CASE REPORT   

Chirurgia 2021 April;34(2):88-92

DOI: 10.23736/S0394-9508.20.05115-3

Copyright © 2020 EDIZIONI MINERVA MEDICA

language: English

Successful left pneumonectomy in a case of giant-sized squamous cell carcinoma of the lung after having difficulty in determining resectability

Junzo SHIMIZU ¹ ✉, Makio MORIYA ¹, Tadashi KAMESUI ¹, Toshiro NAGAYOSHI ², Akitaka NONOMURA ³, Yoshihiko ARANO ⁴, Shunji SHINAGAWA ⁵

¹ Departments of Chest Surgery, Hokuriku Central Hospital, Oyabe, Japan; ² Department of Radiology, Hokuriku Central Hospital, Oyabe, Japan; ³ Department of Pathology, Hokuriku Central Hospital, Oyabe, Japan; ⁴ Department of Surgery, KKR Hokuriku Hospital, Kanazawa, Japan; ⁵ Department of Respiratory Medicine, Nanto Municipal Hospital, Nanto, Japan

In patients with giant-sized lung cancer and those with metastatic lymph nodes (LN) in the central hilum, it may be difficult to determine resectability even during open chest surgery. We recently encountered a case of giant-sized carcinoma of the lung measuring 14 cm in diameter in the left upper lobe (LUL) in which pneumonectomy (PN) was performed with a tailored approach. A 67-year-old man presented to a nearby physician with chief complaints of left chest pain and bloody sputum. A chest X-ray showed a giant mass in the left lung, and his sputum cytology was class V (squamous cell carcinoma). He was thus referred to our department. Contrast-enhanced computed tomography showed that the main trunk of the left pulmonary artery (PA) was displaced by the mass, and the left superior pulmonary vein (PV) was narrowed by the mass or metastatic LN. The mass was broadly in contact with the chest wall. Thoracotomy was performed through the fifth intercostal space. The giant-sized mass was broadly adhered to the pleura, and thus the left lung had no passive movement. Under thoracoscopic observation, the adhesion was separated extrapleurally, but the left lung still had no passive movement. Therefore, the dorsal side of the lung was explored, and the descending aorta was identified. Then, exploration was directed toward the mediastinum, and the left lower PV and the A¹⁺²a+b of the left PA were confirmed. At this point, the resectability was not confirmed, but dissection was made in the periphery of the A¹⁺²a+b of the PA; furthermore, the left lower PV and left lower lobe (LLL) bronchus (Br) were dissected, and the normal LLL was removed. This allowed some passive movement of the LUL, and the main trunk of the left PA was exposed and dissected. Subsequently, the left main Br was dissected, and the root of the upper PV was dissected after exposing the pericardium. The LUL was removed and left PN was completed. Histological examination showed that the cancer cells infiltrated into the fatty tissue in the chest wall as well as to the outer membrane of the PA. Metastasis was observed in one hilar LN (station 12), and the tumor was finally diagnosed as pT4N1M0, pStage IIIA. As the carcinoma was massive, the normal LLL was resected to create a working space. Subsequently, the LUL containing cancer was resected, and left PN was completed. The patient has been alive without recurrence for 2 years after surgery. However, distant metastasis may occur in the future. In this case, immune checkpoint inhibitors may be used because the expression of PD-L1 was high.

KEY WORDS: Lung neoplasms; Pneumonectomy; Case reports