Eur J Cardiothorac Surg 2004;26:652-654
© 2004 Elsevier Science NL
Successful outcome after resection of lung, liver and diaphragm for locally advanced lung cancer
J. Smitha*,
S. Karthika,
J.P.A. Lodgeb,
J.A.C. Thorpea
a Thoracic Unit, Leeds General Infirmary, Great George Street, Leeds LS1 3EX, UK
b Hepatobiliary Unit, Saint James' University Hospital, Leeds, UK
Received 10 February 2004;
accepted 3 May 2004.
* Corresponding author. Tel.: +44-113-294-8901; fax: +44-113-392-8436
e-mail: drjonsmith{at}hotmail.com
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Abstract
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A 63-year-old man presented with a 2 month history of intermittent right subcostal and shoulder tip pain. Preoperative imaging confirmed a locally advanced right lower lobe lung tumour involving the diaphragm and liver. Bronchoscopic biopsy confirmed squamous cell carcinoma and mediastinoscopy was negative. The patient underwent a right bilobectomy with resection of the right hemi-diaphragm and a right hemi-hepatectomy. His postoperative recovery was satisfactory and he remains well 18 months after the surgery. We believe that in selected cases, patients with locally advanced lung tumours invading the liver may have a survival advantage following resection.
Key Words: Locally advanced lung cancer
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1. Introduction
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Direct invasion of a lung cancer into adjacent structures is well known. However, a very small percentage of these are operable at the time of diagnosis. We report an unusual case of a locally advanced non-small cell lung carcinoma invading directly into the liver through the diaphragm with a successful outcome following surgical resection.
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2. Case report
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A 63-year-old man presented to the chest clinic with a 2 month history of intermittent right subcostal and shoulder tip pain, especially on deep inspiration. He was known to have hypertension and a 30 pack year history of cigarette smoking. Clinical examination did not reveal any obvious signs. Chest radiograph revealed a right basal mass with a small right pleural effusion (Fig. 1 a). Computerised tomographic scan of the thorax showed a 7 cm mass in the right lower lobe of the lung invading through the diaphragm into the right lobe of liver. Magnetic resonance imaging (MRI) scan confirmed these findings (Fig. 1b and c).
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Fig. 1. (a) Chest X-ray showing right basal mass. (b) and (c) Coronal and sagittal MRI scans showing the contiguity of the mass from the lung through the liver.
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A bronchoscopy was performed and the tumour was found infiltrating the basal segments of the right lower lobe. Histology indicated a squamous cell carcinoma. Staging mediastinoscopy was negative. All routine preoperative investigations and pulmonary function tests indicated that the patient was a fit candidate for surgery. After discussing the case at a multidisciplinary team meeting, the patient was presented with the option of surgery with possibility of preoperative chemotherapy. However, the patient declined chemotherapy and hence, we decided to proceed with surgery.
A combined procedure was carried out, by the thoracic and hepatobiliary surgical teams, through a right thoracoabdominal incision. At surgery, the tumour was found to arise primarily from the right lower pulmonary lobe with involvement of the adjacent areas of the right middle lobe, right hemi-diaphragm and the adjoining part of the right lobe of liver. An en-bloc resection of the right middle and lower lobes of the lung, the right hemi-diaphragm with a right hemi-hepatectomy (segments 5–8) was carried out (Fig. 2a and b)
. The diaphragm was reconstructed with a polytetrafluoroethylene patch.
The patient's immediate postoperative period was uneventful. On the third postoperative day, he developed atrial fibrillation with a fast ventricular rate. This was treated with intravenous amiodarone. He reverted back to sinus rhythm shortly thereafter. His postoperative recovery was otherwise uneventful and he was discharged home on day 20.
Histology confirmed a moderately differentiated squamous cell lung carcinoma with direct invasion into the diaphragm and liver. There was no evidence of any lymph node involvement and the resection margins were all clear of disease. Patient declined postoperative chemotherapy and has opted to remain on a close follow-up. The patient was reviewed recently in clinic and remains well 18 months following surgery without any evidence of recurrent or residual disease.
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3. Discussion
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Hepatic involvement by primary lung cancer lending itself to curative resection is extremely rare. We found three similar cases that have been reported previously in Japan [1–3]. As such cases are rare; there is limited information on treatment and outcomes after surgery and survival.
In the first report, a 77-year-old lady underwent a combined resection of lung, diaphragm and liver. She survived the operation but died from bilateral metastatic disease 4 months later [1]. In the other two cases [2,3], patients were alive 5 years, 10 months and a year after the operation. The first two cases were squamous cell carcinoma while the third one was a large cell cancer. In all these cases, a limited resection of the diaphragm and liver was performed with reconstruction of diaphragm.
Our patient also had node negative squamous cell cancer invading the diaphragm and liver. He needed a more extensive resection of not only the lower pulmonary lobe and diaphragm, but also a right hemi-hepatectomy and also the adjacent right middle lobe. We believe that the surgical approach to such locally advanced tumours must be aggressive, especially if they are node negative and the patient is fit to undergo major lung resection. They are best carried out by combined teams with individual expertise in thoracic and hepatic resections.
We believe that this is the first reported case of a successful outcome after surgical resection of a locally advanced lung tumour invading liver outside Japan. This case illustrates that combined resections should be considered in selected cases of locally advanced non-small cell lung cancer. Complete resection is usually associated with good outcomes.
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References
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- Sakamoto K., Suda T., Ide K. Extended operation for non-small lung cancer invading into the liver. Jpn J Thorac Cardiovasc Surg 2000;48(7):464-467.[Medline]
- Matsumoto H., Shimotakahara T., Ogawa H., Toyoyama H., Yanagi M., Nishijima H., Aikou T. A case of advanced lung cancer with long term survival, involving direct invasion to the liver. Kyobu Geka 1997;50(7):595-597.[Medline]
- Nishioka K., Mitsudomi T., Saitoh G., Maruyama R., Ishida T., Takenaka K., Sugimachi K. Combined resections of diaphragm and the liver for a locally advanced non-small-cell lung cancer. Respiration 1996;63(5):314-317.[Medline]
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Abstract
1. Introduction
