Stage IB squamous lung cancer: sleeve lobectomy complicated by pulmonary artery pseudoaneurysm

What happened, in summary

This 55-year-old man first presented with 6 months of refractory dry cough and bloody sputum. Chest CT showed a lesion in the left upper lobe with obstructive lobar pneumonitis, and bronchoscopy found a neoplasm in the left superior lobar bronchus with mucosal swelling extending toward the distal left main bronchus. Biopsy confirmed squamous cell carcinoma. After distant metastasis was excluded, he underwent open thoracotomy with sleeve lobectomy. Surgeons removed 3 rings of the distal left lower main bronchus and performed end-to-end bronchial reconstruction after confirming negative margins. Mediastinal lymph nodes from stations 4-9 were dissected. Because the remaining pulmonary artery became tortuous after the bronchial resection, the artery was shortened with a running suture. Final pathology showed pT2N0M0 Stage IB squamous cell carcinoma of the left upper lung. He initially recovered well and went home on postoperative day 9, but soon developed high fever, dark-yellow sputum, and hemoptysis. CT angiography later showed a 3.2 × 2.8 cm left pulmonary artery pseudoaneurysm surrounded by pleural effusion and infected lung tissue. Because rupture could be fatal, emergency completion pneumonectomy was performed. Pathology showed infected left lower lobe tissue and pulmonary pseudoaneurysm. Postoperative empyema required prolonged iodine pleural lavage and water-sealed chest tube drainage, eventually healing after 46 days. Cultures from infected pulmonary tissue grew Leuconostoc mesenteroides subspecies and Streptococcus mitis, organisms resistant to some antibiotics, which helps explain the difficult recovery. No chemotherapy was given after the lung operations. As of October 2013, he had normal quality of life and remained cancer-free 1 year after the first operation.