Eur J Cardiothorac Surg 1999;15:726-728
© 1999 Elsevier Science NL
Metachronous pulmonary and oesophageal neoplasia
David J.C. Burton,
David A.C. Sharpe,
Nigel R. Saunders
Department of Cardiothoracic Surgery, The Yorkshire Heart Centre, The General Infirmary at Leeds, Great George Street, Leeds, LS1 3EX, UK
Received 5 October 1998;
received in revised form 26 January 1999;
accepted 10 February 1999.
Corresponding author. Tel.: +44-1132-432-799; fax: +44-1132-926-336.
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Abstract
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Primary carcinomas of the lung and oesophagus are common, surgical resection offers the only hope of long-term survival with both conditions. We present the unusual case of a patient who underwent transhiatal oesophagectomy for an adenocarcinoma carcinoma of the oesophagus, 5 years after left pneumonectomy for small cell carcinoma of the lung.
Key Words: Oesophagectomy • Pneumonectomy • Neoplasia
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Introduction
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Small cell carcinoma of the lung is associated with early metastasis and a poor prognosis
[1]. Complete surgical resection, although rarely feasible, offers the only hope for a cure.
Transhaital oesophagectomy, using an upper abdominal and cervical incision, has been used for the resection of distal oesophageal neoplasms
[2]. This approach avoids a thoracotomy or thoraco-abdominal incision, allowing the anastamosis of the stomach tube to the stump of the oesophagus in the neck.
We report the challenging surgical problem of a patient presenting with a resectable carcinoma of the distal oesophagus, having undergone a curative pneumonectomy for lung cancer 5 years previously.
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Case report
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A 53-years-old male presented with a 3-month history of dysphagia at the level of the xiphiod cartilage. He had a 5-year history of reflux oesophagitis. The patient had undergone left pneumonectomy in 1992 for a small cell carcinoma of the lung (pT2 N0 M0), followed by chemotherapy and radiotherapy. Oesophagoscopy and biopsy revealed a small (less than 1 cm) adenocarcinoma at the oesophagastric junction. An extensive metastasis screen found no evidence for spread of either the oesophageal cancer or evidence of recurrence of the lung cancer.
Plain chest radiography (
Fig. 1
) and computer tomography (
Fig. 2
) of the thorax showed a contracted pneumonectomy space with a shift of the mediastinal structures to the left. There was no evidence of extra oesophageal extension of the carcinoma.
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Fig. 1. Plain chest radiogram demonstrating the left pneumonectomy space and the marked deviation of the mediastinum to the left.
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Fig. 2. Computerized tomography scan of the chest and mediastinum showing the oesophageal tumour in relation to the distorted intra thoracic anatomy.
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Bronchoscopy that showed no evidence of invasion of the bronchial tree. Transhiatal oesophagectomy was performed through a midline laparotomy and a right-sided neck incision; oesophago–gastric anastamosis was performed in the neck. Total parenteral nutrition was commenced on the first postoperative day. The patient made a full and uneventful recovery from the procedure, he was allowed to take fluids on the 5th postoperative day and then steadily built up to a normal diet over the next 3 days. He left hospital on the 13th postoperative day. Subsequent follow-up clinic at 1 month found him to have dysphagia at the level of the anastamosis; this was treated with dilation. Further follow-up at 3 and 6 months have shown him to be well with no evidence of recurrent neoplastic disease.
Histological examination of the resected specimen revealed all resection margins to be tumour free, a single lymph node from the lesser curve of the stomach contained metastic carcinoma pT3 N1 M0.
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Comment
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Resection of synchronous tumours of the oesophagus and lung have been reported previously, we cannot find an account of an oesophagectomy being performed several years after a pneumonectomy for a metachronous neoplasm
[3]. The setting of altered thoracic anatomy and single lung ventilation with a potentially curable oesophageal neoplasm presented an interesting surgical challenge.
the thoraco–abdominal approach through the pneumonectomy space would have the advantage of not disturbing the lung. It would mean operating through the dense contracted fibrous tissue of the pneumonectomy space, in the presence of grossly distorted intra thoracic anatomy. For these reasons we rejected this approach.
The approach to the oesophagus through the right hand side of the chest was considered, this would provide adequate exposure of the oesophagus through the enlarged hemithorax and would allow us to perform a two or three stage oesophagectomy. It would require either operating around the single functioning lung or a period of extracorporeal circulation to support the patient while the lung was not ventilated. In view of theses potential difficulties this too was rejected as an operative approach.
We elected to perform a transhiatal approach. Dissection through the virgin territory of the abdomen allowed easy dissection and mobilization of the stomach. Similarly there had been no previous surgery in the neck allowing for easy mobilization. The short segment of blunt oesophagectomy was performed with no difficulty despite the distorted intra thoracic anatomy. We would recommend this approach in patients who have undergone previous thoracic surgery which would complicate the surgical approach to the oesophagus.
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References
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- Southami R.L., Law K. Longevity in small cell lung cancer. A report to the lung cancer sub committee of the United Kingdom co-ordinating committee for cancer research. Br J Cancer 1990;61:584-589.[Medline]
- Ruedi TP. Non thoracotomy oesophageal resection. In: Jameison GG. editor. Surgery of the oesophagus. New York: Churchill Livingstone, 1988:639–645.
- Morimoto M., Ohno T., Yamashita Y., Honda M., Asada S. Two surgical cases of double carcinoma of the lung and oesophagus and review of 10 documented cases in Japan. J Jap Assoc Thorac Surg 1991;39:245-250.
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Abstract
Introduction
