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Letters to the Editor |
Department of Thoracic Surgery, Bilim University Faculty of Medicine, Esentepe/Sisli 34394, Istanbul, Turkey
Received 19 October 2008; accepted 28 October 2008.
* Corresponding author. Tel.: +90 5322660234; fax: +90 2122313956. (Email: semihh{at}atlas.net.tr).
Key Words: Pneumonectomy • Lobectomy • Wedge resection • Lung cancer
I read with great interest the article of Grodzki et al. [1] on additional pulmonary resection after pneumonectomy. They performed 18 pulmonary wedge resections in a mean of 26 months after a pneumonectomy in patients with non-small cell lung cancer and, reported the long-term survival and functional results. The authors did not perform preoperative invasive mediastinal investigation if there were no enlarged mediastinal lymph nodes on computed tomography (CT) of the patients. Seven patients had metastatic N2 lymph nodes found at thoracotomy and these patients had significantly lower 5-year survival rate when compared to those patients with pathologically proven N0-1 disease (14% vs 63%). Well documented high rate of ipsilateral mediastinal lymph node metastases (39%) and subsequent lower survival rates in patients with metachronous lung cancer with N2 disease in the authors’ series obliges the routine use of invasive (i.e. mediastinoscopy, mediastinotomy, VATS) and/or less invasive (i.e. endobronchial/endo-oesophageal ultrasound guided needle aspiration) preoperative mediastinal investigation procedures to select the appropriate patients who can benefit from second pulmonary resection after pneumonectomy.
Although the series contained no additional pulmonary resection other than wedge excision of the tumour, the authors made the statement that ‘limited resections should be the method of choice after a pneumonectomy’ and support their thesis by a study that retrospectively compared the results of 20 wedge resections, three segmentectomies and one lobectomy performed after pneumonectomy [2]. The recommendation of wedge excision is valid for all small and peripheral tumours existing in a metachronous, synchronous or metastatic fashion on the contralateral lung in a patient who previously underwent a pneumonectomy. However, accepting a patient who has no other options but upper or middle lobectomy for the second tumour on the right lung after undergoing left pneumonectomy as unresectable lacks the convincing evidence. In fact, details of the authors’ series support the contrast judgment. Eleven patients underwent right and seven patients underwent left pneumonectomy plus wedge resection on the contralateral lung. Of these patients, four had received adjuvant radiotherapy after pneumonectomy (before the wedge resection) and two received radiotherapy after pneumonectomy and wedge resection of the contralateral lung. However, there were no severe postoperative cardiopulmonary complications and only one patient died due to cor pulmonale more than 7 years after the second operation.
There are a few case reports documenting the successful results of left pneumonectomy plus right upper or middle lobectomy performed following a careful cardiopulmonary evaluation [3–5], as we have observed the similar outcomes in two of our patients one of whom underwent right upper lobectomy and the other underwent middle lobectomy before and after left pneumonectomy, respectively.
When observing even a wedge resection of one of the two remaining lobes of the left lung after right pneumonectomy could be well tolerated by the patients who received radiotherapy also [1], can we still continue to judge that ‘left pneumonectomy plus right middle or upper lobectomy cannot be tolerated’?
References
This article has been cited by other articles:
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  T. Grodzki Reply to Halezeroglu Eur. J. Cardiothorac. Surg., February 1, 2009; 35(2): 376 - 376. [Full Text] [PDF]
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