A tumor that grows into the main bronchus, crosses the fissure between lobes, or involves the main pulmonary artery leaves no healthy lobe to keep. Bulky lymph nodes at the root of the lung lead to the same answer.
Fitness for surgery
First question, always.
It is obvious that greater care was taken in selection among the older pneumonectomy patients.
Lung Cancer Study Group, 2,220 resections, 1983
The tests before surgery
Heart first, then lungs
The European Respiratory Society and the European Society of Thoracic Surgery set out the order of testing in a joint guideline. Heart risk comes first, then breathing tests, measuring the air you blow out in one second, FEV1, and how well the lungs pass oxygen into the blood, DLCO.
1
Heart assessment
ECG and echocardiogram, with a cardiology review when heart disease exists.
2
Breathing tests
Spirometry for FEV1 and a diffusion test for DLCO.
3
Perfusion scan
A lung scan showing how much blood flow, and so how much function, each lung carries.
4
Exercise test
A cardiopulmonary exercise test on a bicycle when the earlier results fall short.
Predicted values after surgery
Combining the breathing tests with the perfusion scan predicts your FEV1 and DLCO after the lung comes out. Values that stay well above a third of normal point to a safe operation. Low predicted values send you to the exercise test.
The exercise test
Peak oxygen uptake
The bicycle test measures the most oxygen your body can use, VO2max. In the ERS and ESTS guideline, a value above 20 ml/kg/min allows a pneumonectomy, and a value below 10 ml/kg/min carries a high risk with any major lung resection.
Staging the cancer
Lymph nodes in the middle of the chest
A PET-CT shows spread, and an EBUS biopsy through a bronchoscope or a mediastinoscopy samples the lymph nodes between the lungs. Cancer in these nodes, called N2 disease, changes the plan.
N2 disease
Chemotherapy or immunotherapy first
For N2 disease, our tumor board considers treatment before surgery to shrink the cancer, and avoids pneumonectomy after radiotherapy wherever another route exists, for the reasons the next section explains.
Age and risk
In the 2,220 resections of the Lung Cancer Study Group, 30-day mortality ran at 1.3 percent under 60, 4.1 percent between 60 and 69 and 7.1 percent at 70 or older. Age alone rules nobody out. It raises the bar the tests have to clear.
Mortality by operation
The mortality rate for pneumonectomy was 6.2% and for lobectomy, 2.9%.
Lung Cancer Study Group, 1983
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30-day mortality after lung cancer resection, 2,220 operations
| Group |
30-day mortality |
| Pneumonectomy |
6.2 percent |
| Lobectomy |
2.9 percent |
| Segment or wedge resection |
1.4 percent |
| Patients 70 or older, all operations |
7.1 percent |
Sleeve lobectomy can be done with a much lower risk of operative mortality than PN.
Laval University series of 1,230 patients, Annals of Thoracic Surgery, 2004
Risks, recovery and the stay in Istanbul
One lung, all the load. Complications after pneumonectomy hit harder than after a lobectomy, because nothing remains in reserve when the single remaining lung fills with fluid or infection, and the heart has to push its whole output through it.
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Main risks after pneumonectomy and how we manage them
| Risk |
What happens |
What we do |
| Bronchopleural fistula |
The closed bronchus stump leaks air into the empty space |
Stump covered with living tissue, bronchoscopy, repair |
| Empyema |
Infection of the fluid in the empty space |
Drainage and antibiotics |
| Atrial fibrillation |
An irregular heartbeat in the first week |
Heart monitoring and medication |
| Fluid on the remaining lung |
Breathlessness from waterlogged lung tissue |
Strict fluid limits during and after surgery |
Right side against left
A right pneumonectomy removes more lung and leaves a bronchus stump without the cover the left side gets from surrounding tissue, so fistula and fluid problems appear more on the right. We cover the stump with a flap of muscle or fat on the right as routine.
- Sudden cough with thin, salty or blood-stained fluid.
- Fever after the first week.
- Breathlessness at rest.
- A racing or irregular heartbeat.
Five to eight nights in hospital. Then two weeks in Istanbul, with walks every day and breathing exercises with our physiotherapists, who teach you to clear phlegm from the remaining lung, pace stairs and build up distance until a twenty-minute walk feels easy. Our surgeon confirms fitness to fly before you leave, with a check of oxygen levels at rest and on walking, since cabin air holds less oxygen. A companion can sleep in your room. Our coordinators speak English, Arabic, French, Russian, Serbian, Romanian and Spanish, and follow-up after you return home runs through them, with the pathology report and the plan for any chemotherapy sent to your oncologist. The cost depends on the operation, the stay and any treatment before surgery, and the estimate after the free review lists each.
Pneumonectomy in stage III lung cancer
The Intergroup 0139 trial randomized 396 patients with stage IIIA cancer in the central chest lymph nodes to chemotherapy with radiotherapy alone, or the same treatment followed by surgery.
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Intergroup 0139, chemoradiotherapy with or without surgery, 396 patients
| Outcome |
With surgery |
Without surgery |
| Median survival |
23.6 months |
22.2 months, no significant difference |
| Alive at five years |
27 percent |
20 percent |
| Treatment-related deaths |
8 percent |
2 percent |
Chemotherapy plus radiotherapy with or without resection (preferably lobectomy) are options for patients with stage IIIA(N2) non-small-cell lung cancer.
Intergroup 0139 trial, Lancet, 2009
Lobectomy helped, pneumonectomy did not
In an exploratory analysis, survival improved for patients whose surgery was a lobectomy, and not for those who needed a pneumonectomy. For stage III cancer after chemoradiotherapy, we plan pneumonectomy only in exceptional cases, and tell you why.
- A CT of the chest and a PET-CT under six weeks old.
- Spirometry and DLCO results.
- The biopsy report and any lymph node biopsy.
- A list of heart conditions and medicines.
Sleeve lobectomy against pneumonectomy
Deslauriers and colleagues in Quebec compared 184 sleeve lobectomies with 1,046 pneumonectomies, doing a sleeve whenever technically possible. Operative mortality, 1.6 against 5.3 percent. Five-year survival, 52 against 31 percent.
SL is more worthy to be done than PN in suitable patients with less mortality and better long-term survival.
Meta-analysis of 19 studies, World Journal of Surgical Oncology, 2012
The pooled evidence
Shi and colleagues pooled 19 studies of 3,878 patients. Sleeve lobectomy halved the odds of death after surgery and cut the risk of death over the following years by more than a third. Patients having a pneumonectomy carry bigger tumors, so part of the gap reflects the cancer, and both studies say so.
Pneumonectomy FAQ
Can you live a normal life with one lung?
Yes, for patients who pass the breathing and exercise tests. Heavy exertion brings breathlessness sooner.
Why not just remove the tumor and keep the lung?
When the tumor grows into the main bronchus or artery, or crosses between lobes, no lobe stays free of cancer. A sleeve lobectomy keeps lung tissue whenever it can clear the tumor.
How dangerous is a pneumonectomy?
In the Lung Cancer Study Group, 6.2 percent of patients died within 30 days, twice the rate after lobectomy. Careful testing and selection lower the risk.
Can a pneumonectomy be done by keyhole surgery?
In selected patients. Most pneumonectomies for central tumors need an open approach for safe control of the main vessels.
How long until I can fly home?
Two to three weeks after surgery, once an oxygen check at rest and on walking shows the remaining lung copes with cabin air.
References
- Ginsberg RJ, Hill LD, Eagan RT, et al. Modern thirty-day operative mortality for surgical resections in lung cancer. Journal of Thoracic and Cardiovascular Surgery. 1983;86(5):654-658.
- Brunelli A, Charloux A, Bolliger CT, et al. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). European Respiratory Journal. 2009;34(1):17-41.
- Deslauriers J, Gregoire J, Jacques LF, et al. Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites or recurrences. Annals of Thoracic Surgery. 2004;77(4):1152-1156.
- Shi W, Zhang W, Sun H, Shao Y. Sleeve lobectomy versus pneumonectomy for non-small cell lung cancer: a meta-analysis. World Journal of Surgical Oncology. 2012;10:265.
- Albain KS, Swann RS, Rusch VW, et al. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial. Lancet. 2009;374(9687):379-386.
