Carinal Resection and Extended Sleeve Lobectomy After Right Upper Sleeve Lobectomy: 1 Step Beyond

We describe the case of a 54-year-old man with a history of non–small cell lung cancer for which we performed a right upper sleeve lobectomy after chemotherapy. Pathologic examination reported a ypT1 N1 M0 R0 epidermoid carcinoma. Two years later, a local recurrence involving the tracheal carina and the previous anastomosis line was diagnosed. Carinal sleeve resection, including middle sleeve lobectomy extended to segment 6, replacement of the right pulmonary artery, and lower lobe reimplantation in the left main bronchus, was performed, achieving complete resection. Twelve months after the surgery, the patient is recurrence free. We describe the case of a 54-year-old man with a history of non–small cell lung cancer for which we performed a right upper sleeve lobectomy after chemotherapy. Pathologic examination reported a ypT1 N1 M0 R0 epidermoid carcinoma. Two years later, a local recurrence involving the tracheal carina and the previous anastomosis line was diagnosed. Carinal sleeve resection, including middle sleeve lobectomy extended to segment 6, replacement of the right pulmonary artery, and lower lobe reimplantation in the left main bronchus, was performed, achieving complete resection. Twelve months after the surgery, the patient is recurrence free. In centrally located non–small cell lung cancer (NSCLC), sparing of pulmonary parenchyma allows better respiratory function, higher access to adjuvant therapy, and additional contralateral surgical treatment. Local control of the disease has been proven to be equal between pneumonectomy and parenchymal preservation (PP) techniques.1Li Z. Chen W. Xia M. et al.Sleeve lobectomy compared with pneumonectomy for operable centrally located non–small cell lung cancer: a meta-analysis.Transl Lung Cancer Res. 2019; 8: 775-786Crossref PubMed Scopus (15) Google Scholar The most usual surgical option for ipsilateral recurrence after a previous lobectomy or sleeve lobectomy (SL) is completion pneumonectomy (CPN). However, CPN comes with a high morbidity and mortality. Nonsurgical treatment is often the preferred strategy. PP is in most cases not considered at all. As an alternative to CPN or nonsurgical treatment, we present a case of carinal resection with middle SL extended to segment 6, with pulmonary artery replacement by autologous pericardial conduit and segment 7 to 10 implantation, for a local recurrence after ipsilateral previous right upper SL. A 54-year-old man, formerly a heavy smoker, underwent a right upper SL for a ypT1 N1 M0 epidermoid carcinoma, achieving complete R0 resection after 3 cycles of vinorelbine-cisplatin. During oncologic follow-up 2 years later, a single local recurrence was detected (Figure 1) by positron emission tomography scan, confirmed by the pathologic examination of bronchoscopic biopsy specimens. Endoscopy showed a partial obstruction of the origin of the right main bronchus that extended to the previous anastomosis, occluding the middle lobe bronchus. The carina appeared to be involved. The positron emission tomography scan showed isolated central hypermetabolism in the right main bronchus without mediastinal node fixation or distant metastasis. A complete preoperative assessment was performed, allowing CPN. Posterolateral thoracotomy was repeated. On intraoperative examination, the tumor involved the right pulmonary artery, the tracheobronchial angle with the tracheal carina, and the residual part of the intermediate bronchus and extended to the middle lobe and segment 6 distally. Carinal resection was performed en bloc, including a right pulmonary artery segment, the previous anastomosis, the middle lobe, and segment 6. An intrapericardial approach was necessary. Multiple intraoperative frozen sections were analyzed until clear margins were obtained. A tracheal and left main bronchus end-to-end anastomoses was performed, with attention paid to the caliber. The bronchus cap of the lower lobe segments (7, 8, 9, and 10) was reimplanted into the left main bronchus (Figure 2). Finally, the use of an autologous pericardium conduit was necessary for the arterial reconstruction. Pathologic examination confirmed an epidermoid carcinoma, staged pT4 N0 M0, with complete resection. The postoperative course was uneventful. Twelve months after surgery, the patient is currently recurrence free (Figure 3). PP is becoming a critical spotlight for contemporary thoracic surgery. Numerous authors have shown the feasibility with equivalent results, if not better, of PP surgeries in oncologic thoracic diseases. At the level of peripheral NSCLC, the JCOG0802 study confirmed the benefits of segmentectomy vs lobectomy in selected cases.2Saji H. Okada M. Tsuboi M. et al.Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicenter, open-label, phase 3, randomized, controlled, non-inferiority trial.Lancet. 2022; 399: 1607-1617Abstract Full Text Full Text PDF PubMed Scopus (325) Google Scholar At the level of central NSCLC, SL became the “gold standard” when feasible, confirmed by a meta-analysis comparing SL and pneumonectomy, showing a 5-year overall survival of 25.77% vs 7.34%, respectively.1Li Z. Chen W. Xia M. et al.Sleeve lobectomy compared with pneumonectomy for operable centrally located non–small cell lung cancer: a meta-analysis.Transl Lung Cancer Res. 2019; 8: 775-786Crossref PubMed Scopus (15) Google Scholar In the case of ipsilateral local recurrence of NSCLC, the management remains debated. For many years, CPN and radiation therapy were the 2 main treatment modalities. After CPN, the overall 5-year survival rate reaches 33% and comes with a nonnegligible morbidity,3Miyahara N. Nii K. Benazzo A. et al.Completion pneumonectomy for second primary/primary lung cancer and local recurrence lung cancer.Ann Thorac Surg. 2022; 114: 1073-1083Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar whereas after radiation therapy, the overall 5-year survival rate is around 28%.4Wu A.J. Garay E. Foster A. et al.Definitive radiotherapy for local recurrence of NSCLC after surgery.Clin Lung Cancer. 2017; 18: e161-e168Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Although PP seems to be an appealing strategy overall, its application for ipsilateral local recurrence of NSCLC is suitable only at early stages. Currently, lobectomy completion in ipsilateral recurrence after primary segmentectomy is becoming a usual indication. In case of central recurrence initially treated by SL, the opportunity of surgical treatment is rarely considered. CPN is usually the only surgical management available, although it can be proposed only in selected cases: absence of distant metastasis, preoperative respiratory and cardiac clearance, radiologic quality of lung remnant, and perioperative technical feasibility and complete resection proved in the operating room. The historical series of Van Schil and coworkers5Van Schil P.E. Brutel de la Rivière A. Knaepen P.J. et al.Completion pneumonectomy after bronchial sleeve resection: incidence, indications, and results.Ann Thorac Surg. 1992; 53: 1042-1045Abstract Full Text PDF PubMed Scopus (27) Google Scholar reported the initial feasibility of CPN after SL, with an operative mortality rate of 15.8%. Similarly, another series of 165 CPNs performed for a benign or malignant tumor met a morbidity rate of 55.1%, with development of bronchopleural fistula in 7.9%.6Cardillo G. Galetta D. van Schil P. et al.Completion pneumonectomy: a multicentre international study on 165 patients.Eur J Cardiothorac Surg. 2012; 42: 405-409Crossref PubMed Scopus (22) Google Scholar Sleeve pneumonectomy represents a potentially promising surgical option, although it is rarely performed for primary lung cancer because of a morbidity rate ranging between 30% and 60%, including 14% of postoperative anastomotic complications, resulting in death in up to 50% of cases.7Eichhorn F. Storz K. Hoffmann H. Sleeve pneumonectomy for central non–small cell lung cancer: indications, complications, and survival.Ann Thorac Surg. 2013; 96: 253-258Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar However, 1 case referred to a completion sleeve pneumonectomy after bronchial sleeve resection.8Hanaoka J. Kawaguchi Y. Okamoto K. et al.Right sleeve pneumonectomy for local recurrent lung cancer following right sleeve upper lobectomy with bronchoplasty: a case report.J Cardiothorac Surg. 2020; 15: 130Crossref PubMed Scopus (0) Google Scholar With an aggressive policy toward PP, we have presented here a case report of an extended SL after sleeve lobectomy, saving 4 pulmonary segments. We insist on the importance of the perioperative management of ventilation. Surgeons and anesthesiologists need to be highly familiar with repetitive maneuvers of selective ventilation, in and out of the surgical field. In highly selected cases of central recurrence after previous major NSCLC resection, PP should be discussed in tertiary centers. This aggressive policy toward PP requires a high capacity for adaptation of the operating strategy in the operating room with perfect mastery of advanced bronchial and pulmonary artery reconstruction techniques. The authors have no funding sources to disclose.