Prior Pneumonectomy Research Articles

Coronary Bypass Surgery in Patients with Previous Pneumonectomy

Introduction: Severe pulmonary dysfunction is a commonly occurring postoperative complication following cardiac surgery. Resection of a lung causes major anatomical and physiological changes. Shift of the mediastinum and reduction in respiratory function following pneumonectomy makes cardiac surgery challenging not only for the surgeon but also for the anaesthetist. The reported experience is sparse for patients with prior pneumonectomy who are undergoing surgery for ischemic or valvular heart disease.
 We report a case of cardiac surgery following pneumonectomy to highlight certain important features that we think are important while managing these patients.
 Case Presentation: The patient was a 56-year male who had undergone extra-pericardial pneumonectomy 30 years earlier for tuberculosis of the left lung. Echocardiography showed a left ventricular function of 50%. His coronary angiogram revealed severe triple vessle disease. Preoperative spirometry showed FVC 1.94 L (52% of predicted), FEV1 1.3 L (48% of predicted), FEV1/FVC ratio 70%. The pre-operative workup of this patient included computerised tomography of the chest to assess distortion of intra-thoracic anatomy. In an attempt to improve the pulmonary function this patient was admitted 10 days prior to surgery for intensive chest physiotherapy and incentive spirometry. He underwent coronary artery bypass grafting (CABG) using cardiopulmonary bypass and antegrade cold blood cardioplegia. Internal thoracic artery was used to graft left anterior descending artery (LAD), saphenous vein (SVG) was used to graft posterolateral branch of the right coronary artery, first diagonal and frist obtuse marginal arteries. Access to arteries in the circumflex region was difficult due to shift of heart to the left side. The patient was weaned from the ventilator 14 hours after and CPAP helmet was immediately applied for a period of 48 hours continuosly. After on it was applied at intervals for 5 days. The subsequent recovery was slow but progressive and the patient was discharged on the 11th postoperative day in good conditions.
 Conclusion: We conclude that with attention to the specific features of the preoperative, intraoperative, and postoperative management, open heart procedures can be performed successfully on patients after pneumonectomy.

Is lung stereotactic ablative radiotherapy safe after pneumonectomy?-a systematic review.

Patients treated with surgery for lung cancer are at risk of second primary lung cancers (SPLCs), which when localized, may be amenable to radical treatment. Treatment options, however, are limited due to reduced cardiopulmonary reserve and competing mortality risks. The aim of this study was to perform a systematic review of publications examining treatment planning considerations, clinical outcomes, and toxicity rates of stereotactic ablative radiotherapy (SABR) in patients who have previously undergone pneumonectomy. A systematic review of the literature was conducted in accordance with PRISMA guidelines using PubMed and EMBASE from inception to July 2018. Articles were limited to those published in the English language. Non-review articles with patients who received exclusively lung SABR post-pneumonectomy were included. Two reviewers independently performed abstract and full-text review, with discrepancies settled by a third reviewer. Of the 215 articles identified by the initial search, 6 articles comprising 53 patients who received lung SABR post-pneumonectomy met inclusion criteria. The mean age was 68, and most patients were male (73.7%). The mean time to pneumonectomy was 6.5 years. The mean biologically effective dose was 115 Gy, and the most common dose fractionation schemes were 54 Gy in 3 fractions, 48 Gy in 4 fractions, and 50 Gy in 5 fractions. The mean follow-up was 25.4 months. The mean 1-year overall survival and 2-year local control rates were 80.6% and 89.4%. Grade 3 or higher toxicity was reported in 13.2% of patients. SABR appears to be a safe and feasible option for SPLCs in patients with prior pneumonectomy. Multi-institutional and/or prospective studies would be helpful to determine the true risk and appropriateness of SABR in this high-risk patient population.

Edge-to-Edge Repair After Prior Left-Sided Pneumonectomy

Edge-to-Edge Repair After Prior Left-Sided Pneumonectomy

Microwave ablation for lung cancer patients with a single lung: Clinical evaluation of 11 cases.

BackgroundThe study was conducted to retrospectively evaluate the safety and effectiveness of computed tomography (CT)‐guided percutaneous microwave ablation (MWA) for peripheral non‐small cell lung cancer (NSCLC) in 11 patients with a single lung after pneumonectomy.MethodsFrom May 2011 to March 2015, 11 single‐lung patients (8 men and 3 women; mean age 60.3 years, range 46–71) with peripheral NSCLC underwent 12 sessions of MWA. Eleven tumors measuring 13–52 mm (mean 30.2 mm) were treated. Follow‐up was performed via CT scan at 1, 3, 6, 12, 18, and 24 months after the procedure and annually thereafter. Clinical outcomes were evaluated and complications after MWA were summarized.ResultsAt a median follow‐up period of 20 months (range 6–38), four patients showed evidence of local recurrence at a rate of 36.4% (4/11). Median overall survival was 20 months. The overall survival rates at one, two, and three years after MWA were 88.7%, 63.6%, and 42.3%, respectively. Complications after MWA included pneumothorax (33.3%), hemoptysis (33.3%), intrapulmonary bleeding (25%), pleural effusion (16.7%), and pulmonary infection (8.3%). None of the patients died during the procedure or in the 30 days after MWA.ConclusionCT‐guided percutaneous MWA is safe and effective for the treatment of peripheral NSCLC in patients with a single lung after prior pneumonectomy.

Stereotactic body radiation therapy for early-stage non-small cell lung cancer: Executive Summary of an ASTRO Evidence-Based Guideline

PurposeThis guideline presents evidence-based recommendations for stereotactic body radiation therapy (SBRT) in challenging clinical scenarios in early-stage non-small cell lung cancer (NSCLC). Methods and materialsThe American Society for Radiation Oncology convened a task force to perform a systematic literature review on 4 key questions addressing: (1) application of SBRT to operable patients; (2) appropriate use of SBRT in tumors that are centrally located, large, multifocal, or unbiopsied; (3) individual tailoring of SBRT in “high-risk” clinical scenarios; and (4) SBRT as salvage therapy after recurrence. Guideline recommendations were created using a predefined consensus-building methodology supported by American Society for Radiation Oncology–approved tools for grading evidence quality and recommendation strength. ResultsAlthough few randomized trials have been completed for SBRT, strong consensus recommendations based on extensive, consistent publications were generated for several questions, including recommendations for fractionation for central tumors and surgery versus SBRT in standard-risk medically operable patients with early-stage NSCLC. Lower quality evidence led to conditional recommendations on use of SBRT for tumors >5 cm, patients with prior pneumonectomy, T3 tumors with chest wall invasion, synchronous multiple primary lung cancer, and as a salvage therapy after prior radiation therapy. These areas of moderate- and low-quality evidence highlight the importance of clinical trial enrollment as well as the role of prospective data registries. ConclusionsSBRT has an important role to play in treating early-stage NSCLC, particularly for medically inoperable patients with limited other treatment options. Shared decision-making with patients should be performed in all cases to ensure the patient understands the risks related to SBRT, the side effects, and the alternative treatments available.

SBRT for centrally localized NSCLC - What is too central?

PurposeCurrent guidelines recommend stereotactic body radiotherapy (SBRT) for stage I non-small-cell lung cancer (NSCLC) in medically inoperable patients. There are excellent outcome and toxicity data for SBRT of peripheral lung tumors. However, the discussion on SBRT for centrally located tumors is controversial. This study evaluated current clinical practice regarding SBRT of centrally located lung tumors, to identify common fractionation schedules and commonly accepted contraindications for SBRT.MethodsA questionnaire consisting of two parts was introduced at the annual meeting of the DEGRO working group on stereotactic radiotherapy, representing centers in Germany and Switzerland. The first part of the questionnaire covered general information about the centers, whereas the second part specifically addressed SBRT of centrally located lung tumors, using case examples of nine primary NSCLC patients. Reconstructions of a contrast enhanced CT, as well as PET-Imaging for each case were demonstrated to the participants.ResultsTwenty-six centers participated in the meeting. The majority was academic (73%), participated in interdisciplinary thoracic oncology tumorboards (88%) and offered SBRT for lung tumors (96%). Two centers questioned the indication of SBRT for central lung tumors because of lack of evidence. The majority of centers had experience in SBRT for central lung tumors (88%) and half of the centers reported more than ten cases treated during a median period of five years. Most fractionation schedules used PTV encompassing doses of 48–60 Gy in eight fractions with maximum doses of 125–150%.A clear indication for SBRT treatment was seen by more than 85% of centers in three of the nine patients in whom tumors were small and not closer than 2 cm to the main bronchus. Prior pneumonectomy or immediate adjacency to hilar/mediastinal structures were not considered as contraindications for SBRT. In cases where the tumor exceeded 4 cm in diameter or was located closer than 4 cm to the carina 50–80% of centers saw an indication for SBRT. One case, with a 7 cm tumor reaching to the carina would have been treated with SBRT only by one center.ConclusionWithin DEGRO working group on stereotactic radiotherapy, SBRT for small (<4 cm) early stage NSCLC is a common indication, if the minimal distance to the main bronchi is at least 2 cm. The controversy on the treatment of larger and more central tumors will hopefully be solved by ongoing prospective clinical trials.

Oxygenation and Ventilation Strategies for Patients Undergoing Lung Resection Surgery After Prior Lobectomy or Pneumonectomy

Lung resection surgery after a prior lobectomy or pneumonectomy is becoming more prevalent. Elevated shunt fractions and reduced functional lung parenchyma complicate one-lung ventilation in the patient with a prior contralateral lobectomy. Meanwhile, lung resection after pneumonectomy requires reliance on the solitary, surgical lung for adequate oxygenation and ventilation without impeding surgical progress. These challenges require appropriate preoperative investigations and planning to facilitate a technique that balances the need for adequate gas exchange and lung injury prevention with the desire for sufficient exposure to allow for a complete surgical resection and optimal oncologic outcomes.

Lung Stereotactic Body Radiotherapy for Early-Stage NSCLC in Patients With Prior Pneumonectomy: A Case Report

Stereotactic body radiotherapy (SBRT) has become the standard of care for patients with medically inoperable early-stage non-small cell lung cancer (NSCLC). A paucity of published data exists regarding the safety of SBRT use in patients with prior pneumonectomy. This report describes 2 patients with NSCLC and prior pneumonectomy who were treated with lung SBRT and experienced a favorable treatment response with no major adverse treatment effects. The data presented herein are promising and provide early evidence that lung SBRT is a safe and feasible option in this subset of patients.

The Effect of Prior Pneumonectomy or Lobectomy on Subsequent Lung Transplantation

Lung transplantation in patients with prior lobectomy or pneumonectomy is not well understood. Using the United Network for Organ Sharing (UNOS) database, we address the impact of priormajor lung resection on lung transplantation outcomes. Retrospective review of adult lung transplants from October 1999 to December 2011 in the UNOS database identified 15,300 lung transplants; 102 patients had undergone major lung resection, defined as prior pneumonectomy (n= 22) or lobectomy (n= 80). Propensity match with nonparametric 3:1 nearest-neighbor matching algorithm adjusted for treatment-level differences. After matching, the primary outcome (90-day mortality) and secondary outcome (airway dehiscence, need for dialysis, length of stay more than 25 days) were assessed with univariable and multivariable methods. Subanalysis of pneumonectomy and lobectomy individually compared with matched nonresection patients was done in a similar manner. The Kaplan-Meier method estimated long-term survival. After matching, no significant differences were noted between groups for recipient, donor, or operative characteristics. There were 10 double lung and 12 single lung transplants after pneumonectomy and 51 double lung and 29 single lung transplants after lobectomy. Mortality at 90 days was 13.9% (n= 14) for the resection group and 8.6% (n= 1,247) for the nonresection group (p= 0.09). After matching, a significant increase was noted in 90-day mortality (p= 0.017) and perioperative dialysis (p= 0.039) for the resection versus nonresection patients. Dialysis was significantly higher among pneumonectomy patients (p= 0.03). No long-term survival difference was observed (p= 0.514). After propensity-matching, resection was associated with increased 90-day mortality and dialysis. Careful patient selection is necessary with patients who have undergone prior major lung resection, given their increased risk of perioperative mortality and dialysis.

Stereotactic Body Radiotherapy in Patients with Previous Pneumonectomy: Safety and Efficacy

There are limited treatment options for patients with prior pneumonectomy and a new lung malignancy. The safety and efficacy of stereotactic body radiotherapy in this subpopulation has not been well defined. Postpneumonectomy patients treated with lung SBRT were identified from a prospective single institution database. Treatment toxicity was recorded prospectively using the Common Terminology Criteria for Adverse Events version 3.0. Disease recurrences were categorized as local, regional, or distant metastatic disease. Overall survival was calculated using the Kaplan-Meier method. Of 406 patients, 13 postpneumonectomy patients were identified and 14 tumors were treated with SBRT. Median age was 69 years. Three lesions were biopsy confirmed. The SBRT doses were 60 Gy/3 (n = 1), 54 Gy/3 (n = 1), 48 Gy/4 (n = 7), 60 Gy/8 (n = 2), and 50 Gy/10 (n = 3). Median follow-up was 24 months. Two patients had grade 3 radiation pneumonitis 3 and 4 months post-SBRT; they died 3 and 1 months later, respectively, one of myocardial infarction and the other of progressive dyspnea thought to be related to congestive heart failure. There were no local failures, one regional failure, and three distant failures. Median survival was 29 months, 1 and 2 year overall survival were 69% (95% confidence interval: 48-100%) and 61% (95% confidence interval: 39-95%), respectively. SBRT in patients with prior pneumonectomy poses challenges because of limited lung reserve. However, local control and long-term survival can be achieved using SBRT in this inoperable population. Careful consideration must be given to radiation planning to minimize the risk of radiation pneumonitis.

Predictive parameters of symptomatic radiation pneumonitis following stereotactic or hypofractionated radiotherapy delivered using volumetric modulated arcs

PurposeTo identify dosimetric factors that predict development of radiation pneumonitis (RP) following stereotactic or hypofractionated radiotherapy for lung tumors. MethodsSeventy-nine consecutive patients with either a planning target volume (PTV)>100cm3 (n=69) or prior pneumonectomy or bi-lobectomy (n=13) were identified. Radiation doses (range: 5–50Gy, with 5Gy increments) were converted to equivalent doses (EQD2Gy) (α/β=3). Total lung (TL), ipsilateral (IL) and contralateral lung (CL) volumes minus PTV, receiving 5Gy (V5) up to 50Gy (V50) and mean lung dose (MLD) were analyzed. Predictors of grade ⩾3 RP (CTCAEv4.03) were identified with concordance-statistics (C-statistic) and p-values used to quantify the performance of the model. Factors found to be significant were entered into a recursive partitioning analysis (RPA). ResultsMedian PTV was 150cm3. Grade ⩾3 RP was observed in 8 patients (10%). In univariable analysis, CL-MLD, CL-V5-15, TL-MLD, TL-V5-V10 and ITV size were predictive of RP (p<0.05). In multivariable analysis, contralateral MLD (p=.007) and ITV (p=.063) were the strongest predictors of grade ⩾3 RP, with excellent discrimination (C-statistic: 0.868). ConclusionContralateral MLD and ITV size are both strong predictors of grade ⩾3 RP post treatment. Planning constraints should aim to keep contralateral MLD below 3.6Gy.

Radiotherapy for lung tumors arising after a prior pneumonectomy.

Treatment of patients with lung tumors in the contralateral lung after a prior pneumonectomy is challenging, especially for centrally located lesions. The curative modalities have included surgery, cryoablation, radiofrequency ablation, and radiotherapy (1-5). Unfortunately, available data on curative treatment of lung tumors after pneumonectomy by these modalities are limited to small series and case reports, and the safety and efficacy of these modalities remained unclear (1-5).

Radiofrequency ablation for non-small-cell lung cancer in a single-lung patient: Case report and review of the literature

BackgroundRadiofrequency thermal ablation is an alternative option to manage primary or metastatic lung malignancies. It is particular useful for unresectable lesions because of the disease's location, prior resection, or comorbidities. Patients presenting with a lung tumor that occurs in a single lung due to a prior pneumonectomy are difficult to manage with a curative intent due to the risk of complications after local treatment. Materials and methodsWe hereby report on treatment of a primary non-small-cell lung cancer in a previously contralateral pneumonectomised patient using per-cutaneous pulmonary radiofrequency thermal ablation. We also discuss literature that describes similar alternative minimally invasive procedures. ConclusionDespite being a high-risk procedure, radiofrequency should be considered for patients with a single lung particularly when ineligible to surgery or stereotactic ablative radiation therapy. The procedure should be ideally associated with a pre-operative preventive chest tube.

Coronary surgery following prior pneumonectomy —A challenging clinical scenario with excellent results

Coronary artery bypass grafting (CABG) in patients with prior pneumonectomy is challenging because of the decreased pulmonary function and the anatomical alterations of the thoracic cavity. Due to extended morbidity and mortality in this special patient cohort, only very few reports in the world literature focus on this topic. Overall, no general recommendations exist with regard to the optimal management of this continuously growing patient cohort. We present our experience with another successful case.

Coronary Artery bypass grafting and/or valvular surgery in patients with previous pneumonectomy

There is a lack of data regarding heart surgery on patients who have been previously pneumectomized. These patients pose unique challenges and surgical management may necessitate deviations from standard methods in the perioperative course. To summarize the available knowledge and to assess the optimal methods, we reviewed all reported patients with prior pneumonectomy who were subjected to coronary artery bypass grafting and/or valve surgery.In a Medline search from 1966 to May 2011 carefully undertaken, we identified 22 articles, including 29 patients who underwent 30 operations: CABG 70%, valvular surgery 23%, and combination 7%. Severe morbidity was 37% and 30-day mortality 13%.Although postoperative morbidity and mortality remain higher in previously pneumectomized patients undergoing coronary artery bypass grafting and valvular surgery, the gathered experience up to date suggests that a carefully planned surgical strategy, along with the use of advanced modern techniques may reduce morbidity and improve final outcome.

CATHETER ABLATION OF ATRIAL FIBRILLATION INVOLVING PULMONARY VEIN STUMPS IN PATIENTS WITH PRIOR LUNG RESECTION

AF ablation in the patients involving PV stumps from prior lobectomy and pneumonectomy has not been described in literature. We describe a multicenter experience of all patients with residual PV stumps after lung resection undergoing AF ablation. 14 patients with lung resection (for tumors in 9,

Pulmonary Thermal Ablation in Patients With Prior Pneumonectomy

The purpose of this article is to review the safety and efficacy of thermal ablation of lung malignancies after pneumonectomy. We reviewed patients who underwent thermal ablation for malignant lung tumors after pneumonectomy between 1999 and 2009. Patient demographics, complications, procedural success, and oncologic outcomes were recorded. Technique effectiveness was evaluated at imaging 4-6 weeks after ablation. The Kaplan-Meier method was used to evaluate overall survival. A cumulative incidence and competing risk method was used to account for progression-free tumors at the time of patient death. Of 619 lung ablations, 17 were performed to treat 13 tumors (nine primary and four metastatic) in 12 patients with a single lung. The median tumor size was 2 cm (range, 1.2-4 cm). Technical success was documented in all 17 cases. Technical effectiveness was documented in 10 of 12 patients. Local tumor progression occurred in five lesions within a median of 12 months (range, 10-22 months) after ablation and was treated with repeat ablation in four lesions. Complications included six (35%) of 17 pneumothoraces requiring thoracostomy. Deaths occurred within 2-12 days after three (19%) of 16 ablation sessions. The median time to primary local tumor progression was 18 months (95% CI, 12 months through not reached), and the median time to assisted (after repeat ablation) local tumor progression was 33 months (95% CI, not reached). Median overall survival was 21 months (95% CI, 18-53 months). After excluding the two early deaths complicating the initial ablation procedure, median overall survival was 37 months. Thermal ablation can offer local tumor control after pneumonectomy, despite a relatively high postprocedure clinical risk.

Early Pulmonary Toxicity of Lung Stereotactic Body Radiation Therapy (SBRT) Delivered as Consecutive Daily Fractions

Early Pulmonary Toxicity of Lung Stereotactic Body Radiation Therapy (SBRT) Delivered as Consecutive Daily Fractions

Long-Term Ambulatory Continuous Nerve Blocks for Terminally Ill Patients: A Case Series

Intolerable side effects and dissatisfactory pain control with traditional analgesics prompted the utilization of long-term, ambulatory, continuous peripheral nerve blocks (CPNBs) in terminally ill patients for palliative care. Case series. Continuous peripheral nerve catheters were placed in terminally ill patients in an ambulatory setting. The patients were managed at their homes, with nursing services available to manage the infusions and provide routine monitoring and care. This is a case series of patients with severe peripheral pain and a terminal diagnosis in whom the goals of care were aimed at palliation. All three cases had an unfavorable coagulation status; case 2 had a prior pneumonectomy on the contralateral side and a large tumor on the ipsilateral lung of the continuous brachial plexus block. Interventions included CPNBs, with infusion of local anesthetic. Specific techniques used include cervical paravertebral block and lumbar paravertebral block. After infusion and titration of local anesthetic doses, oral opioid medication was significantly reduced, which resulted in an improved quality of life. The nerve blocks did not hasten death in any of the patients despite their coexisting conditions. CPNBs are a reasonably effective modality to decrease opioid usage when side effects are undesirable for end-of-life care. The risk of unfavorable coagulation status, poor lung function, and risk of infection was outweighed by the benefit in this patient population.

Does induction chemoradiation effect perioperative mortality and overall survival in patients undergoing pneumonectomy for non-small cell lung cancer?

7061 Background: Induction chemoradiation before pneumonectomy allows patients to achieve long term survival, increases resectability rates, and is proven to be safe in previously published studies. Unfortunately, the mortality and morbidity of pneumonectomy after induction chemoradiation is high. This study aims to compare pneumonectomy only with induction chemoradiation and pneumonectomy at our institution, assessing perioperative mortality and overall survival. Methods: Patients with non-small cell lung cancer and prior pneumonectomy at our institution from December 1993 until February 2009 were retrospectively reviewed and their information was entered into a generalized database. Propensity matching and Kaplan Meier Survival curves were used to evaluate perioperative mortality and overall survival. Results: 158 patients were reviewed, 50 patients underwent induction chemoradiation prior to pneumonectomy and 108 patients had only a pneumonectomy. For all patients, 30 and 90 day survival rates were 5.7% and 8.86% respectively. Mortality in the pneumonectomy alone group versus pneumonectomy and induction therapy was 4.63% and 8% respectively at 30 days (p=0.475), and 7.41% and 12% at 90 days (p=0.374). The Propensity Matching Scores showed no significant difference between overall survival of patients with and without induction therapy prior to pneumonectomy, with hazard ratios of 1.125 (unweighted) and 1.312 (weighted). No significant differences were found when Propensity Matching was weighted for mediastinoscopy, side, diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease, histology, clinical stage. Conclusions: Although mortality rates for patients with pneumonectomies alone are shown to be lower than those with induction therapy at 30 days, 90 days, and overall, we find no significant difference. In specialized cancer centers such as ours, the overall mortality for pneumonectomies remains low. Additional details with subgroup analyses will be presented at the Meeting. No significant financial relationships to disclose.