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Eur J Cardiothorac Surg 2002;21:370-371
© 2002 Elsevier Science NL

Letter to the Editor

Combined left pneumonectomy and off-pump coronary artery bypass: principles of cancer surgery

Alper Toker^*, ükrü Dilege, Göksel Kalayci

Department of General Thoracic Surgery, Istanbul Medical School, Istanbul University, Istanbul, Turkey

Received 6 October 2001; accepted 24 November 2001.

* Corresponding author. Inönü Cad. Yildiz Sok. STFA Bloklari, B/6 Blok, No: 13 81090, Kozyatagi, Istanbul, Turkey. Tel.: +90-216-416-64-26; fax: +90-216-338-43-80
e-mail: aetoker{at}superonline.com

Al-Attar et al. [1] presented a case report about a combined left pneumonectomy and off-pump coronary artery bypass through left thoracotomy, which had not been reported previously. The approach is very attractive and brilliant. This combined procedure will certainly help patients with lung cancer and ischemic heart disease.

The patient was an 80-year-old male with myocardial infarction and arteriopathy of the lower limbs, presented with hemoptysis and chest pain. Bronchoscopic examination revealed complete obstruction of the left lower lobe bronchus with infringement on the lingual bronchus by a large extrinsic mass, that resulted in a biopsy of undifferentiated carcinoma. In the absence of mediastinal lymphadenopathies and systemic metastases, they decided to perform a complete resection. During exploration, they noticed a 10-cm rounded mass limited to left lower lobe, with small lymphadenopathies around the inferior pulmonary vein and bronchus. Involvement of inferior pulmonary vein, required a cuff resection of the left atrium. The authors performed pneumonectomy. The histopathological examination revealed a small cell carcinoma (p T3 N2 M0).

We appreciate Dr Al-Attar et al. for performing such a combined procedure through the same incision and using OPCAB technique for more comfort in the postoperative period.

But this successful surgery deserves comments on the principles of lung cancer surgery. The following principles should have been considered before and during surgery.

1. The mass was noted to be 5 cm in the longer axis with the computerized tomography (CT) findings. Operative findings described a 10-cm mass. This could have alerted the surgeon about a small cell lung cancer, if the date of CT were not too old.
   
2. Undifferentiated bronchogenic carcinoma is not a definite cytology, furthermore; it is an indication of mediastinoscopy.
   
3. Clinical staging of the tumor was at least T2 or may be T3 due to invasion of the inferior pulmonary vein which could be seen in CT. We believe that an 80-year-old patient should have mediastinoscopy to carry out such a combined procedure even in the absence of radiological positive lymph nodes.
   
4. According to recent data, mainstem therapy in T3 N2 small cell lung carcinoma is not surgery. Chemotherapy has been generally accepted because of its high response rate for small cell carcinoma of the lung. Recently, operation as a locoregional treatment with combined chemotherapy has been recommended for cases of limited disease without mediastinal lymphatic metastases [2,3]. Additionally mediastinoscopy is thought to be necessary in clinical N1 patients with small cell lung cancer [4].
   
5. Perioperative frozen section analysis of the mass and lymph nodes should have been performed before a pneumonectomy was done. We believe that an unnecessary pneumonectomy was performed.
   

Such major combined procedures could have been reserved for patients who were clinically and/or surgically staged in pre and perioperative period.

References

1. Al-Attar N., Salvi S., Sebbag U., Nataf P. Combined left pneumonectomy and off-pump coronar artery bypass through left thoracotomy. Eur J Cardiothorac Surg 2001;19:226-228.[Abstract/Free Full Text]
2. Shepherd F.A., Ginsberg R.J., Feld R., Evans W.K., Johansen E. Surgical treatment of for limited small cell lung cancer. J Thorac Cardiovasc Surg 1991;101:385-S93.[Abstract]
3. Deslauriers J. Surgery for small cell lung cancer. Lung Cancer 1997;17(Suppl 1):S91-S98.
4. Inoue M., Nakagawa K., Fujiwara K., Fukuhara K., Yasumito T. Ann Thorac Surg 2000;70:1620-1623.[Abstract/Free Full Text]

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alper Toker Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Toker, A. Articles by Kalayci, G. Search for Related Content PubMed PubMed Citation Articles by Toker, A. Articles by Kalayci, G. Related Collections Lung - cancer