Lung Cancer Surgery in the Early Phase After Acute COVID-19 Pneumonitis.

A 65-year-old woman was diagnosed with early-stage lung cancer in 2020 and scheduled for robotic assisted-left upper lobectomy. Unfortunately, the patient contracted symptomatic COVID-19, resulting in postponement of lung resection. She was admitted for surgery 6 weeks after the acute infection. A preoperative computed tomographic scan showed widespread interstitial pneumonitis. However, the operation went ahead given concerns over tumor progression, albeit with a lesser resection to preserve lung tissue because the patient was slightly hypoxic. Her postoperative recovery was uneventful, and she was discharged 5 days later. Final histology confirmed a fully resected stage T1c N0 M0 adenocarcinoma of the lung.

Since, the arrival of COVID-19 in the United Kingdom, more than 4.3 million cases have been identified. This has mounted extreme pressure on the National Health Service and has led to severe bed shortages and cancelled elective operations. As of today, 10 million people are awaiting surgical procedures in the United Kingdom, an increase from 4 million before the pandemic. Waiting times for elective operations are now at their highest, with the focus now on restoring services to prepandemic levels. Currently, there are no guidelines regarding the timing of thoracic operations after an acute COVID-19 infection in the United Kingdom. As the number of post-COVID-19 patients requiring thoracic operations increases, guidelines outlining recommended time frames for surgical intervention after infection will become more crucial. We present a case of a successful pulmonary left upper division segmentectomy 6 weeks after acute COVID-19 infection in a 65-year-old woman.

The case patient presented to her general practitioner with a 3-week history of a persistent cough. The patient was a recent former smoker. A chest roentgenogram ordered by the general practitioner identified an abnormality in the left upper zone (Figure 1 ). Upon referral to the thoracic surgical unit, a computed tomographic scan and a positron emission tomography scan showed a 2-cm fludeoxyglucose-avid lesion in the left upper lobe (Figure 2 ). The standardized uptake value of the lesion was 14. Given the early staging of the tumor, the patient was scheduled for a left robotic-assisted upper lobectomy to take place in January 2021. Spirometry showed her forced expiratory volume in 1 second was 1.6 L (75% of predicted), forced vital capacity was 2.2 liters, (87% predicted), and transfer factor was 5.5 mmol/min/kPa (77% of predicted).

Figure 1

Chest roentgenogram shows a left upper zone nodule.

Figure 2

Computed tomographic scan of the thorax shows (A) lung left upper lobe lung nodule and (B) normal parenchymal appearances of the lung.

Unfortunately, the patient contracted symptomatic COVID-19 (confirmed on preoperative polymerase chain reaction testing) before admission, and therefore, her operation was postponed. She had not yet been vaccinated. Thankfully, admission to hospital was not required, and the patient was managed in the community, albeit with significant shortness of breath. Several weeks after the acute COVID-19 infection, the patient was still breathless; however, she mentioned that this had been improving. She was provisionally rescheduled for surgical resection 6 weeks after the positive COVID-19 test result for February 2021.

Upon admission, a repeat computed tomographic scan revealed slight enlargement of the upper lobe nodule, with widespread COVID pneumonitis despite resolution of the patient’s breathlessness (Figure 3 ). The patient was saturating at 91% on air with no respiratory compromise. Repeat COVID-19 polymerase chain reaction result was negative. Lung function tests were not repeated preoperatively.

Figure 3

A repeat computed tomographic scan of the chest at 6 weeks after acute COVID-19 infection shows (A) left upper lobe nodule and (B) widespread pneumonitis.

On balancing the risk of operating on a patient with residual COVID pneumonitis against the risk of disease progression, the decision was made to proceed with surgical resection. A lesser lung resection was undertaken, with a robotic-assisted left upper division segmentectomy being preferred to lobectomy to preserve lingula parenchyma. Final histology confirmed a fully resected stage T1c N0 M0 adenocarcinoma of the lung.

Postoperatively, the patient received aggressive physiotherapy and high-flow nasal oxygen to aid with sputum expectoration. A chest drain was removed on day 2 after the operation. A hospital-acquired pneumonia later developed, and the patient was commenced on intravenous co-amoxiclav (amoxicillin/clavulanic acid). Her inflammatory markers continued to improve, and she was discharged on oral antibiotics on day 5 after her operation. She continues to make an excellent postoperative recovery at home, with no further complications.

Comment

With the COVID-19 pandemic continuing, it is inevitable that a greater number of post–COVID-19 patients will require surgical intervention. Additionally, COVID-19 infection can lead to pulmonary complications that require thoracic intervention, thus further increasing surgical demand during this pandemic. As it currently stands, there are no official guidelines that describe the optimum timing of elective cancer surgery after symptomatic COVID-19 infection. Instead, research up to now suggests that surgical procedures should be delayed arbitrarily or replaced with nonsurgical management, but as restrictions on elective surgery are lifted, assessing post–COVID-19 patients’ suitability for surgery will become more commonplace.

Non-small cell lung cancer (NSCLC) remains, by far, the biggest cause of cancer deaths globally. Surgery is the most efficacious treatment, with excellent outcomes, particularly in patients with stage I disease. Patients undergoing lung resection for NSCLC routinely undergo lung function testing to assess for fitness, tailor the extent of lung resection, and stratify risk of postoperative complications, breathlessness, and death.

COVID pneumonitis causes significant acute and often long-term hypoxia, breathlessness, and lung scarring. A fine balance must be made between offering lung-sparing surgery while maintaining adequate tumor clearance using anatomical lung resection, which is the gold standard surgical treatment for NSCLC. We decided to perform lingular-sparing surgery in this patient to reduce the risk of significant postoperative pulmonary complications and breathlessness.

Multiple previous studies have highlighted the increased risk of postoperative pulmonary complications and higher mortality rates after a COVID-19 infection, , with one study demonstrating a mortality rate of 20.5% after surgery with a concurrent COVID-19 infection and 44.1% of patients requiring intensive care unit level care. The rates of postoperative pulmonary complications have been shown to be approximately 50%, with mortality rates also much greater in patients with COVID-19. On the converse, a large cohort study of 40,000 people found that delaying surgery by 8 weeks for stage 1 NSCLC was associated with pathological upstaging of the tumor, a greater 30-day mortality, and a decreased median survival. It is therefore essential that we time operations on the balance of the severity of post–COVID-19 complications against the risk of disease progression to produce the safest outcomes for patients. One study has suggested that surgical procedures should be delayed by a minimum of 7 weeks after an acute COVID-19 infection to prevent against such complications. However, we present a case of a successful and uncomplicated left upper segmentectomy in a patient with significant COVID-19 pneumonitis in a shorter time frame.

To conclude, we present a successful case of anatomical lung resection in a 65-year-old woman 6 weeks after acute COVID-19 pneumonitis. This case highlights the importance of balancing the risk of disease progression against the patient’s comorbid status and clinical condition. Uncomplicated thoracic surgical intervention is possible, even with ongoing radiographic evidence of pneumonitis. Further studies are required to delineate the optimal timing of surgery during this pandemic.