Right lower lobectomy after right upper lobectomy for multiple metastases in lung cancer of the right lower lobe: Benefit of middle lobe preservation

Abstract

Clinical Summary A 60-year-old woman with lung cancer underwent right upper lobectomy. The tumor specimen was a well-differentiated adenocarcinoma, pathologic stage IA (T1 N0 M0). Multiple slow-growing nodules were noted in the right lower lobe 4 years postoperatively. Recurrent lesions are generally multiple and disseminated, and additional surgical intervention is not usually indicated. However, no nodules were apparent in other lobes during 1 year of follow-up. The patient was therefore referred to our department for surgical treatment. Routine blood biochemistry and coagulation studies yielded normal results and carcinoembryonic antigen level was 2.6 ng/mL. A chest computed tomographic scan from 4 years earlier showed the primary lung cancer as a solid tumor in the right upper lobe (Figure 1, A), compared with the scan of multiple nodules limited to the right lower lobe for the metastases (Figure 1, B). These multiple tumors showed no uptake on a fluorodeoxyglucose positron emission tomographic scan. Transbronchiolar lung biopsy was not performed owing to patient refusal. No extrathoracic metastatic lesions were identified. Preoperative forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1.0) were 2420 mL and 1510 mL, respectively. We evaluated predicted results of completion pnuemonectomy using perfusion scintigraphy and pulmonary artery obstruction testing. Predicted FVC and FEV1.0 after completion pneumonectomy were 1114 mL and 695 mL, respectively. Obstruction of the right pulmonary artery yielded a pressure of 19 mm Hg. Video-assisted right lower lobectomy was performed, preserving the middle lobe. Adhesion of the lower lobe to the chest wall was easily removed by the thoracoscopic view. The middle lobe was also adherent to the chest wall and helped to prevent middle lobe torsion. On final pathologic examination, the specimen from the lower lobe was characteristic of metastatic adenocarcinoma from the previous lung cancer of the right upper lobe (Figure 1, C and D). Postoperative FVC and FEV1.0 were 1570 mL and 1200 mL, respectively. Perfusion scintigraphy showed 391,199 (21.7%) of 1,801,504 counts for the preserved middle lobe (Figure 2). Respiratory function after right upper and lower lobectomies preserved more than half of the original respiratory function. The postoperative course was uneventful. Chest computed tomographic imaging after 1 year of preservation of the middle lobe showed adequate volume without emphysematous change. After 17 months of follow-up, the patient is doing well with no evidence of disease or requirement for additional oxygen support.