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Ann Thorac Surg 1996;61:174-176
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Unsuspected Lung Cancer Found in Work-up for Lung Reduction Operation

Section of Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Accepted for publication August 22, 1995.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. Lung reduction surgery is gaining acceptance in the treatment of patients suffering from severe diffuse emphysema. At the University of Pittsburgh 210 patients have been evaluated and 128 patients have undergone lung reduction operations.

Methods. Ten patients, representing 7.8% of the operated group, have had asymptomatic cancerous or neoplastic lesions diagnosed on preoperative evaluation or pathologic analysis of resected tissue.

Results. Six primary lung cancers (three squamous, three adenocarcinoma) and four other neoplastic lesions (squamous dysplasia, chemodectoma, and two carcinoid tumorlets) have been identified. All patients were heavy smokers, and all had markedly impaired pulmonary function. Patients whose lesions were identified on preoperative testing underwent thoracoscopic wedge excision of the tumor alone.

Conclusions. Our experience suggests that patients with impaired pulmonary function (chronic obstructive pulmonary disease) presenting for lung reduction operations are at a high risk of harboring an unsuspected neoplastic lesion. Complete preoperative evaluation of radiographic studies and preoperative bronchoscopic examination are mandatory.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Lung reduction surgery is a recent development in the treatment of patients suffering from severe diffuse emphysema [1, 2]. Primary lung neoplasms, previously unsuspected, were identified in a number of prospective candidates only because they were being evaluated for the lung reduction procedure. This report identifies a significant risk of underlying lung pathology in these patients and stresses the importance of complete preoperative evaluation of radiographic and endobronchial anatomy before operative intervention.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
At our center, 210 prospective surgical candidates have undergone extensive physiologic screening for lung reduction operations. Patients undergo a rigorous preoperative assessment as part of an investigational database approved by our Institutional Review Board for Biomedical Research. This includes physical examination, chest roentgenogram, chest computed tomography, echocardiography, pulmonary function and arterial blood gases, ventilation scan with tomographic (single-photon emission computed tomography) perfusion scan, and exercise testing. In the operating room complete fiberoptic bronchoscopic examination of the airway is performed preoperatively.

Patients whose lesion was identified on preoperative testing underwent video-assisted thoracoscopic wedge excision as detailed previously [3]. All other patients underwent lung reduction operation as detailed elsewhere [1] and summarized below. The side chosen for lung reduction was determined by the computed tomographic and single-photon emission computed tomographic scan findings of hyperinflation and reduced parenchymal perfusion. Strips of lung tissue were excised using endoscopic staplers to resect the areas of worst disease. The majority of operations were unilateral thoracoscopic procedures; however, bilateral lung reduction through median sternotomy or sequential bilateral thoracoscopy under the same anesthetic were performed in a minority of patients.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Ten patients harbored previously unsuspected neoplastic lesions that were discovered as a result of their workup for, or the performance of, lung reduction operation. This group represented 4.8% of the 210 patients who were evaluated for the procedure and 7.8% of the 128 patients who underwent operations. Among these 10 patients, there were 6 women and 4 men, with an average age of 67 years. All patients were heavy cigarette smokers, averaging 72 pack/years at the time of evaluation, although none admitted concurrent smoking. Pulmonary function testing demonstrated severe impairment with an average forced expiratory volume in 1 second of 25% of predicted, a forced vital capacity of 27% of predicted, and a diffusing capacity of 30% of predicted. Six of these 10 patients were found to have primary lung cancers (3 squamous, 3 adenocarcinoma), whereas 4 patients were diagnosed with assorted other neoplastic lesions.

Four of the six primary lung carcinomas were suspected on the basis of preoperative radiographic evaluation (Fig 1), but due to severe pulmonary impairment, anatomic resection was not considered an option, and wedge excisions were performed. Lung reduction procedures were not carried out on these individuals. One tumor, a microscopic focus of invasive adenocarcinoma, was identified on routine pathologic examination of one of the resected tissue strips after lung reduction operation. One patient was found, at the time of preoperative bronchoscopy, to have a squamous cell cancer arising in the orifice of the right upper lobe bronchus. This tumor was not amenable to resection, and the patient underwent endobronchial photodynamic therapy.

View larger version (108K): [in this window] [in a new window]   Fig 1. . Asymptomatic spiculated mass in right upper lobe identified on preoperative computed tomographic scan of chest for evaluation of diffuse emphysema. Lesion was excised by thoracoscopic wedge resection and proved to be an adenocarcinoma.

The remainder of the lesions (1 chemodectoma, 1 squamous dysplasia, and 2 carcinoid tumorlets) were unsuspected at the time of lung reduction operation and found on routine pathologic examination of the resected tissue. All margins were negative.

All 10 patients were discharged from the hospital with close follow-up as dictated by our clinical protocol.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Laser staple bullectomy, or lung reduction operation, is a recent development in the treatment of patients with end-stage chronic obstructive pulmonary disease that may offer hope of remission [1, 2]. This report suggests a significant risk of underlying malignant lung pathology, and stresses the importance of complete preoperative evaluation of radiographic and endobronchial anatomy before operative intervention.

Four of the six primary lung cancers were suspected on the basis of preoperative computed tomographic scan, and a fifth was diagnosed by endobronchial examination and biopsy before the procedure. Only one lesion, an adenocarcinoma, was completely unsuspected after the preoperative evaluations. The four additional neoplasms were very small (2 to 5 mm) and only diagnosed on microscopic examination. Although the clinical significance of these lesions may be debated, squamous dysplasia is clearly a premalignant lesion, and there are reports of carcinoid tumorlets metastizing to mediastinal nodes and beyond [4–6].

All patients in this series were former heavy cigarette smokers. Although tobacco use is clearly a risk factor for the development of lung cancer, this report dramatically illustrates the relationship between cigarette smoking, objective functional impairment, and coincident pulmonary neoplasia. The association between tobacco smoke and the development of chronic obstructive pulmonary disease and lung cancer has been long established [7–9]. The risk of lung cancer for smokers is 10 times that of nonsmokers [10].

Although carcinogenesis is clearly multifactorial, our experience would seem to suggest that the patient population presenting for lung reduction operation constitutes a particularly high risk group. These findings are gaining new relevance as the surgical treatment of severe chronic obstructive pulmonary disease expands. It is precisely these patients who are increasingly referred for lung reduction operation. Patients with severe impairment of cardiopulmonary physiology are not candidates for lobectomy. Limited resection for these patients is a viable alternative with a higher risk of local recurrence but an equivalent 5-year survival compared with patients undergoing lobectomy [11]. In general, local recurrence in these debilitated patients would be best treated with radiation therapy.

As more of these patients become surgical candidates, the recognition of associated pathology is crucial. The importance of vigilant evaluation of preoperative studies, preoperative bronchoscopy, and the maintenance of a high index of suspicion for underlying pathology cannot be overestimated.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Keenan, Section of Thoracic Surgery, University of Pittsburgh Medical Center, Suite 300, 3471 Fifth Ave., Pittsburgh, PA 15213.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

1. Wakabayashi A, Brenner M, Kayaleh RA, et al. Thoracoscopic carbon dioxide laser treatment of bullous emphysema. Lancet 1991;337:881–3.[Medline]
2. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumonectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109: 106–19.[Abstract/Free Full Text]
3. Landreneau RJ, Hazelrigg SR, Dowling R, et al. Thoracoscopic resection of 85 peripheral pulmonary lesions. Ann Thorac Surg 1992;54:415–20.[Abstract]
4. Saccomanno G, Archer VE, Auerbach O, et al. Development of carcinoma of the lung as reflected in exfoliated cells. Cancer 1974;33:256–70.[Medline]
5. Churg A, Warnock ML. Pulmonary tumorlet: a form of peripheral carcinoid. Cancer 1976;37:1469–77.[Medline]
6. Carter D, Eggleston JC. Tumorlet type bronchial carcinoid tumors. In: Hartmann WH, ed. Tumors of the lower respiratory tract. Atlas of tumor pathology. Bethesda, MD: Armed Forces Institute of Pathology, 1980:181-8.
7. Vial WC. Southwestern Internal Medicine Conference: cigarette smoking and lung disease. Am J Med Sci 1986;291:130–2.[Medline]
8. Samet JM. The epidemiology of lung cancer. Chest 1993;103:20s–9s.[Medline]
9. US Department of Health and Human Services. The health consequences of smoking: cancer. A report of the Surgeon General. Washington, DC: US Government Printing Office, 1982:DHHS publication (PHS) 82-50179.
10. Hammond EC, Horn D. Smoking and death rates: report on forty-four months of follow up of 187,783 men: part 1. Total mortality, part 2. Death rates by cause. JAMA 1958;166:1159–72, 1294–308.
11. Ginsberg RJ, Rubenstein L. The comparison of limited resection to lobectomy for T1N0 non-small cell lung cancer. Chest 1994;106(Suppl):318S–9S.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Frank A. Pigula Robert J. Keenan Peter F. Ferson Rodney J. Landreneau Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pigula, F. A. Articles by Landreneau, R. J. Search for Related Content PubMed PubMed Citation Articles by Pigula, F. A. Articles by Landreneau, R. J.