Preoperative Empyema From Non-small Cell Lung Cancer: Does Video-assisted Thoracoscopy Achieve Control Or Delay Treatment?
Joseph M. Arcidi1, Ray E. Peters, Jr.2, V. Anand Gottumukkala2.
1Michigan Center for Heart Valve Surgery, Flint, MI, USA, 2Poplar Bluff Regional Medical Center, Poplar Bluff, MO, USA.
OBJECTIVE: Preoperative empyema is rare in lung cancer patients, but has been described from tumor rupture after chemoradiotherapy. Thoracoscopic (VATS) drainage has been advocated for control of pleural space infection with definitive resection two or more weeks later. We recently managed a patient whose course questioned the utility of such an approach.
METHODS: This 66yo man with a >7cm Stage IIIA left lower lobe squamous cell carcinoma presented with fever, hypoxemia, leukocytosis, and a large pleural effusion containing an air-fluid level. He had not yet started chemoradiotherapy. After diagnostic thoracentesis, VATS was performed through a 1-inch port, with evacuation of a multiloculated fibrinopurulent empyema and aggressive decortication. The source of the empyema was a 2cm superior segment cavity filled with caseous purulent and necrotic debris, also evacuated (image, right) and biopsied. Three full-length channel drains provided complete pleural space drainage. Postoperative imaging showed markedly improved lower lobe expansion. Cultures grew pan-sensitive Strep. anginosus, but neither pleural fluid cytology nor cavity biopsies showed malignancy. The patient initially improved, but by day 4, fever, tachycardia, and leukocytosis worsened, despite dual intravenous antibiotics and chest tubes draining thin, nonturbid fluid. CT scan showed no residual pleural fluid collections. Lobectomy was planned to control sepsis. Through a complete muscle-sparing thoracotomy, extensive extrapleural VATS dissection was necessary to expose densely adherent upper and lower lobes. There was no undrained pleural space purulence. A well-vascularized intercostal muscle flap provided generous bronchial stump coverage.
RESULTS: Postoperatively, the patient was extubated promptly. Chest tubes were removed beginning day 3, with discharge to rehab on day 7 after a course complicated only by mild C. difficile colitis and atrial fibrillation.
CONCLUSIONS: In our patient, unlike other reports, lung cancer rupture producing empyema was not preceded by chemoradiotherapy. While VATS and adequate drainage limited pleural space contamination, it did not control the source of sepsis. Moreover, our patient’s favorable course after urgently performed lobectomy with bronchial coverage favors reconsideration of prolonged tube drainage before resection.
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