When to Consider a Pneumonectomy
The decision to perform a pneumonectomy, rather than a lesser form of lung resection, is based on the location of tumors in the lung and on the degree of invasion of mediastinal lymph nodes (located within the chest cavity between the lungs).
A 10-year study of 193 pneumonectomies performed in Switzerland between 1990 and 2000 found that squamous cell carcinoma was the most common histologic type of cancer for which the procedure was implemented (69%), followed by adenocarcinoma (22%).
In spite of improvements in operative techniques and postoperative care, this surgery still presents higher mortality and morbidity rates than lesser resection surgeries such as a lobectomy. In fact, in one study comprising 433 patients, the mortality after pneumonectomy was almost twice that of a lobectomy (9.4% vs. 5%). Therefore, surgeons must balance the operative risks of the procedure against the hoped-for benefits in terms of increased survival time and quality of life.
Doctors will generally not recommend this surgery in cases where a patient’s cancer has already spread to other parts of the body or if the remaining lung is not in good working condition. In addition, candidates must be in relatively good health with strong heart function.
In some difficult surgeries, doctors must convert from a pleurectomy with decortication to extrapleural pneumonectomy. In a 2021 study, researchers concluded this was the case in about 10% of surgeries and resulted in a lower median overall survival of about 29 months, compared to 57 months for pleurectomy with decortication.
Surgical Consultation for Pneumonectomy
A surgical consultation is an important step toward a pneumonectomy. Potential candidates for the procedure meet with the surgeon and surgical team for a consultation so the team can review the patient’s medical records and the patient can learn more about the surgery.
Thoroughly reviewing past and current medical records allows the team to determine if the patient is qualified for the procedure. The consultation gives patients the opportunity to ask questions about the procedure and bring up concerns that should be addressed. These consultations may happen in person or virtually through video conferencing.
The Procedure and Recovery
This surgery is performed under general anesthesia. The surgeon begins the operation by performing a thoracotomy, which is a long incision on the same side of the chest as the diseased lung.
Sometimes all or part of a rib will be removed to get a better view and help facilitate surgery. The affected lung will then be collapsed, and any attached blood vessels will be stapled across and divided or clamped, cut, and tied off, along with the bronchus — the main tube flowing air into the lung.
The diseased organ can then be removed through the incision. The cut tubes and vessels are thoroughly inspected to ensure nothing is leaking, and a temporary drainage tube is inserted to draw air, fluid and blood out of the surgical cavity before the chest incision is closed.
Rarely, patients will need to breathe with the assistance of a respirator for one to two days after the operation, and the drainage tubes will remain in place to monitor for bleeding and air leakage. They may be fed and medicated intravenously before being transferred from intensive care to a regular hospital room.
Care during a normal one-week hospitalization focuses on:
- Relieving pain
- Monitoring blood oxygen levels
- Encouraging a patient to cough up accumulated lung secretions
- Helping the patient walk to prevent the formation of blood clots
Full recovery may take as long as two or three months.
A pneumonectomy is part of a common mesothelioma surgery known as an extrapleural pneumonectomy (EPP), where the affected lung is removed along with parts of the lining of the lung (pleura), heart lining (pericardium), diaphragm and nearby lymph nodes.
The goal of this procedure is to remove as much cancerous tissue as possible from the chest cavity. This slows the cancer’s progression and improves breathing and quality of life.
Although an EPP is considered a more radical approach than other treatments, the procedure can increase a patient’s survival by months or even years. EPP is only available to a select group of pleural mesothelioma patients who are in relatively good health and whose cancer is confined to one chest cavity.
Risks of Lung Removal
The prognosis following a pneumonectomy depends on many factors, including the lung to be removed, the type and stage of a patient’s cancer, and the patient’s gender, age and health.
Approximately 6% of patients struggle with shortness of breath for up to six months following surgery, as the remaining lung gradually takes on the work of two lungs. The risks for any surgical procedure include adverse reactions to medication, bleeding and infection.
Risks for pneumonectomy patients include:
- Prolonged need for a respirator
- Heart problems such as cardiac arrhythmia (abnormal heart rhythm) and myocardial infarction (heart attack)
- Pulmonary edema (fluid accumulation in the lung)
- A pulmonary embolism (blood clot) in the remaining lung
- Post-pneumonectomy empyema (infection of the pleural cavity and accumulation of pus in the pleural space)
- Kidney or other organ failure
- Bronchopleural fistula (an abnormal fusion of the stump of the cut bronchus and the pleural space)
- Post-pneumonectomy syndrome (other organs in the chest moving into the space left by the surgery)
Despite the risks, a successful pneumonectomy (or extrapleural pneumonectomy) can greatly improve the quality of life for mesothelioma patients by reducing the debilitating symptoms of their disease, while adding several months — and sometimes years — to their lives.
In the U.S., the immediate survival rate for left lung removal is between 96 and 98 percent, and for right lung removal, between 88% and 90% (because of greater risk of complications involving the stump of the cut bronchus).
According to a three-year, multicenter study, pleural mesothelioma patients who underwent EPP had a survival rate of 89.5% survival rate (10.5% mortality rate) within 30 days of surgery.