Preconditioning Surgery for Pneumonectomy: A Case Report of Contralateral Lung Bullectomy

Abstract

The preferred treatment for non-small cell lung cancer is surgical resection, and pneumonectomy may be necessary for centrally located tumors. Adequate pulmonary reserve is critical for pneumonectomy; otherwise, nonsurgical treatment options should be considered. Some patients who are initially inoperable due to insufficient pulmonary function may become surgical candidates after rehabilitation interventions. Here, we present a case of right bullectomy followed by left pneumonectomy successfully performed in a patient with bilateral giant bullous lung disease and a left hilar mass. The patient has remained complication- and recurrence-free for 2 years.

Case report

Pneumonectomy may be required in the management of centrally located lung cancers, and physicians must carefully evaluate a patient’s respiratory reserve before surgery. Pneumonectomy is contraindicated in patients with severely limited lung capacity, such as those with chronic obstructive pulmonary disease, bullous lung disease, or diffuse parenchymal lung disease, and these patients may instead be referred for nonsurgical therapies [1]. To provide surgical options, physicians should determine whether the disease impairing pulmonary reserve is in an active phase and consider treatments or interventions aimed at improving lung capacity and surgical feasibility [2]. We present a case of contralateral bullectomy followed by pneumonectomy in a patient with bilateral giant bullae who required pneumonectomy for left hilar non-small cell lung cancer. A 64-year-old man presented with cough and hemoptysis. Thoracic computed tomography revealed a 65-mm mass in the left hilar region with bilateral giant bullae (Fig. 1). Histopathological analysis of a biopsy obtained by fiberoptic bronchoscopy demonstrated keratinizing squamous cell carcinoma. Clinical staging with positron emission tomography–computed tomography, endobronchial ultrasound-guided transbronchial needle aspiration, and cranial magnetic resonance imaging determined stage IIB disease according to the eighth TNM (tumor-node-metastasis) classification. Molecular analysis did not detect PD-L1 expression. Pulmonary function testing showed a forced expiratory volume in 1 second (FEV1) of 1.78 L (68%) and diffusing capacity of the lungs for carbon monoxide of 75%. Although a left pneumonectomy was planned for cancer treatment, the right-sided giant bullae posed perioperative and postoperative risks. First, 1-lung ventilation during surgery could have been intolerable. Second, positive airway pressure might have caused bullae rupture with life-threatening pneumothorax. Finally, bulla infection could have led to severe morbidity. For these reasons, we decided to perform right bullectomy as the initial procedure. The patient underwent right bullectomy via bi-portal video-assisted thoracoscopic surgery, which achieved full lung expansion, and was discharged uneventfully on the fourth postoperative day (Fig. 2A). Two weeks later, he was readmitted for left pneumonectomy. Repeat pulmonary function tests showed FEV1 improved to 2 L (78%). Left pneumonectomy with mediastinal lymph node dissection was performed via posterolateral thoracotomy. Intraoperative 1-lung ventilation and postoperative recovery were uneventful, and he was discharged on postoperative day 7. Pathology confirmed pT3N0M0 (stage IIB) disease, and he received adjuvant chemotherapy with 4 cycles of cisplatin–etoposide. At 2-year follow-up, there was no recurrence (Fig. 2B–D). Postoperatively, his respiratory function remained adequate; he was able to climb 3 flights of stairs without rest or support, and his Eastern Cooperative Oncology Group performance score was 0. Written informed consent for publication was obtained from the patient.

Fig. 1.

(A, B) Thoracic computed tomography (CT) shows bilateral giant lung bullae and a left hilar mass. (C) An 18F-fluorodeoxyglucose positron emission tomography (PET)–CT scan shows a pathologically increased uptake on the left hilar mass (SUVmax=16.3). SUVmax, maximum standardized uptake value.

Fig. 2.

(A) Patient’s chest X-ray taken after bullectomy, showing right lung expansion. (B–D) Chest computed tomography obtained 2 years after pneumonectomy, showing neither complications nor recurrence.

Discussion

We report a contralateral bullectomy performed as a bridging intervention before pneumonectomy. Adequate reserve of the remaining lung is crucial in pneumonectomy [1]. Patients who are initially deemed inoperable based on respiratory parameters may become candidates for pulmonary resection after targeted rehabilitation strategies. Goldsmith et al. [3] demonstrated that patients initially considered inoperable by subjective and objective criteria could tolerate resection after completing a Prehab program, which improved their pulmonary reserve. Although our patient’s quantitative measures indicated that pneumonectomy was feasible, contralateral bullectomy was prioritized because of the risks posed by giant bullae. Specifically, intraoperative difficulty with 1-lung ventilation, as well as postoperative complications such as pneumothorax or infection, represented major concerns. For patients with poor respiratory reserve but without distant metastases, radiosurgery may be an option for local control. While stereotactic body radiotherapy (SBRT) has shown favorable results in T1–T2 tumors, evidence in T3–T4 disease remains limited, partly due to the larger irradiated volumes and advanced tumor stages [4]. In our case, we favored surgical treatment rather than SBRT because the tumor was centrally located and classified as cT3. Complications associated with giant bullae include pneumothorax, infection, and even malignancy at the bulla base. Bullectomy has been shown to improve both symptoms and respiratory function [5]. In this patient, although pulmonary function was not severely impaired, resection of the contralateral bullae was undertaken first to reduce the risk of fatal complications such as postoperative pneumothorax or infection. In conclusion, in patients with central lung cancer requiring pneumonectomy and concomitant contralateral bullous-emphysematous disease, bullectomy or lung volume reduction surgery should be considered before declaring medical inoperability.