64. Pneumonectomy

Question 1

A 67-year-old man is listed for a right pneumonectomy for carcinoma of the lung.

What histological types of bronchial carcinoma are there?

Answer 1

Squamous 35%

Small (oat) cell 25%

Adenocarcinoma 20%

Large cell 20%

Question 2

What are the symptoms and signs of bronchial carcinoma?

Answer 2

The commonest symptoms are
cough,
haemoptysis
dyspnoea,
followed by chest pain,
wheeze
weight loss.

Signs include
clubbing,
wheeze,
stridor
supraclavicular lymph nodes.

The signs of the complications of bronchial carcinoma
are varied and can be categorised into:

Question 3

The signs of the complications of bronchial carcinoma

Answer 3

Intra-thoracic

Pleural effusion
SVC obstruction
Recurrent laryngeal nerve palsy
Phrenic nerve palsy
Horner’s syndrome
Pericarditis, cardiac arrhythmias (especially AF)
Rib erosion

Non-metastatic
Ectopic hormone secretion, e.g. ADH/ACTH from oat cell tumours
Neuromuscular, e.g. mixed sensorimotor peripheral neuropathy, encephalopathy, proximal myopathy,

Eaton–Lambert (myasthenic) syndrome and polymyositis

Haematological, e.g. anaemia, polycythaemia, bleeding disorders

Weight loss

Hypertrophic pulmonary osteoarthropathy
Thrombophlebitis migrans

Metastatic Brain, bone, liver, adrenals, skin, kidney

Question 4

What are the risk factors for developing a bronchial carcinoma?

Answer 4

The biggest risk factor is cigarette smoking but others include:
Increasing age
Male > female
Asbestos exposure
Radiation

Question 5

What are the important considerations in your pre-operative
assessment?

Answer 5

There are now guidelines to aid the selection of patients with lung cancer for
surgery. These assess a patient’s fitness for surgery, based heavily on age,
pulmonary function and cardiovascular fitness. Risk is stratified into minor,
intermediate and major.

Age

Peri-operative morbidity for lung cancer surgery increases with age. Mortality
rates for pneumonectomy average 14% in the elderly (higher than in younger
patients), and therefore age should be a factor in assessing suitability for
pneumonectomy.

Question 6

Pulmonary function

Answer 6

1. If FEV1 > 2.0 l then no further respiratory function tests are required.
   (>1.5 lobectomy)
2. If FEV1 < 2.0 l then post-operative FEV1 and TLCO need to be estimated and
   compared to predicted values for normal patients.

Estimated post-operative FEV1 > 40% predicted
Estimated post-operative TLCO > 40% predicted
Saturation > 90% on air
=
average risk

Estimated post-operative FEV1 < 40% predicted
Estimated post-operative TLCO < 40% predicted
=
high risk

All others – exercise testing

High-risk patients need formal multi-disciplinary discussion and consideration
of alternative treatment.

Question 7

Cardiovascular fitness

Answer 7

There is little specific information relating to the cardiac risks of patients who
are undergoing pneumonectomy and most data surrounds the ‘non-cardiac
surgery’ group. Clinical predictors of increased peri-operative cardiovascular
risk include

Major
Recent MI
Grade 3 or 4 angina (Canadian Cardiovascular Society)
Decompensated CCF
Significant arrhythmias
Severe valvular disease

Intermediate
Grade 1 or 2 angina (CCS)
Prior MI
Compensated CCF
Diabetes mellitus

Minor
Advanced age
Abnormal ECG
Rhythm other than sinus
Low functional capacity
History of stroke