A 59-year-old woman was admitted to our hospital with locally advanced lung adenocarcinoma. Chest computed tomography (CT) showed a tumor in the right upper lobe that had invaded the middle lobe and S6 segment, as well as hilar lymphadenopathy (#12u and #11 s) without mediastinal lymph node swelling (cT2aN1M0). An ESL procedure (right upper, middle lobectomies and S6 segmentectomy) that preserves the basal segment with a double-sleeve technique was considered in order to avoid a right pneumonectomy in this patient. Since successful ex situ auto-transplantation after a pneumonectomy for locally advanced lung cancer has been reported [5, 6], the Dokkyo Medical University Hospital Ethics Committee approved our protocol (#26030) for an operation including a back-table procedure and auto-lung transplantation after a pneumonectomy for locally advanced lung cancer to examine its merits. Such an auto-lung-transplantation protocol was performed in the present case for curative resection and basal-segment preservation. Consent to participate and to publish this study was obtained from the patient before surgery.
We initially performed a 5th intercostal posterolateral thoracotomy. After administration of intravenous heparin and prostaglandin E1, the pulmonary artery and vein were clamped, and the right pneumonectomy was completed. For a venous anastomosis between the lower pulmonary vein of the graft and upper pulmonary vein of the body, the pulmonary veins were dissected as distal as possible for the upper pulmonary vein and proximal as possible as for the lower pulmonary vein (Fig. 1). Following completion of the pneumonectomy, the excised lung was irrigated with a cold low-potassium phosphate-buffered dextran glucose solution (EP-TU solution; Cell Science & Technology Institute, Sendai, Japan) to protect the lung graft from ischemia-reperfusion injury during preparation of the graft of the basal segment as a back-table procedure. At the same time, another surgeon performed a mediastinal lymph node dissection to shorten the operation time. Thereafter, basal segment auto-transplantation was performed in the order of bronchus, pulmonary artery, and pulmonary vein anastomosis. Finally, the basal pulmonary vein of the graft was anastomosed to the upper pulmonary vein orifice. The operation time was 359 min and blood loss was 305 g.
The postoperative course was uneventful and no ischemia-reperfusion injury was observed, and the patient was discharged from the intensive care unit 1 day after the operation. The pathological diagnosis was pT2aN2M0 adenocarcinoma. Following surgery, the patient received adjuvant chemotherapy with carboplatin and nab-paclitaxel. At 9 months after the operation, she had returned to normal life without recurrence of the primary disease.
We have performed ESL for 37 patients with locally advanced non-small cell lung cancer at our hospital. Thirty-two of those were considered to have a good risk for undergoing a pneumonectomy, while the others had compromised cardio-pulmonary function. Thirteen underwent a basal-segment preserving ESL, for whom the operation time was 334 ± 75 min and blood loss was 445 ± 394 g. Operation time and blood loss for patients who underwent auto-transplantation preserving the basal segment were similar to those who underwent a usual ESL procedure preserving the basal segment (Fig. 2). Thus, our complicated protocol using auto-transplantation does not increase operation time or blood loss.