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Eur J Cardiothorac Surg 2000;18:372-374
© 2000 Elsevier Science NL

Letter to the Editor

Combined surgery for emphysema and lung cancer

Vincenzo Ambrogi, Eugenio Pompeo, Giuseppe Matteucci, Tommaso Claudio Mineo

Department of Thoracic Surgery and Postgraduate School of Thoracic Surgery, Tor Vergata University, Rome, Italy

Received 8 September 1999; received in revised form 17 April 2000; accepted 17 April 2000.

Corresponding author. Thoracic Surgery, S. Eugenio Hospital, 10 p.le Umanesimo, 00144 Rome, Italy. Tel.: +39-06-5100-2286; fax: +39-06-592-2681
e-mail: mineo{at}med.uniroma2.it

The advent of the surgery of emphysema changed the classic limits for lung resection in patients with pulmonary hyperinflation and this could also affect oncological surgery [1–3].

From October 1995 to March 1999 we operated a total of 73 patients with severe emphysema. Eight of those who had concomitant peripheral lung cancer underwent combined reduction pneumoplasty (RP) and tumour excision. They were all males ageing from 61 to 75 years (mean age 66.6±4.53) (Table 1).


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  		Table 1. Operative details and survival in patients who underwent combined operation for both emphysema and lung cancer

 
Preoperative mean forced expiratory volume in 1 s (FEV1) and residual volume (RV) were 0.76±0.22 and 5.29±0.73 l, respectively (Table 2). Five patients were directly referred for presumed lung cancer. In the other patients the tumour was an incidental discovery during the routine workup for RP evaluation. Six patients took steroids regularly and four required supplemental oxygen therapy. Tumour was resected by wedge (n=5), segmentectomy (n=2) or lobectomy (n=1). In six cases the tumour was included in the same area excised or pneumoplasty. In five cases the volume reduction was monolateral. However, in three patients due to the presence of a well-defined target area in a hyperinflated controlateral lung the RP was accomplished also on the other side. Mean size of the tumour was 2.52±1.42 cm (range 1.2–5.0).


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  		Table 2. Comparison between preoperative and 3-, 6-, 12-month postoperative functional resultsa,b

 
No neoplastic lymph node was found during surgical exploration. Multiple benign granulomas were found in two patients and one hamartoma in another. There was no perioperative mortality. The average hospital length of stay was 9.75±2.55 days (range 7–14). Postoperative complications were mainly prolonged air leak (n=4) and cardiac arrhythmia (n=1). Postoperative lung function tests showed a general improvement (Table 2). Two patients underwent radiotherapy and the patient with small cell received adjuvant chemotherapy. Seven patients are at the present alive and free of tumour, two with a follow-up longer than 3 years. Only one patient developed brain metastases after 16 months and died. The mean follow-up length for disease-free patients was 19.62 months (range 3–39).

Only few years ago it would be unthinkable to submit these patients to any kind of lung resection. The possibility of removing the tumour and yet improving the lung function at the same time has enlarged the indications for oncological surgery.

Due to the continuous radiological surveillance the possibility of discovering early tumour or enlarging opacities in the emphysematous patients is higher compared to normal population. Therefore, the size and the stage of the tumour is usually not advanced and incidental microscopic tumours have been found in apparently normal tissue resected at RP [4,5].

The extent of the resection should be a logical compromise between degree of hyperinflation, extension of the target area and size and location of the tumour. Tumour or any suspicious nodule growing in the same lobe of the target area must be resected in a single step aiming to encompass it in the same resection. Segmentectomy or lobectomy are preferred for deeply sited tumours not amenable to wedge or ‘hockey stick’ resection. When the tumour and the target area are located in different lobes minimal resection can be associated with homo- or contralateral RP.

In conclusion, these findings suggest that lung volume reduction effect may extend the indication for lung cancer surgery in emphysematous patients, which were once only considered for palliative therapy.

Footnotes

Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999.

References

  1. McKenna R.J., Fischel R.J., Brenner M., Gelb A.F. Combined operations for lung volume reduction surgery and lung cancer. Chest 1996;110:885-888.[Abstract/Free Full Text]
  2. DeMeester S.R., Patterson G.A., Sundaresan R.S., Cooper J.D. Lobectomy combined with volume reduction for patients with lung cancer and advanced emphysema. J Thorac Cardiovasc Surg 1998;115:681-688.[Abstract/Free Full Text]
  3. Korst R.J., Ginsberg R.J., Ailawadi M., Bains M.S., Downey U., Rusch V.W., Stover D. Lobectomy improves ventilatory function in selected patients with severe COPD. Ann Thorac Surg 1998;66:898-902.[Abstract/Free Full Text]
  4. Pigula F.A., Keenan R.J., Ferson P.F., Landreneau U. Unsuspected lung cancer found in work-up for lung reduction operation. Ann Thorac Surg 1996;61:174-176.[Abstract/Free Full Text]
  5. Keller C.A., Naunheim K.S., Osterloch J., Espiritu J., McDonald J.W., Ramos R.R. Histopathologic diagnosis made in lung tissue resected from patients with severe emphysema undergoing lung volume reduction surgery. Chest 1997;111:941-947.[Abstract/Free Full Text]



This article has been cited by other articles:


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Ann. Thorac. Surg., December 1, 2003; 76(6): 1821 - 1827.
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