A pneumonectomy is the surgical removal (-ectomy) of a lung (pneumo-). Pneumonectomy is considered an aggressive treatment for mesothelioma. Proper patient selection is critical in determining the success of the pneumonectomy. In other words, not every patient with mesothelioma is a candidate for pneumonectomy. Generally speaking, doctors do not recommend this procedure for patients with cancer that has spread to other parts of the body, or if the other lung does not function properly.
Since malignant mesothelioma tends to invade structures surrounding the lung itself, the lung and surrounding tissues may be removed in a related, but more extensive procedure called an extrapleural pneumonectomy. In an extrapleural pneumonectomy, the thin covering of the lung (visceral pleura) and on the inside the chest wall (parietal pleura) are also removed. When the tumor has spread farther within the chest cavity, the pericardium (sac around the heart) and part of the lung diaphragm may be removed as well. In both procedures, patients are left with a single lung.
The Pneumonectomy Procedure
A pneumonectomy is performed under general anesthesia, but since the surgery involves the lungs, the typical anesthetic gases may not be used. Instead, patients receive anesthesia through an epidural catheter (tube) placed in the spinal area. Blood pressure, cardiac function, and oxygen in the blood are monitored throughout the surgery through various devices.
The surgery is performed through an incision in the chest, or a thoracotomy, over the affected lung. In some cases, all or part of a rib is removed to increase visibility and access. The diseased lung is then collapsed, and attached blood vessels and the bronchitis are cut and tied off. The lung is then removed through the incision site, and the cavity is carefully examined and drained with tubes prior to closing the incision.
Once the surgery is completed, patients are moved to the post-anesthesia care unit (PACU) for several hours and then moved to the intensive care unit (ICU). Pneumonectomy patients are placed on a ventilator for the initial part of their recovery, which is the reason an ICU stay is required. Drainage tubes also remain in place to remove any excess fluid.
During this time, patients receive medications to relieve pain and prevent blood clots and infections. In some instances, pneumonectomy patients wear intermittent compression stockings for blood clot control rather than take anticoagulant drugs.
As you can imagine, removing an entire lung makes a profound difference in the anatomy of the chest. The space that remains in the chest cavity will initially fill with air, which is normal. Over 24 hours, fluid begins to replace air and by three days after the procedure, the chest cavity is 70% fluid/30% air. By two weeks, 80 to 90% of the cavity is fluid-filled, and it takes about 4 months for the entire area to fill with fluid.
Once the patient can breathe without a ventilator, he or she is moved out of the ICU to a monitored hospital room. The patient will likely undergo one or more forms of physical therapy with the goal of walking around, regaining strength, and maximizing function in the remaining lung. Patients can expect to be in the hospital for up to two weeks after the pneumonectomy procedure. Full recovery from pneumonectomy, however, may take several months.
Complications and Risks
Prognosis following surgery depends on a variety of factors. Roughly 60% of patients experience shortness of breath for up to 6 months after surgery. While adverse reactions to medication, bleeding, and infection are risks of most surgeries, pneumonectomy complications also include:
- Pulmonary edema – Watery fluid accumulates around the healthy lung. Steroids administered during surgery may reduce this risk.
- Empyema – Pus accumulates around the healthy lung. Empyema occurs in about 5% of cases.
- Chylothorax – Lymphatic fluid accumulates within the chest cavity. Chylothorax occurs in less than 1% of patients who have pneumonectomy.
- Pneumothorax – While it is common for air to accumulate in the space left by the removed lung, air trapped between the chest cavity the healthy lung can be a serious complication.
- Hemothorax – Blood accumulates in the chest cavity left by the removed lung.
- Bronchopleural fistula – An abnormal connection is formed between the bronchus and the pleura. A bronchopleural fistula occurs in 1.5 to 4.5% of pneumonectomy cases.
- Cardiac arrhythmias – Abnormal heart rhythms occur in one out of five patients undergoing pneumonectomy. Atrial fibrillation is the most common cardiac arrhythmia and the least serious.
- Myocardial infarction – A myocardial infarction or heart attack occurs after pneumonectomy 1.5 to 5% of the time.
- Embolism – An embolism is a foreign substance traveling through the bloodstream. After pneumonectomy, embolism may be caused by a blood clot, air, or a bit of the tumor itself.
- Postpneumonectomy scoliosis – An abnormal curvature of the spine that occurs after pneumonectomy.
- Postpneumonectomy syndrome – The bronchus and trachea become compressed because the healthy lung and surrounding tissues press into the postpneumonectomy space. Postpneumonectomy syndrome causes progressive shortness of breath, cough, stridor during inspiration, and recurrent pneumonia.
In spite of risks and potential complication, a successful pneumonectomy may significantly improve a patient’s quality of life by reducing symptoms. In carefully-selected patients with malignant mesothelioma, pneumonectomy can modestly extend life. In the United States, the immediate rate of survival for a pneumonectomy of the left lung is approximately 97%, and 89% for the right lung.
Survival is further increased if the pneumonectomy surgery is combined with chemotherapy and radiation therapy at the proper time. It is important to note that long-term survival benefits that come from reducing tumor burden through pneumonectomy may be diminished by short-term surgical complications. Therefore, to achieve the maximum possible benefit from pneumonectomy, the first 30 days after the procedure are critical and require close medical observation and care.
Is a Pneumonectomy Right For You?
To be considered for a pneumonectomy, patients must go through a number of tests and studies. The cancer must be limited to one side of the chest (i.e., hemithorax), which may be determined by lung CT, MRI, and/or positron emission tomography (PET) scans. Mesothelioma patients are not considered a candidate for pneumonectomy if the cancer extends below the diaphragm, into the ribs, or across to the opposite side of the chest.
The patient must be healthy enough to undergo major surgery, which means that heart and lung function must be reasonably good. American and British medical authorities agree that prospective pneumonectomy patients should have sufficient function in the healthy lung, which may be evaluated by pulmonary function testing. At a minimum, patients undergo spirometry and diffusing capacity for carbon monoxide (DLCO) tests, which can predict morbidity (risk of complications) and mortality (risk of death). When cardiovascular health may be an issue, prospective patients may undergo integrated cardiopulmonary exercise testing. Talk with your doctor to find out if this option is right for you.