Should pulmonary lesions be resected at the time of open heart surgery?

The prevalence and malignant potential of pulmonary lesions found preoperatively in patients undergoing coronary artery bypass grafting (CABG) surgery are poorly defined. In a review of 3364 consecutive patients undergoing CABG, 191 (5%) were found to have pulmonary lesions. Granulomatous disease was suspected in all patients who had only calcified lesions (n = 151). These were empirically observed with no changes seen at follow-up. The 40 patients with noncalcified lesions (NCLs) were managed variously. Twenty patients underwent resection of the suspicious pulmonary lesion at the time of cardiac surgery. One patient underwent wedge resection of a pulmonary lesion (benign granuloma) 4 days before CABG. Eighteen patients underwent concomitant pulmonary resection and CABG through the median sternotomy (7 benign, 11 malignant). A delayed pneumonectomy was performed 17 days after CABG in another patient. Three of 40 patients died during the perioperative period without pathologic diagnosis. The remaining 17 were followed with serial roentgenograms. Three of 17 (18%) had lesional enlargement in the follow-up period their lesions were found to be malignant. The remaining 14 patients have been observed without surgical intervention now with a mean follow-up of 5.7 years (range, 20 months to 13 years). The prevalence of malignancy in lesions found on CABG preoperative chest roentgenograms was 15 out of 191 (7.8%); however, among patients with NCL the prevalence of malignancy was 15 out of 40 (37%), and malignancy was present in 12/13 (92%) of patients with NCLs that were >/= 2 cm in diameter. When malignancy is diagnosed in an NCL before CABG surgery, the decision to proceed with CABG should be based upon the coronary pathophysiology and the stage and cell type of the malignancy. Concomitant CABG and pulmonary resection is possible in most cases; however, we prefer a staged resection of all newly diagnosed NCLs when these are identified in patients requiring emergent revascularization or when these lesions are difficult to access through sternotomy. The mortality rate may be slightly increased in patients having concomitant procedures (5.47%) versus isolated CABG (3%). The incidence of malignancy in these NCLs is related to size. If a staged resection is not undertaken after CABG, careful observation of NCLs is important, as 18 per cent of these so managed were ultimately found to be malignant.