung transplantation: a single-center experience. J Heart Lung Transplant 2012;31:585–90. [4] Bonser RS, Taylor R, Collett D, Thomas HL, Dark JH, Neuberger J. Effect of donor smoking on survival after lung transplantation: a cohort study of a prospective registry. Lancet 2012;380:747–55.
CASE REPORT
trisegmentectomy after lung transplantation because of dense adhesions at the first branch of the pulmonary artery. We have previously published our experience with bronchial carcinoma after lung transplantation. Between January 2000 and June 2011, 494 lung and heart–lung transplantations were performed. Thirteen patients developed bronchial carcinoma, 8 of them were transplanted for emphysema and 5 for pulmonary fibrosis. Nine of 101 single-lung transplants developed bronchial carcinoma in their native lung compared with only 4 of 393 bilateral transplants in a transplanted lung [3]. Bonser et al. found no difference in rate of death from malignancy between recipients of lungs from donors with or those without a smoking history. However, overall mortality was higher. The authors urge caution with donors who smoke more than 1 pack per day. Nevertheless, the numbers of life-years lost are significantly higher if lung of donors with smoking histories would not to be used, due to waiting list mortality [4]. An interesting discussion is whether a mediastinal lymph node dissection is warranted, because one would expect the lymphatic drainage to be disrupted after lung transplantation. In our published series, 1 in 3 patients who were operated on for lung cancer in a transplanted lung had unforeseen N2 disease [3]. This suggests renewal of lymphatic drainage to the mediastinum. Therefore, we believe that the international recommendations for lymph node clearance should be followed in these patients.
517
CASE REPORT – THORACIC
Thoracoscopic lobectomy after bilateral lung transplantation Herbert Decaluwea,b,*, Dirk Van Raemdoncka,b, Geert Verledenb,c and Paul De Leyna,b a b c
Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium Department of Respiratory Medicine, University Hospitals Leuven, Leuven, Belgium
* Corresponding author. Herestraat 49, 3000 Leuven, Belgium. Tel: +32-163-46820; fax: +32-163-46821; e-mail: [email protected] (H. Decaluwé). Received 3 March 2014; accepted 7 April 2014
Abstract A 61-year-old female patient with a coin lesion in the right upper lobe was referred for surgery. Six years previously she had undergone bilateral lung transplantation through bilateral anterior thoracotomies. Computed tomography and positron emission tomography of the thorax revealed a 19-mm hypermetabolic lesion in the right upper lobe, but no other locoregional or distant disorder. The patient underwent wedge resection by video-assisted thoracic surgery (VATS). Frozen section revealed a large-cell carcinoma. Subsequently, a VATS right upper lobectomy with mediastinal lymph node dissection was performed. Final pathology demonstrated a pT1bN0M0 non-small-cell lung cancer of the right upper lobe. One year after the operation, the patient was alive and disease free. This case report and video illustrate the feasibility of a VATS anatomical resection after lung transplantation.
INTRODUCTION Thoracoscopic lobectomy has become the standard in the surgical treatment of early non-small-cell lung cancer (NSCLC) [1]. Advantages of video-assisted thoracic surgery (VATS) are shorter hospital stay and less morbidity, whereas oncological results are at least equal to those of thoracotomy [1]. Both more extensive resections and procedures after previous thoracic surgery are being reported with increasing frequency [1, 2]. The prevalence of bronchogenic carcinoma after lung transplantation is 2.6%. It is most frequent in the native lung after single-lung transplantation. After bilateral lung transplantation, the prevalence of donor-related bronchogenic carcinoma is around 1% [3].
CASE REPORT A 61-year-old woman was referred with a coin lesion in the right upper lobe. Six years previously she had undergone bilateral lung transplantation for emphysema. The patient stopped smoking 12 years previously. The donor was a 46-year-old female who had died after a subarachnoidal bleed. Smoking history was unknown. Sequential single-lung transplantation was performed through a bilateral anterior thoracotomy. A lesion 15 mm in diameter was found in the right upper lobe on yearly computed tomography (CT). A repeat CT scan 2 months later revealed growth to 19 mm. Positron emission tomography (PET) showed metabolic activity in the nodule only (Fig. 1). Pulmonary function tests are listed in Table 1. Bronchoscopy was negative. The case was discussed at a multidisciplinary board meeting, and a VATS wedge resection, if positive followed by lobectomy, was planned. After placement of an epidural catheter, a bronchoscopicguided double lumen endotracheal tube was placed. The patient
was installed on the left side with the table flexed at the level of the xyphoid. A common three-port access was used with the surgeon and the assistant standing ventral to the patient. We placed a 10-mm camera port at the anterior axillary line at the seventh intercostal space. Lateral to the breast, a 3-cm utility incision was made. The third port was made posterior to the camera port forming a right triangle. After clearance of adhesions between the lung and chest wall, the lesion was visualized in the right upper lobe, close to the fissure between the middle, upper and lower lobe. Frozen section after wedge resection revealed NSCLC. We proceeded with a lobectomy (Video 1). All adhesions between the lung, pericardium and diaphragm and posterior wall were divided. Posteriorly, we freed the sub-carinal space with removal of Position 7 lymph nodes and the secondary carina with Position 11 nodes, delineating the intermediate and upper lobe bronchus. This facilitated the later division of the posterior part of the fissure. The upper lobe vein and truncal artery were divided with a stapler. A stapler was fired on the fissural parenchyma between the upper lobe and the middle lobe, revealing the posterior ascending artery. We created a tunnel towards the secondary carina and opened the fissure between the upper lobe and lower lobe with staplers. The posterior ascending artery and the bronchus were divided and the lobe removed. Next, Position 4 right was cleared. Surgical operating time was 229 min, 179 min from the moment the result of the frozen section was known. Total blood loss was 350 cc. The postoperative course was uneventful, apart from nausea, which ameliorated with reduction of narcotics. The drain was removed on postoperative day 3. The patient went home on Day 8, when the immunosuppressive therapy reached a stable therapeutic drug level. Final pathology showed a lesion of 2.7 cm, poorly differentiated large-cell carcinoma. All lymph nodes were negative.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CASE REPORT
Keywords: Video-assisted thoracic surgery lobectomy • Lung transplant • Non-small-cell lung cancer • Thoracoscopy • Lung cancer
516
H. Decaluwe et al. / Interactive CardioVascular and Thoracic Surgery
Figure 1: (A and B) PET-CT showing an isolated hypermetabolic lesion and (C) the lesion situated in the right upper lobe close to the fissure with the middle and lower lobes. PET: positron emission tomograph.
Table 1: Evolution of lung function before and after thoracoscopic lobectomy in percentage of the measured to expected value Lung function test FEV1% FEV1/ FVC% FVC% DLCO%
Preoperative 3 weeks 3 months 6 months 9 months
83 63
68 68
80 72
77 72
79 65
110 61
84 NA
93 NA
89 NA
102 NA
FEV1: forced expiratory volume in 1 s; FVC: forced vital capacity; DLCO: diffusion capacity; FEV1/FVC: Tiffenau index; NA: not available.
A new PET-CT scan 9 months postoperatively revealed no loco regional recurrence or metastatic disease.
DISCUSSION To our knowledge, this is the first reported VATS lobectomy after bilateral lung transplantation.
Video 1: The edited video shows the most important steps of the right upper lobectomy, including subcarinal lymph node dissection, identification of hilar structures and division of upper lobe bronchovascular structures and fissure.
VATS lobectomy is now accepted as the standard surgical treatment modality for early lung cancer [1]. Prior thoracic surgery is not a contraindication to thoracoscopic resections [1, 2]. Adhesiolysis can be easier by VATS compared with thoracotomy because the whole pleural space can be reached and visualized [1]. After lung transplantation, one might expect challenging adhesions at the hilum. The adhesions in this case were less dense than expected. Possibly, this was reduced by the immunosuppressive therapy. Moreover, the target dissection area for a lobectomy was more distal from the hilar anastomoses. By contrast, in a previous case, we had to convert a left thoracoscopic upper
H. Decaluwe et al. / Interactive CardioVascular and Thoracic Surgery
CONCLUSION We report a successful VATS lobectomy in a patient with a pT1bN0M0 NSCLC of the right upper lobe 6 years after bilateral lung transplantation. The patient was disease free at 1 year after treatment. VATS lobectomy has now become the standard treatment in early lung cancer and is feasible after previous thoracic surgery, such as transplantation. Conflict of interest: none declared.
REFERENCES [1] Hanna JM, Berry MF, D’Amico TA. Contraindications of video-assisted thoracoscopic surgical lobectomy and determinants of conversion to open. J Thorac Dis 2013;5:S182–9. [2] Yim AP, Liu HP, Hazelrigg SR, Izzat MB, Fung AL, Boley TM et al. Thoracoscopic operations on reoperated chests. ATS 1998;65:328–30. [3] Yserbyt J, Verleden GM, Dupont LJ, Van Raemdonck DE, Dooms C. Bronchial carcinoma after lung transplantation: a single-center experience. J Heart Lung Transplant 2012;31:585–90. [4] Bonser RS, Taylor R, Collett D, Thomas HL, Dark JH, Neuberger J. Effect of donor smoking on survival after lung transplantation: a cohort study of a prospective registry. Lancet 2012;380:747–55.
CASE REPORT
trisegmentectomy after lung transplantation because of dense adhesions at the first branch of the pulmonary artery. We have previously published our experience with bronchial carcinoma after lung transplantation. Between January 2000 and June 2011, 494 lung and heart–lung transplantations were performed. Thirteen patients developed bronchial carcinoma, 8 of them were transplanted for emphysema and 5 for pulmonary fibrosis. Nine of 101 single-lung transplants developed bronchial carcinoma in their native lung compared with only 4 of 393 bilateral transplants in a transplanted lung [3]. Bonser et al. found no difference in rate of death from malignancy between recipients of lungs from donors with or those without a smoking history. However, overall mortality was higher. The authors urge caution with donors who smoke more than 1 pack per day. Nevertheless, the numbers of life-years lost are significantly higher if lung of donors with smoking histories would not to be used, due to waiting list mortality [4]. An interesting discussion is whether a mediastinal lymph node dissection is warranted, because one would expect the lymphatic drainage to be disrupted after lung transplantation. In our published series, 1 in 3 patients who were operated on for lung cancer in a transplanted lung had unforeseen N2 disease [3]. This suggests renewal of lymphatic drainage to the mediastinum. Therefore, we believe that the international recommendations for lymph node clearance should be followed in these patients.
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