Re-VATS Left Upper Lobectomy With Pulmonary Artery Plasty After Induction Chemotherapy

Introduction

Partial or complete resection of the pulmonary artery is a well-known technique for the treatment of non-small cell lung cancer, which provides optimal results in terms of disease control and blood flow [1,2]. In this video tutorial, we demonstrate how to carry out a left upper lobectomy associated with a plasty of the left pulmonary artery using a re-VATS approach. Careful pre-operative planning and evaluation of the patient is mandatory in order to safely perform this procedure.

Patient Presentation

We here present the case of a 69-year-old patient affected by an adenocarcinoma of the left upper lobe and several other comorbidities, such as: atrial fibrillation, GOLD 2 chronic-obstructive pulmonary disease, type 2 diabetes mellitus, and hyperuricemia. The NSCLC was diagnosed by means of a biopsy of the nodal station 5L, performed via a minimally invasive thoracoscopic approach. Then, the patient underwent three cycles of neoadjuvant chemotherapy (carboplatin and gemcitabine). After that systemic treatment, the case was discussed by the multidisciplinary team and considered for surgery. The pre-operative CT scan demonstrated the stability in size of the pulmonary nodule and of the hilar lymphadenopathies, which reached and infiltrated the first two branches of the left pulmonary artery. Moreover, the PET-TC revealed a consistent decrease in SUV of the pulmonary mass and of the hilar and subcarinal lymphadenopathies, without any other site of pathologic uptake of FDG. The pre-operative functional evaluation of the patient consisted of an echocardiogram, pulmonary function tests with DLCO, arterial blood gas analysis, and full blood tests.

Outcome

The post-operative period was uneventful, and the chest drain was removed on the second post-operative day (POD). The patient was discharged on the fifth POD. Final pathological examination described a T2aN2M0 (stage IIIa TNM8th) mucinous adenocarcinoma of the lung. The patient underwent adjuvant chemoradiotherapy and after eight months of follow up, the patient was free from disease recurrence.

Discussion

Pulmonary artery plasty is an important technique in the treatment of lung cancer; indeed, it allows for sparing of the pulmonary parenchyma, while achieving an oncologically radical resection, as demonstrated by many authors [3,4]. Moreover, it has been proven that performing a pneumonectomy has an adverse effect on survival and quality of life [5,6,7]. Therefore, we adopted this technique, together with a minimally invasive approach, as many studies indicate that should be preferred to open thoracotomy because advantages in terms of lower complication rates [8], lower post-operative pain [9], reduced hospital stay [10], faster recovery, and return to daily activities [10]. We think that this combination can lead to optimal results in terms of disease treatment and post-operative quality of life. The technical aspects that must be addressed are that the residual lumen must be wide enough to allow an unimpeded blood flow, and there must not be any kinking of the vessel, especially when the remaining lung is inflated; otherwise, a thrombosis of the segment may occur.

We have also demonstrated that this procedure is feasible when facing a re-VATS after a neoadjuvant chemotherapy treatment. In the video tutorial, the extensive presence of adhesions is clearly visible; these were easily divided at the beginning of the operation in order to better visualize and mobilize the lung parenchyma. It must also be kept in mind that at the hilum dense fibrous tissue may be present, hindering the isolation of the structures; therefore, it is necessary to proceed with great care so as not to damage any vessel or bronchus.

Obviously, this a challenging technique that requires precise pre-operative planning; indeed, it is of paramount importance to obtain recent CT scan images so as not to face any unexpected situations during the operation. Moreover, the function evaluation of the patient must be very accurate, since the eventuality of a pneumonectomy should be taken into consideration.

References

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2. Vannucci J, Matricardi A, Potenza R, Ragusa M, Puma F, Cagini L. Lobectomy with angioplasty: Which is the best technique for pulmonary artery reconstruction? J Thorac Dis. 2018;10(3):S1892-S1898.
3. Schiavon M, Comacchio GM, Mammana M, Faccioli E, Stocca F, Gregori D, Lorenzoni G, Zuin A, Nicotra S, Pasello G, Calabrese F, Dell'Amore A, Rea F. Lobectomy with artery reconstruction and pneumonectomy for NSCLC: a propensity score weighting study. Ann Thorac Surg. 2021 Jan 9 Epub ahead of print. PMID: 33434540.
4. Venuta F, Ciccone AM, Anile M, et al. Reconstruction of the pulmonary artery for lung cancer: Long-term results. J Thorac Cardiovasc Surg. 2009;138(5):1185-1191.
5. Alexiou C, Beggs D, Onyeaka P, et al. Pneumonectomy for stage I (T1N0 and T2N0) nonsmall cell lung cancer has potent, adverse impact on survival. Ann Thorac Surg. 2003;76(4):1023-1028.
6. Ferguson MK, Lehman AG. Sleeve Lobectomy or Pneumonectomy: Optimal Management Strategy Using Decision Analysis Techniques. Ann Thorac Surg. 2003;76(6):1782-1788.
7. Stella F, Dell'Amore A, Caroli G, Dolci G, Cassanelli N, Luciano G, Davoli F, Bini A. Surgical results and long-term follow-up of T(4)-non-small cell lung cancer invading the left atrium or the intrapericardial base of the pulmonary veins. Interact Cardiovasc Thorac Surg. 2012 Apr;14(4):415-9.

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