Two early-stage primary lung cancers and bronchopleural fistula closure with VV-ECMO support

What happened, in summary

A 57-year-old man was treated for heterochronic double primary lung cancers, meaning two separate lung cancers diagnosed at different times. In September 2018, a 27 × 25 mm solid nodule was found in the anterior basal segment of the left lower lobe. He underwent left lower lobectomy, and pathology showed moderately differentiated invasive adenocarcinoma without lymph-node metastasis, staged pT1cN0M0 / Stage IA3. In August 2021, another lung cancer was found: a 37 × 26 mm mass near the left upper lung hilum. Left upper lobectomy showed low-differentiated squamous cell carcinoma, again with no lymph-node metastasis, staged pT2aN0M0 / Stage IB. Twenty-two months after the second operation, he developed fever, cough, and tan fluid and purulent sputum for more than 1 month. CT and bronchoscopy showed a small, about 3 mm, bronchopleural fistula at the left bronchial stump, with pleural thickening, fluid pneumothorax, and right-sided pneumonia. Initial conservative treatment failed. After 2 weeks of closed drainage and anti-infective therapy with imipenem-cilastatin sodium, linezolid, and voriconazole, his fever, cough, sputum, and white blood cell count improved enough for surgery. Because only the right lung remained functional, the fistula was closed through a right-sided thoracoscopic approach with veno-venous extracorporeal membrane oxygenation support. The left main bronchus was stapled and reinforced. The operation lasted 136 minutes, with VV-ECMO support for 115 minutes. He was out of bed within 48 hours, discharged after 15 days, and had no visible bronchopleural fistula on 3-month CT. He had no postoperative complications except incision-site pain, and follow-up imaging showed closure of the residual left thoracic cavity.