Clinical Data
A 37-year-old male, with a history of smoking totaling 75 pack-years, sought medical care for a chronic, irritative cough persisting for three months. The enduring nature and severity of the cough led to comprehensive clinical investigations. A chest CT scan revealed a mass at the left hilar region (Fig. 1A), suggestive of a possible malignancy with potential invasion into the left pulmonary artery trunk (Fig. 1B), but not involving the left lower lobe pulmonary artery (Fig. 1C-D). Further examination through fiberoptic bronchoscopy showed an extrinsic protrusion on the distal membrane of the left main bronchus, with associated mucosal thickening and narrowing in the upper lobe bronchus of the left lung. No abnormalities were detected in the rest of the bronchial tree. Histopathological evaluation confirmed non-small cell lung cancer (NSCLC), adenocarcinoma subtype. Immunohistochemical staining identified adenocarcinoma with micropapillary features and intravascular cancer thrombi. The expression of Programmed Death Ligand-1 (PD-L1) was significantly elevated in 90% of tumor cells and in 10% of immune cells, indicating a likely responsiveness to immune checkpoint inhibitor therapy. These findings offer a potential therapeutic avenue through immunotherapy targeting PD-L1. The Multidisciplinary Team (MDT) developed a treatment protocol involving a left pneumonectomy with ex vivo resection of the left upper lobe and reimplantation of the left lower lobe to preserve lung function. The post-surgical plan includes adjuvant chemotherapy and immunotherapy to optimize treatment outcomes.
Surgical Procedure
After induction with general anesthesia and endotracheal intubation using a double-lumen tube, the patient is positioned in a right lateral decubitus position. The surgical approach includes a 25 cm incision along the anterior lateral aspect of the fifth intercostal space. Additionally, a 1.5cm thoracoscopic port is established in the eighth intercostal space. This setup is commonly used in thoracoscopic surgery, allowing for direct access through the larger incision while the smaller port facilitates minimally invasive techniques for enhanced visualization and instrument handling[1].
Surgical exploration begins at the pulmonary hilum with an incision into the mediastinal pleura, followed by systematic lymphadenectomy. Subsequently, the left main bronchus is circled posteriorly to the hilum. The pericardium, once incised behind the phrenic nerve, reveals the major vascular structures, specifically the left upper and lower pulmonary veins, along with the left pulmonary artery. The left main bronchus is then sequentially transected(Figure 2A)and the veins of the upper and lower lobes are sealed with a stapler (Fig. 2B-C). A vascular clamp is applied to occlude the left pulmonary artery trunk (Fig. 2D), enabling its sharp dissection to secure an adequate length for division (Fig. 2E-F).
The upper lobe of the left lung was resected ex vivo, and the lower lobe was immersed in iced water and perfused anterogradely and retrogradely with a low-potassium dextran solution until the perfusate appeared clear. The bronchi (Fig. 3A), artery (Fig. 3B), and vein (Fig. 3C) of the lower left lobe were prepared for anastomosis.
Rapid intraoperative pathological examination confirmed a classification of T4N1M0 (stage IIIA) with tumor-free margins noted in the bronchial, arterial, and venous tissues. The surgical procedure entailed anastomosis of the lower bronchus to the main bronchus using 3 − 0 Prolene sutures (Fig. 3D). This was followed by suturing the stumps of the pulmonary artery with 5 − 0 Prolene (Fig. 3E) and anastomosis of the lower pulmonary vein to the site of the upper vein using 4 − 0 Prolene sutures (Fig. 3F). Subsequently, the left lung artery and vein were sequentially released. After air evacuation through the venous anastomosis site, the site was secured with a suture. Perfusion and ventilation of the replanted left lower lobe were satisfactory. The surgical intervention spanned 245 minutes and entailed a cold ischemia period of 90 minutes.
Postoperative Management
The patient was observed in the ICU for 48 hours. Therapeutic measures included the administration of antibiotics, anticoagulants, nebulized treatments, and nutritional support. Bronchoscopic suctioning was utilized to clear pulmonary secretions and evaluate the anastomosis. The lymph nodes of the N1 group were positive for metastasis, confirming a stage IIIA tumor (pT4N1M0). The patient's recovery was uneventful, and they were discharged 2 weeks later with satisfactory pulmonary function and without significant morbidity.
Adjuvant Chemotherapy and Immunotherapy
The patient underwent a systemic adjuvant therapy regimen that involved four cycles of chemotherapy with pemetrexed and carboplatin, along with intravenous administration of a PD-L1 inhibitor every three weeks for 16 cycles. This treatment was well-tolerated, with no severe immune-related adverse events observed.
Follow-up and Outcomes
Postoperative chest CT at one week showed favorable lung re-expansion (Fig. 4A). Subsequent imaging three months later showed reduced pulmonary inflammation (Fig. 4B). In December 2021, the patient was admitted due to a COVID-19 infection (Fig. 4C), and imaging one month thereafter confirmed resolution of pulmonary inflammation (Fig. 4D). Follow-up examinations during the second (Fig. 4E) and third years (Fig. 4F) postoperatively revealed no signs of recurrence or tumor metastasis. Pulmonary function tests have remained stable. The patient reports maintaining a high quality of life with unrestricted physical activity.