Surgery to avoid fatal complications and secure radicality after definitive chemoradiotherapy for clinical T4N2M0 stage IIIB non-small cell lung cancer: a case report
- 35 Downloads
Chemoradiotherapy (CRT) is the standard treatment for c-stage IIIB non-small cell lung cancer (NSCLC); however, patients who respond to CRT are at risk of developing fatal complications such as massive hemoptysis or infection. In such cases, surgery is an alternative option. Currently, there are limited reports on surgery for complications arising during definitive CRT for locally advanced NSCLC. We report a case of hemoptysis after definitive CRT for c-T4N2M0 stage IIIB NSCLC that was successfully treated with lower bilobectomy combined with left atrial resection.
A 72-year-old man with c-T4N2M0 stage IIIB NSCLC with left atrial invasion developed hemoptysis during CRT, which was discontinued to control hemoptysis. Chest computed tomography revealed a regressed and cavitated tumor. Three weeks after discontinuation of CRT, surgery was performed to avoid fatal complications and secure radicality. We performed lower bilobectomy combined with partial left atrial resection, which was performed using an automatic tri-stapler. The bronchial stump was covered with an omental flap. The resected specimen pathologically showed complete response with fistula between the intermediate bronchus and necrotic cavity in the tumor. His postoperative course was uneventful, and the patient was disease free at 10 months after surgery.
We successfully performed surgery after definitive CRT in a patient with c-T4N2M0 stage IIIB NSCLC. Partial left atrial resection was safely performed with an automatic tri-stapler. A complete pathological response to CRT was achieved. In a case with a chance of complete (R0) resection, when the risk of developing fatal complications might outweigh the risk of post-CRT surgery perioperative complications, surgery should be considered as a treatment option.
KeywordsLung cancer Chemoradiotherapy Hemoptysis Extended surgery Left atrial resection
Left lower lobe
Non-small cell lung cancer
The standard treatment for c-stage IIIB non-small cell lung cancer (NSCLC) is chemoradiotherapy (CRT). However, patients undergoing CRT are at risk of developing fatal complications, including massive hemoptysis or infection, due to tumor cavitation and fistula formation between the tumor and surrounding organs. The incidence of fatal pulmonary hemorrhage in patients with major cavitation on baseline chest computed tomography (CT) and squamous cell histology is reported to be 33.3% . In such situations, post-CRT surgery is one of the treatment options . Although the efficacy and safety of surgery after CRT has not been widely studied in lung cancer, a report concluded the median overall survival after salvage surgery to be 9–46 months and 5-year survival rate to be 20–75%, which are relatively good results . In stage IIIB cases, the 5-year survival rate after post-CRT surgery was 42% for patients with no mediastinal lymph node involvement at the time of surgery and the rate of postoperative death was 7% . Thus, selected patients might benefit from post-CRT surgery.
Herein, we report a case treated with right lower bilobectomy combined with left atrial resection for c-T4N2M0 NSCLC, which developed hemoptysis during definitive CRT. We highlight the surgical procedures employed to avoid intraoperative and postoperative complications.
After five courses of the regimen with total irradiation of 48 Gy, the patient developed hemoptysis. Therefore, we had to discontinue CRT. Chest CT revealed a cavitated tumor (Fig. 1d), which likely caused the hemoptysis. The right inferior pulmonary vein remained obstructed by the tumor (Fig. 1e). However, tumor extension into the left atrium had regressed (Fig. 1f). Preoperative echocardiogram revealed that the tumor protruding into the left atrium had regressed and that the left atrial wall motion had improved compared with the results of the echocardiogram performed before CRT.
Hemoptysis was controlled by treating with tranexamic acid and antibiotics, and discontinuation of CRT and aspirin prescribed for post-coronary stenting status. However, we considered that the newly developed cavity might develop massive hemoptysis in the future. Based on those findings, we decided to surgically control the life-threatening hemoptysis and achieve radical resection. The patient complicated chemotherapy-induced neutropenia, thrombocytopenia, and radiation-induced dermatitis on his back where the surgical wound would be placed. Therefore, we waited for 3 weeks to go for surgery after the discontinuation of CRT.
Pathological analysis revealed complete response to CRT with no viable cancer cells in the necrotized tumor and lymph nodes. The resected specimen showed fistula formation between the intermediate bronchus and necrotic cavity in the tumor. The existence of cancerous keratin pearl-like structures suggested squamous cell carcinoma.
The postoperative course was uneventful. The patient is alive without recurrence. A CT scan taken at 10 months post-surgery showed that both the bronchial stump and pericardial defect were tightly covered by the omental flap with sufficient volume and blood supply.
We successfully performed surgery to avoid fatal complications and secure radicality after definitive CRT for c-stage IIIB NSCLC. Extending pericardiotomy to the dorsal side to widely expose the left atrium and resecting the left atrium using an automatic tri-stapling system with adaptive firing technology enabled safe, accurate, and prompt suturing and dividing. We used an omental flap to prevent bronchopleural fistula.
This patient did not complicate major cavitation associated with massive hemorrhage on the baseline CT, as described by Ito et al. . However, we emphasize the risk of developing fatal hemorrhage or fistula formation due to tumor necrosis, although the response to the CRT treatment increased the potential for complete resection.
Some literatures reported the use of the Sondergaard technique for left atrial resection to avoid using cardiopulmonary bypass and enable increased margin of resection by performing interatrial groove dissection [5, 6]. Meanwhile, in cases where tumor progression is localized to the origin of the pulmonary vein, like that of our patient, partial atrial resection is performed with a simple atrium clamping technique . In cases where the tumor invades down the origin of the pulmonary vein, and the left atrial wall is tumor free, partial left atrium resection is required to ensure an adequate margin. In these cases, using a stapler is an alternative method to perform left atrium resection. Galvaing et al. reported that partial resection of the left atrium was performed either on clamp or with an automatic staple although left atrium partial resection with tri-stapler has not been described in detail to date . We believe using an automatic stapler for left atrial resection is associated with various advantages: a smaller margin is required for suturing, which enables the operator to secure an adequate safety margin; it avoids the risk of massive bleeding due to dislocation of the clamp forceps while suturing the atrium; it enables accurate and prompt suturing and dividing. However, the stapler should be used with caution, as it may lead to a catastrophic rupture of the left atrium when a stapler malfunctions. Tunezuka et al. reported that they had experienced massive bleeding along the staple line after dividing the left atrium with a stapler . To avoid such risks, surgeons must be prepared to be able to apply forceps and place repair sutures with felt pledgets.
Galvaing et al. described using Endo GIA universal stapler with green cartridges. In our case, we chose the camel cartridge . According to the product information, green cartridges should be used on tissue that can comfortably compress to 2 mm, whereas camel cartridges should be used on tissue that can comfortably compress to 0.88–1.88 mm. Based on the intraoperative findings, we thought that the camel cartridge would be suitable for this patient, who has a relatively small physical size (159 cm tall with body weight of 64 kg) with normal atrial muscle (no hypertrophy or atrophy). Of note, the Adaptive Firing Technology™ that measures the firing force and automatically adjusts the stapler speed of the Signia™ Stapling system (Medtronic) assists in determining the appropriate cartridge because it gives an alarm message if an inadequate cartridge is chosen.
Bronchopleural fistula is one of the most serious postoperative complications of post-CRT surgery. A higher rate of bronchopleural fistula is expected because the necrotized region is close to the bronchial stump along with a post-CRT hypovascular status. Vascularized flaps, such as the intercostal muscle flap, pericardial fat pad, and omental flap, are used to cover the bronchial stump . Of these, we used an omental flap because it has a rich vascular supply and immunologic action and was located outside the radiation field.
We performed lower bilobectomy in a patient with c-stage IIIB NSCLC to prevent fatal bleeding due to tumor cavitation during definitive CRT. An automatic tri-stapler facilitated the resection of the left atrium, and the patient has been alive without major complications or tumor recurrence for 10 months after the surgery. Optimal approaches for stage IIIB NSCLC or post-CRT surgery remain controversial. However, in a case with a chance of complete (R0) resection, when the risk of developing fatal complications might outweigh the risk of post-CRT surgery perioperative complications, surgery should be considered as a treatment option.
YY wrote the manuscript. YY, KK, and HK performed the surgery. MT made the pathological diagnosis. Other co-authors discussed the content of the manuscript. All authors read and approved the final manuscript.
We declare that each author received no funding for this study.
Ethics approval and consent to participate
Consent for publication
Consent for publication has been obtained from the patient presented in this report.
The authors declare that they have no competing interests.
- 3.Dickhoff C, Otten RHJ, Heymans MH, Dahel M. Salvage surgery for recurrent or persistent tumour after radical (chemo) radiotherapy for locally advanced non-small cell lung cancer: a systematic review. Ther Adv Med Oncol. 2018;10:1–12.Google Scholar
- 8.Tunezuka Y, Tanaka N, Fujimori H. Extended right pneumonectomy with partial resection of the left atrium without cardiopulmonary bypass. Kyobu Geka. 2016;69:423–7. (in Japanese)Google Scholar
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.