Surgery for lung adenocarcinoma with smokers’ polycythemia: a case report
© Sugiura et al.; licensee BioMed Central Ltd. 2013
Received: 1 August 2012
Accepted: 30 January 2013
Published: 1 February 2013
Smoking is a cause of cancer and polycythemia. Therefore, surgeons who treat patients with cancer may also encounter patients with polycythemia. However, few cases of surgical patients with polycythemia have been reported; in particular, a surgical case involving smokers’ polycythemia has never been reported. We herein report a patient with lung cancer and smokers’ polycythemia who successfully underwent lobectomy with control of hematocrit based on a modified formula in the perioperative period.
A 67-year-old man underwent abdominoperineal resection for rectal carcinoma in June 2008. A ground glass opacity had been identified in the upper lobe of the right lung and was gradually enlarging. In March 2012, bronchoscopic cytology for investigation of the mass revealed non-small cell lung cancer, suggesting primary lung non-small cell carcinoma (T1bN0M0, Stage IA). When he was referred to our hospital for surgery, his complete blood count showed a red blood cell level of 6.50×106/μL, hemoglobin of 21.0 g/dL, and hematocrit of 60.1%. The hematologists’ diagnosis was secondary polycythemia due to heavy smoking (smokers’ polycythemia) because the white blood cell and platelet counts were within normal limits and the erythropoietin was not increased. We calculated the appropriate phlebotomy and infusion volumes based on a formula that we modified. After 550 g of blood was phlebotomized to reduce the hematocrit to approximately 55%, video-assisted right lung upper lobectomy with lymph node dissection was performed in April 2012. The hematocrit was maintained at <50% postoperatively, and the patient was uneventfully discharged on postoperative day 7. The predictive hematocrit and measured hematocrit were very closely approximated in this case.
We experienced a patient with smokers’ polycythemia who underwent right upper lobectomy for adenocarcinoma. The findings in this case report are meaningful for surgeons treating cancer patients because there are few reports discussing the perioperative care of surgical patients with polycythemia.
KeywordsSmokers’ polycythemia Phlebotomy Predictive hematocrit Lung cancer Lung lobectomy
Smoking is a cause of cancer and polycythemia [1, 2]. Therefore, surgeons who treat patients with cancer may encounter cases of polycythemia. However, few surgical patients with cancer and polycythemia have been reported. We experienced a patient who underwent lung lobectomy for lung cancer and had secondary polycythemia due to smoking. The most frequent complication of polycythemia is thrombosis . We managed this patient’s hematocrit (HCT) to prevent thrombosis by performing phlebotomy and infusion based on a formula that we modified. As a result, the predictive HCT and measured HCT were very closely approximated, and we succeeded in providing effective perioperative care. This report provides useful information for the management of surgical patients with polycythemia.
His hypertension was being treated with 5 mg of amlodipine a day. He had been a three-packs-a-day smoker for 40 years, and he stopped smoking 4 weeks before surgery.
Blood examination results on admission in March 2012
Course of CBC before surgery
Tumor size in maximum diameter (mm)
RBC (×106/μL )
Although a bone marrow examination was not performed, only one factor in the major and minor diagnostic criteria for polycythemia vera (PV) did not match [4, 5]. In the major criteria, HCT was >60%, the cause of the secondary erythrocytosis was smoking, and splenomegaly was not present. In the minor criteria, the platelet count was <400×103/μL, the neutrophil count was <12.5×106/μL, and the serum erythropoietin level was within normal limits. Consultation with hematologists led us to conclude that these data were contradictive to a myeloproliferative disorder (e.g., chronic myeloid leukemia, polycythemia rubra vera, or essential thrombocythemia), and the diagnosis was smokers’ polycythemia (SP).
Pathological findings revealed that the bronchioalveolar carcinoma component occupied >90%. Immunohistologic staining for erythropoietin was negative. The pathological diagnosis was primary lung adenocarcinoma, 42×40×26 mm, pT2aN0M0 Stage IB (lymph node station 2, 0/1; 7, 0/4; 10, 0/7).
The serum erythropoietin level 1 month after discharge was normal at 11.2 mU/dL, as before the operation. However, the Hb and HCT in November 2012 were 22.0 g/dL and 61.0%, respectively.
Smoking is one of the most notorious carcinogenic risk factors and a recognized cause of lung cancer . Smoking is also a known cause of SP . SP with hypertension is called Gaisböck syndrome and is frequently associated with cerebrovascular disease . However, there are very few reports on surgery for patients with SP. Therefore, we reviewed the complications and treatments of PV [5, 7–10]. According to the Polycythemia Vera Study Group, the most common cause of death in patients with polycythemia is thrombosis [3, 10]. Thus, we formulated countermeasures to prevent the thrombosis during the perioperative period.
Cerebrovascular disease and high HCT in patients with SP are correlated, and treatments to prevent these complications include anticoagulants and/or antiplatelet agents and cytoreduction [3, 11, 12]. Thus, we chose to reduce the HCT before the operation because we had to be wary of using anticoagulants or antiplatelets during the perioperative period . The optimal HCT is unclear in patients with SP, even in patients with PV , because, on theoretical grounds, erythrocytosis in this situation represents to a certain extent an “appropriate” physiological response to hypoxemia . Thus, whatever the ideal HCT in cases of primary polycythemia, the corresponding ideal in cases of SP is likely to be higher . We decided that the target HCT just before surgery was 55%, considering the average amount of intraoperative blood loss and for lobectomy in our hospital.
The total circulating blood volume is almost 1/13 (7.5%) of body weight, the RBC mass is 24 to 30 mL/kg, and the plasma volume is 39 to 49 mL/kg . Approximately 25% of physiological saline remains in the vascular space, and the remaining 75% is distributed throughout the interstitial tissue . We calculated the phlebotomy volume using the modified formula in Figure 2. Determination of the predictive HCT and measured HCT in the perioperative period is shown in Figure 3.
The most important condition in this case was that homeostasis was maintained because of the presence of normal renal function and the fact that the patient underwent elective surgery. There are many methods and approaches to accurate calculation of the total circulating blood volume. However, this formula would be reliable if we had assumed that the body fluid, excluding the phlebotomy and infusion volumes, was in a stationary state. Practically, the predictive HCT and measured HCT were very closely approximated in this case.
It is unknown why the polycythemia became obvious after June 2008 and erythrocytosis developed 8 months after surgery. However, Weinberg et al. reported that significant increases in the prevalence and frequency of mutation of the Janus kinase 2 (JAK2) gene, the protein of which is especially important for controlling the production of blood cells from hematopoietic stem cells, may be related to poor DNA repair in smokers as a result of the increased demand for erythrocyte production . JAK2 mutation may have been present in this patient.
In conclusion, we experienced a patient with SP who underwent right upper lobectomy for adenocarcinoma. Smoking is a cause of cancer and polycythemia. Thus, this is a salutary case report for surgeons treating cancer patients because there are few reports discussing the perioperative care of surgical patients with polycythemia. This report is based on the experience of only one patient. Therefore, experience with surgical patients with SP should be accumulated and shared among surgeons to understand and improve treatment these cases.
Written informed consent for the perioperative care and operation in this case was obtained on admission in accordance with institutional guidance based on the Helsinki Declaration. At the time of discharge, we reconfirmed that the patient gave permission to publish a case report about his clinical course. A copy of the written consent is available for review by the Editor-in-Chief of the journal.
Ground glass opacity
Red blood cells
- FEV 1.0:
1-second forced expiratory volume
Diffusing capacity of the lung for carbon monoxide
Janus kinase 2.
We thank Dr. Kei Tadume and his colleagues in Division of Hematology, Hadano Red Cross Hospital (Hadano, Japan) for the advice on diagnosis of smokers’ polycythemia and for preparing this article for publication.
- Steliga MA, Dresler CM: Epidemiology of lung cancer: smoking, secondhand smoke, and genetics. Surg Oncol Clin N Am. 2011, 20: 605-618. 10.1016/j.soc.2011.07.003.PubMedView ArticleGoogle Scholar
- Smith JR, Landaw SA: Smokers' polycythemia. N Engl J Med. 1978, 298: 6-10. 10.1056/NEJM197801052980102.PubMedView ArticleGoogle Scholar
- Marchioli R, Finazzi G, Landolfi R, Kutti J, Gisslinger H, Patrono C, Marilus R, Villegas A, Tognoni G, Barbui T: Vascular and neoplastic risk in a large cohort of patients with polycythemia vera. J Clin Oncol. 2005, 23: 2224-2232. 10.1200/JCO.2005.07.062.PubMedView ArticleGoogle Scholar
- Pearson TC, Messinezy M: The diagnostic criteria of polycythaemia rubra vera. Leuk Lymphoma. 1996, 22 (Suppl 1): 87-93.PubMedGoogle Scholar
- McMullin MF, Bareford D, Campbell P, Green AR, Harrison C, Hunt B, Oscier D, Polkey MI, Reilly JT, Rosenthal E, Ryan K, Pearson TC, Wilkins B, General Haematology Task Force of the British Committee for Standards in H: Guidelines for the diagnosis, investigation and management of polycythaemia/erythrocytosis. Br J Haematol. 2005, 130: 174-195. 10.1111/j.1365-2141.2005.05535.x.PubMedView ArticleGoogle Scholar
- Spiers AS, Levine M: Smokers' polycythaemia. Lancet. 1983, 1: 120-PubMedView ArticleGoogle Scholar
- Landaw SA: Polycythemia vera and other polycythemic states. Clin Lab Med. 1990, 10: 857-871.PubMedGoogle Scholar
- Marchioli R, Finazzi G, Specchia G, Masciulli A, Mennitto MR, Barbui T: The CYTO-PV: A large-scale trial testing the intensity of CYTOreductive therapy to prevent cardiovascular events in patients with polycythemia vera. Thrombosis. 2011, 2011: 794240-PubMedPubMed CentralView ArticleGoogle Scholar
- Tefferi A: Polycythemia vera and essential thrombocythemia: 2012 update on diagnosis, risk stratification, and management. Am J Hematol. 2012, 87: 285-293.PubMedView ArticleGoogle Scholar
- Wasserman LR, Berk PD, Berlin NI: Treatment of polycythemia vera: a summary of clinical trials conducted by the Polycythemia Vera Study Group. Polycythemia vera and the myeloproliferative disorders. Edited by: Wasserman LR, Berk PD, Berlin NI. 1995, Philadelphia: WB Saunders, 166-Google Scholar
- Raval M, Paul A: Cerebral Venous Thrombosis and Venous Infarction: Case Report of a Rare Initial Presentation of Smoker's Polycythemia. Case Rep Neurol. 2010, 2: 150-156. 10.1159/000322571.PubMedPubMed CentralView ArticleGoogle Scholar
- De Stefano V, Za T, Rossi E, Vannucchi AM, Ruggeri M, Elli E, Mico C, Tieghi A, Cacciola RR, Santoro C, Gerli G, Vianelli N, Guglielmelli P, Pieri L, Scognamiglio F, Rodeghiero F, Pogliani EM, Finazzi G, Gugliotta L, Marchioli R, Leone G, Barbui T, Party GC-W: Recurrent thrombosis in patients with polycythemia vera and essential thrombocythemia: incidence, risk factors, and effect of treatments. Haematologica. 2008, 93: 372-380. 10.3324/haematol.12053.PubMedView ArticleGoogle Scholar
- Newton LK: Neurologic complications of polycythemia and their impact on therapy. Oncology (Williston Park). 1990, 4: 59-64. discussion 64–56Google Scholar
- Di Nisio M, Barbui T, Di Gennaro L, Borrelli G, Finazzi G, Landolfi R, Leone G, Marfisi R, Porreca E, Ruggeri M, Rutjes AW, Tognoni G, Vannucchi AM, Marchioli R, European Collaboration on Low-dose Aspirin in Polycythemia Vera I: The haematocrit and platelet target in polycythemia vera. Br J Haematol. 2007, 136: 249-259. 10.1111/j.1365-2141.2006.06430.x.PubMedView ArticleGoogle Scholar
- Thakur KT, Westover MB: Cerebral infarction due to smoker's polycythemia. BMJ Case Rep. 2011, 10.1136/bcr.08.2011.4714.Google Scholar
- Pearson TC, Guthrie DL, Simpson J, Chinn S, Barosi G, Ferrant A, Lewis SM, Najean Y: Interpretation of measured red cell mass and plasma volume in adults: Expert Panel on Radionuclides of the International Council for Standardization in Haematology. Br J Haematol. 1995, 89: 748-756.PubMedView ArticleGoogle Scholar
- Yeager MP, Spence BC: Perioperative fluid management: current consensus and controversies. Semin Dial. 2006, 19: 472-479. 10.1111/j.1525-139X.2006.00209.x.PubMedView ArticleGoogle Scholar
- Fujioka S: Formula for a prediction of venous hematocrit value following phlebotomy and infusion in polycythemia vera. Med Biol. 1988, 117: 247-249.Google Scholar
- Weinberg I, Borohovitz A, Krichevsky S, Perlman R, Ben-Yehuda A, Ben-Yehuda D: Janus kinase V617F mutation in cigarette smokers. Am J Hematol. 2012, 87: 5-8. 10.1002/ajh.22180.PubMedView ArticleGoogle Scholar