A 71-year-old Asian male lung cancer patient, with total obstruction of the right upper bronchus, underwent right upper sleeve lobectomy with bronchoplasty and lymph node dissection combined with preoperative induction and postoperative adjuvant chemotherapy with docetaxel and platinum agents in 2007. Thereafter, partial resection with right radical neck dissection was performed for tongue cancer of pT1N1M0. In 2016, a new undiagnosed hilar mass near the anastomosis site, as a lung metastasis of tongue cancer found on chest computed tomography (CT), was treated with radiotherapy of 36 Gy at a previous hospital. The tumor responded transiently to radiotherapy, but progressed. On chest CT at the first visit in 2018, a tumor involving the remaining two lobes compressed the pulmonary artery at the cut end of the superior trunk (Figure 1a, b). Moreover, the tumor extended from the periphery of the anastomosis site to the tracheal bifurcation and to the inflow to the superior vena cava (SVC) of the azygos vein (ligated previously), which was ligated previously, along with the membranous side of the right main bronchus (Figure 1c, d). In 2016, chest CT on initial detection of recurrence suggested lobar lymph node recurrence near the anastomotic site. On bronchoscopy, the bronchial anastomosis site was on the peripheral two rings from the tracheal bifurcation; tumor infiltration was suspected in the immediate periphery on that membranous side, but histological diagnosis could not be obtained from biopsy on this site. Distant metastasis was not observed in fluorodeoxyglucose-positron emission tomography, and the clinical stage was stage IB of cT2aN0M0, if it was a primary lung cancer. The high-risk patient had no abnormality in the electrocardiogram and the echocardiography in spite of having a history of coronary vasospastic angina; however, both %ppo-FEV1 and %ppo-DLco were slightly less than 40% (38.0% and 37.8%, respectively) in the pulmonary function test. Because radiotherapy has already been performed by the previous hospital and appropriate drugs could not be selected as there was no information on definitive diagnosis and gene mutation, we selected the most effective surgical treatment despite being a high-risk patient. For surgical management, after securing and cutting the proximal side of the main pulmonary artery with a median sternotomy, the tumor in contact with the azygos vein stump was divided safely from the SVC, and sleeve pneumonectomy was performed under good vision via the posterior lateral thoracotomy approach.
Median sternotomy in the supine position was performed under general anesthesia. The proximal part of the right main pulmonary artery could only be secured in front of the left main bronchus because of severe adhesion from the tracheal bifurcation to the right main bronchus. The right main pulmonary artery was occluded for approximately 15 min to prevent deterioration of circulatory dynamics. Although the remaining lymph nodes around the trachea were dissected and the SVC was adequately detached (Figure 2a), confirming the adhesion between the tumor and azygos vein was difficult under direct vision from this position. After dividing the proximal site of the right main pulmonary artery with a vascular stapler (Figure 2b), posterior lateral thoracotomy was performed in the left lateral position. The azygos vein stump, which was in contact with the tumor, could be observed from the thoracic cavity side. After the inferior pulmonary vein and middle lobe vein were cut, the area around the stump of the azygos vein was peeled off and divided at the edge of the bifurcation from the SVC using vascular stapler (Figure 2c). As the bronchial stump proximally from the anastomosis showed infiltration of cancer cells by frozen section, sleeve pneumonectomy was performed. The left main bronchus and distal trachea were exposed and mobilized with blunt dissection to avoid excessive peeling and preserve maximal blood supply. After dividing the left main bronchus, a spiral tube was intubated from the operative field; the tracheobronchial sleeve above the carina was then resected (Figure 2d). The distal and proximal margins were confirmed radical by frozen sections. Reconstruction was performed by telescoping the left main bronchus into the distal trachea to overcome marked caliber mismatch. The distal trachea, around the anastomosis, has thickening and low-mobility area, so the first three sutures at the deepest anastomosis edge were knotted extraluminally and 15 interrupted stitches with a 3-0 PDS were placed alternately from both sides (Figure 2e). After tying the sutures, the anastomosis site was covered with pericardial fat pads.
Postoperative pathological examination diagnosed a recurrence of lung squamous cell carcinoma because of its similarity to the previous histologic type. A tumor measuring 40 × 32 × 30 mm in diameter had central necrosis because of radiotherapy. The resected lymph nodes were free from metastasis.
Postoperatively, treatment for circulatory insufficiency associated with arrhythmia and pneumonia was required (Figure 1f), but the patient was transferred to a public hospital on postoperative day 87 for rehabilitation. He is still alive during the 13 months after the operation without anastomotic problems and recurrence.