A 72-year-old man, who was a former smoker for 76 pack-years, presented with dry cough persisting for 2 months. Chest CT revealed a 5.8-cm tumor in the right lower lobe (S 6/7 segment) fused with the enlarged hilar lymph nodes and mediastinal #7 lymph nodes (Fig. 1a). The mediastinal #4 lymph nodes were also enlarged. The tumor extended into the left atrium via the right inferior pulmonary vein (Fig. 1b). The left atrium was compressed by the tumor, which showed poor margins, suggesting direct invasion of the left atrial wall (Fig. 1c). Transbronchial lung biopsy failed to obtain sufficient material to make a diagnosis because of the bleeding tendency of the tumor. Based on the chest CT along with a serum carcinoembryonic antigen value of 12.3 ng/mL, we made a clinical diagnosis of right lower lobe c-T4N2M0 stage IIIB NSCLC. CRT was administered (weekly carboplatin [AUC2] plus paclitaxel [40 mg/m2] with concurrent thoracic radiotherapy; daily dose, 2 Gy).
After five courses of the regimen with total irradiation of 48 Gy, the patient developed hemoptysis. Therefore, we had to discontinue CRT. Chest CT revealed a cavitated tumor (Fig. 1d), which likely caused the hemoptysis. The right inferior pulmonary vein remained obstructed by the tumor (Fig. 1e). However, tumor extension into the left atrium had regressed (Fig. 1f). Preoperative echocardiogram revealed that the tumor protruding into the left atrium had regressed and that the left atrial wall motion had improved compared with the results of the echocardiogram performed before CRT.
Hemoptysis was controlled by treating with tranexamic acid and antibiotics, and discontinuation of CRT and aspirin prescribed for post-coronary stenting status. However, we considered that the newly developed cavity might develop massive hemoptysis in the future. Based on those findings, we decided to surgically control the life-threatening hemoptysis and achieve radical resection. The patient complicated chemotherapy-induced neutropenia, thrombocytopenia, and radiation-induced dermatitis on his back where the surgical wound would be placed. Therefore, we waited for 3 weeks to go for surgery after the discontinuation of CRT.
Right thoracotomy revealed severe scar formation in the hilar region, and a shrunken tumor was palpated at the hilum beneath the bifurcation of the upper lobe bronchus. No direct tumor invasion into the intrapericardial space or left atrial wall was found through pericardiotomy. A tourniquet was positioned around the right main pulmonary artery to facilitate safer bleeding control. The origin of the right inferior pulmonary vein was surrounded by dense adhesion and scar tissue. We extended the pericardiotomy to the dorsal side to widely expose the left atrium and perform partial resection with an adequate safety margin (Fig. 2). This was performed using an automatic stapler (Signia™ Stapling System; Medtronic, Dublin, Ireland) with a tri-staple curved tip camel 60 cartridge (Endo GIA™ 60; Medtronic). Upon clamping the left atrium with the cartridge, no error message was displayed on the automatic stapling system, and no change in firing speed was observed. As pulmonary artery could not be exposed, it was transected with surrounding scar tissue beneath the apicoposterior branch under clamping the right main pulmonary artery and closed with running polypropylene suture. The bronchial wall was necrotized from the distal portion of the intermediate bronchus to the B6 segmental bronchus. The proximal intermediate bronchi were isolated and divided using the automatic stapler. However, the bronchial stump was close to the necrotized bronchus (Fig. 3) and was entirely included in the radiation field. The omental flap, which was well vascularized by the right gastro-omental artery, was transported into the right hemithorax through the diaphragm. The bronchial stump and pericardial defect were covered with the omental flap.
Pathological analysis revealed complete response to CRT with no viable cancer cells in the necrotized tumor and lymph nodes. The resected specimen showed fistula formation between the intermediate bronchus and necrotic cavity in the tumor. The existence of cancerous keratin pearl-like structures suggested squamous cell carcinoma.
The postoperative course was uneventful. The patient is alive without recurrence. A CT scan taken at 10 months post-surgery showed that both the bronchial stump and pericardial defect were tightly covered by the omental flap with sufficient volume and blood supply.