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Acta chir belg, 2004, 104, 451-453

Introduction
Surgery is regarded as the optimal treatment for com-
plete resectable non-small cell lung cancer. When a
lobectomy is performed for a lung tumour that is also
invading the phrenic nerve (tumour classification T3),
hemidiaphragmatic paralysis due to nerve transection
could result in a further limitation of the post-operative
respiratory function.
On occasion, during the operation, surgeons are con-
fronted with a lung cancer on the left side invading the
phrenic nerve. At our institution an estimated 15 cases
have been reported in over 3000 lung resections for car-
cinoma. To date, no trials or studies have addressed the
problem of whether these cases are best dealt with by a
lobectomy or a pneumonectomy with regard to the post-
operative pulmonary function tests (PFT), exercise
capacity and health related quality of life.
Case report
A 58-year-old male was referred to the University
Hospital of Leuven, after an episode of acute bronchitis.
The patient, a clerk, had a smoking history of 10 pack-
years. The patients medical history did not reveal any
abnormalities and he did not take any medication. There
were however complaints of a non-productive cough and
decreased exercise tolerance. A chest x-ray showed a
pathological density in the left lungfield. Subsequent
blood chemistry revealed elevated inflammatory para-
meters, a CEA of 30 ng/ml (normal value : < 5 ng/ml )
and normal liver enzymes. The CT-scan showed a mass,
approximately 4 cm in diameter, located in the left hilus,
anterior to the bronchus of the anterior segment of the
left upper lobe. No enlarged nodes were observed. At
bronchoscopy no signs of endoluminal growth were pre-
sent. Bronchus aspiration for cytological examination
revealed no abnormalities.
Extensive technical screening did not show signs of
tumour spread or intrathoracic lymph node metastasis. A
ventilation-perfusion (V/Q) scan revealed a marked
asymmetric distribution of pulmonary perfusion (38%)
and ventilation (37%) in the left lung as compared to the
right side. Post-bronchodilator spirometry revealed an
obstructive flow pattern ; a forced expiratory volume in
1 second (FEV
1
) of 2.34 L (62% predicted volume (pv)),
a vital capacity (VC) of 4.58 L (95% pv) and a signifi-
cant decrease in lung diffusion (33%).
Based on the imaging techniques and the negative
pre-operative cervical mediastinoscopy, the clinical
tumour stage was defined as cT2N0. Surgical excision
was regarded as the optimal curative option.
During the subsequent operative procedure, a tumour,
fixed to the pericardium and invading the left phrenic
nerve, was revealed. Furthermore, both the left upper
and lower lobes showed clear signs of emphysema. The
frozen section of tumour tissue, taken around the
phrenic nerve, showed an adenocarcinoma.
As a complete tumour resection would also imply
sacrificing the phrenic nerve, with subsequent loss of
Surgical Options for Complete Resectable Lung Cancer
Invading the Phrenic Nerve
W. Willaert
1
., R. Kessler
2
, G. Deneffe
3
1
Department of Surgery, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, B-3000, Belgium ;
2
Department of Pneumology, St. Elisabeth Ziekenhuis, B-1180 Brussels, Belgium ;
3
Emeritus Professor of Thoracic
Surgery, Katholieke Universiteit Leuven, B-3000, Belgium.
Abstract. We describe a 58-year-old male diagnosed with a tumour of the left lung, which on subsequent thoracotomy
proved to be invading the phrenic nerve. The clinical and spirometric outcome of a lobectomy, which resulted in a post-
operative ipsilateral hemidiaphragmatic paralysis, versus the alternative surgical option of a pneumonectomy is dis-
cussed.
Key-words. Lung cancer, surgery ; phrenic nerve ; diaphragmatic paralysis ; pneumonectomy ; lobectomy.
Case reports
452 W. Willaert et al.
ipsilateral diaphragm function and possible impairment
of residual lung ventilation, a pneumonectomy of the
left lung was considered. However, because of the mod-
est pulmonary reserve demonstrated by spirometry, a
pneumonectomy was considered less favourable and
therefore an upper lobectomy with a partial pericardec-
tomy and transection of the phrenic nerve was per-
formed. The post-operative course was uneventful and
the patient was discharged in good clinical condition.
Pathological examination of the resection specimens
revealed a medium grade invasive adenocarcinoma with
a diameter of 6 cm; one hilar node and the pericardium
were invaded (pT3N1).
Adjuvant chemotherapy was administered. On regu-
lar follow-up the patients clinical condition remained
stable. Two years after the initial diagnosis the PFT
showed a decrease in lung function : an FEV
1
of 1.64 L
(44%pv), a VC of 3.74 L (78%pv) and a diffusion capac-
ity of 31%.
Two years later the CEA rose to 153 ng/ml. A solitary
metastasis in the right adrenal gland was diagnosed, for
which an adrenalectomy was performed. PFT showed an
FEV
1
of 1.11 L (30%pv), a VC of 2.93 L (62%pv), a dif-
fusion of 30%. An asymmetric V/Q distribution, with a
pulmonary perfusion of 26% and ventilation of 21% in
the left lung was noted. To date the patient is in good
clinical health.
Discussion
Surgical resection remains the appropriate treatment for
complete resectable bronchus carcinoma. The post-oper-
ative outcome is primarily determined by the extent of
resected lung parenchyma and by the concomitant
degree of chronic obstructive pulmonary disease.
Numerous trials have shown that pneumonectomies
are associated with an increased reduction of PFT and an
increased limitation of exercise capacity, as compared to
operations involving the resection of less lung parenchy-
ma (approximately 30% loss of PFT in pneumonec-
tomies vs. 15% with lobectomies) (1,2,3). However,
when a lobectomy implies transection of the phrenic
nerve, the subsequent ipsilateral hemidiaphragmatic
paralysis and loss of inspiratory muscle strength consti-
tutes a further limitation of the post-operative respirato-
ry function.
Despite an extensive literature search, no trials were
found that addressed the problem of whether lung can-
cer patients, who were pre-operatively considered as
candidates for a lobectomy, are indeed optimally aided
by this procedure rather than by a pneumonectomy, in
cases where the operative exploration reveals an involve-
ment of the phrenic nerve.
Phrenic nerve invasion due to bronchial carcinoma
constitutes the single most frequent identifiable cause of
unilateral diaphragm paralysis. However, phrenic nerve
invasion and hemidiaphragm paralysis is often only
determined in the operative phase. This is due to the lack
of a more specific clinical presentation and because of
the use of compensatory inspiratory muscles (4,5).
Lung function tests show a reduction of ventilation
and perfusion of the lower lobe on the affected side,
regional ventilation-perfusion mismatches and a reduc-
tion in VC (to 80%pv), total lung capacity, and forced
vital capacity (FVC) (4,5). Presumably the functional
residual capacity decreases as well. The decrease in lung
volumes associated with hemidiaphragm paralysis is
more significant when concomitant lung disease is pre-
sent
(5)
.
The pre-operative FEV
1
in the present case report
measured 2.34 L (62%pv). The predicted post-operative
FEV
1
, not taking into account any possible effect of the
diaphragm paralysis, was estimated as 1.85 L (FVC
followed a similar evolution). In comparison the
FEV
1
measured two years after the resection (1.64 L
(44% pv)) was relatively well maintained, taking into
consideration that the left upper lobe had been resected
and the left diaphragm was paralysed. In contrast, if a
pneumonectomy had been performed, the predicted
post-operative FEV
1
would only have amounted to
1.15L.
In the present case report a lobectomy seems to have
been the optimal operative procedure. In spite of tumour
invasion of the phrenic nerve, necessitating nerve
transection and subsequent loss of inspiratory diaphrag-
matic muscle strength, the pulmonary function, mea-
sured by spirometry and a ventilation-perfusion scan, is
relatively well preserved. Although the V/Q scan per-
formed 4 years after the initial diagnosis showed a larg-
er asymmetrical distribution compared to data taken
before the operation, no ventilation-perfusion mismatch
was seen. The preserved lung function is most probably
the result of compensatory inspiratory muscle use, a
more adequate expansion of the residual emphysematic
lobe and the larger residual lung volume compared to
that following a pneumonectomy.
With respect to the post-operative PFT, exercise
capacity and health related quality of life, further obser-
vations are necessary to confirm whether patients with
operable lung cancer and the diagnosis of phrenic nerve
invasion before or during the operative procedure,
should rather be treated with a complete lobectomy,
instead of a pneumectomy.
References
1. BOLLIGER C. T, JORDAN P., SOLER M., et al. Pulmonary function and
exercise after lung resection. Eur Respir J, 1996, 9 : 415-421.
2. NEZU K., KUSHIBE K., TOJO T., et al. Recovery and limitation of
exercise capacity after lung resection for lung cancer. Chest, 1998,
113 : 1511-16.
Surgical Options for Complete Resectable Lung Cancer 453
3. Hjalmarsen A., Aesebo U., Lie M. Pulmonary function 3-12
months after pneumonectomy, lobectomy or bilobectomy for lung
cancer. Scan J Thor Cardiovasc Surg, 1995, 29 : 71-74.
4. Gibson G. J. Diaphragmatic paresis : pathophysiology, clinical
features, and investigation. Thorax, 1989, 44 : 960-970.
5. LISBOA C., PARE P. D., PERTUZE J., et al. Inspiratory muscle func-
tion in unilateral diaphragmatic paralysis. Am Rev Respir Dis,
1986, 134 : 488-492.
Willem Willaert
Frankrijklei 90
B-2000 Antwerp
Belgium.
Tel. : 0032-3-2272428
Fax : 0032-3-2272428
E-mail : wimwillaert@hotmail.com

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