We report the case of a 54-year-old white man who presented to his primary care physician with a chief complaint of cough, fever, and hemoptysis of two weeks duration. He denied associated weight loss or chest pain, but did experience dyspnea with mild exertion. A forty pack/year history of smoking was noted, the patient having quit tobacco use for the past five years, along with no reported exposure to tuberculosis. Initial chest radiograph showed a right upper lobe infiltrate. After intermittent oral antibiotics for six weeks and no resolution of his symptoms a repeat chest radiograph (Figure 1) demonstrated progression of his infiltrate to lobar atelectasis.
Further evaluation with computed tomography of the chest (Figure 2) showed an irregular mass obstructing the right upper lobe bronchus and dense consolidation of the lobe immediately adjacent to the posterior thorax and pericardium. Pulmonary function tests yielded an FEV1 of 2.1 L (74% predicted) and a room air PaO2 of 81 Torr. Fiberoptic bronchoscopy and biopsy allowed visualization of a focal carcinoma in situ with areas of microinvasion and severe dysplasia in the right upper lobe and bronchus intermedius.
After placement of a thoracic epidural catheter for postoperative analgesia, and a double lumen endotracheal tube for selective lung ventilation, a standard posterolateral thoracotomy was performed through the fourth interspace. Dense pleural adhesions with a semi-fixed, noncompressible right upper and middle lobe were encountered on entry to the thorax. After initial lysis of adhesions broad fibrous bands tethered the atelectatic upper lobe to the subclavian vessels, azygous vein, and esophagus. Inability to retract the upper lobe precluded visualization of these structures which were not amenable to simple blunt dissection. Introduction of a 30-degree thoracoscope and use of laparoscopic electrosurgical and scissor dissection allowed continued progress. Multiple biopsies of fibrous tissue encountered and adjacent pleura were sent for frozen section to insure the absence of malignant cells and hence, resectability of the tumor.
Having completed division of the adhesions from the upper lobe, the thoracoscope was employed to assist in dissection of the pulmonary artery and superior pulmonary vein. The resection was completed with stapling of the right mainstem bronchus and individual pulmonary vessels. The bronchial margin was free of tumor. A moderately differentiated, deeply infiltrating squamous cell carcinoma of the right upper and middle lobe bronchi was found on pathological examination. (Figure 3) Station 2, 4, 7, and 9 nodes were free of tumor.