Prediction of the postoperative pulmonary function and complication rate in elderly patients

Variation in Prevertebral Soft Tissue Swelling after Staged Combined Multilevel Anterior-Posterior Complex Cervical Spine Surgery: Anterior Then Posterior (AP) versus Posterior Then Anterior-Posterior (PAP) Surgery

The influence of the sequence of surgery in the development of prevertebral soft tissue swelling (PSTS) in staged combined multilevel anterior-posterior complex spine surgery was examined. This study was conducted as a retrospective study of patients who underwent staged combined multilevel anterior-posterior complex cervical spine surgery from March 2014 to February 2021. Eighty-two patients were identified, of which fifty-seven were included in the final analysis after screening. PSTS was measured from routine serial monitoring lateral cervical radiographs prior to and after surgery for five consecutive days at each cervical level from C2 to C7 in patients who underwent anterior then posterior (AP) and posterior then anterior-posterior (PAP) surgery. The mean PSTS measurements significantly differed from the preoperative to postoperative monitoring days at all cervical levels (p = 0.0000) using repeated measures analysis of variance in both groups. PSTS was significantly greater in PAP than in AP at level C2 on postoperative day (POD) 1 (p = 0.0001). PSTS was more prominent at levels C2-4 during PODs 2-4 for both groups. In staged combined multilevel anterior-posterior complex spine surgery, PSTS is an inevitable complication. Therefore, surgeons should monitor PSTS after surgery when performing anterior-posterior complex cervical spine surgery, especially in the immediate postoperative period after PAP surgery.

Surgical complication and postoperative pulmonary function in patients undergoing tumor surgery with thoracic wall resection

Postoperative complications of thoracic wall resection include respiratory complications, skin necrosis and infection. The aim of the present study was to examine postoperative complications in patients who required combined thoracic wall resection during the surgical removal of a tumor. The present study included 68 patients; there were 50 patients with lung tumors and 18 patients with musculoskeletal tumors. The clinical factors associated with complications were compared between the two groups. Preoperative and postoperative pulmonary function tests were performed to examine the residual pulmonary function in 16 patients. Thoracic cage reconstruction was performed in 46 patients. Postoperative complications occurred in 30 (44.1%) patients, and one patient died from postoperative pneumonitis. Compared with the pulmonary function preoperative test results, the postoperative results revealed a decrease in the mean vital capacity percentage and an increase in the mean forced expiratory volume within 1 sec as a percent of the forced vital capacity. In patients with lung tumors, pneumonectomy can result in an increased rate of complications following thoracic wall resection. Residual pulmonary function is affected by impaired thoracic cage expansion and removal of the lung. However, the results of the present study demonstrated that these complications can be somewhat stabilized by thoracic wall reconstruction.

Stereotactic body radiotherapy in patients with stage I non-small-cell lung cancer aged 75 years and older: retrospective results from a multicenter consortium

BACKGROUND

This study was a retrospective analysis of elderly patients treated with stereotactic body radiotherapy (SBRT) in the setting of a multi-institutional consortium.

PATIENTS AND METHODS

Three institutions pooled data on patients aged ≥ 75 years who received SBRT for stage I non-small-cell lung cancer (NSCLC). Forty-seven tumors in 46 patients were analyzed in patients aged 75 to 92 years (median, 82 years). Treatment was delivered during 2007 to 2009, with a median follow-up of 12.4 months. All patients underwent staging positron emission tomography-computed tomography (PET-CT), and 87% of tumors were confirmed by biopsy results. Total doses were 35 to 60 Gy, mainly in 3 to 5 fractions. All tumors were treated using a linear accelerator, with 96% of patients receiving 3-dimensional (3D) conformal RT and 4% undergoing intensity modulated RT (IMRT).

RESULTS

At the time of analysis, the local failure rate was 2% (1 of 47). The regional failure rate was 9% (4 of 47). The distant failure rate was 6% (3 of 47). The combined failure rate was 15% (7 of 47) because 1 patient experienced both regional and distant failure. Among 20 tumors with any acute toxicity, there were no ≥ grade 3 toxicities. Pneumonitis (n = 10) grades 1 (n = 3) and 2 (n = 2) was seen in 15% and 10% of patients, respectively; these data were missing for 25% of patients.

CONCLUSION

SBRT in patients aged ≥ 75 years with stage I NSCLC proved tolerable, with toxicity rates comparable to those in younger patients. Excellent rates of local, regional, and distant control were achieved at a median follow-up of 12.4 months. This patient population represents a rapidly growing segment of the early lung cancer population, and SBRT appears to be a safe and effective treatment option for patients who are not optimal candidates for surgery.

Thoracoscopic surgery for non-small-cell lung cancer: elderly vs. octogenarians

Background: Octogenarians are rarely referred for surgical treatment of lung cancer owing to the morbidity and mortality of pulmonary resection, their frailty, and limited lifespan. We reviewed the results of thoracoscopic surgery, performed completely under the monitor, for treatment of primary non-small-cell lung cancer in octogenarians, and compared them with those in elderly patients.

Patients and methods: Between September 25, 2002 and August 25, 2011, a retrospective database of 24 octogenarians and 70 elderly patients (age range, 75–79 years) who underwent thoracoscopic surgery for treatment of primary non-small-cell lung cancer were reviewed. Demographic, histopathologic, preoperative, perioperative, postoperative, outcome variables, and survival were assessed.

Results: In the octogenarian group, 29% had postoperative respiratory complications, 4% had postoperative cardiac complications, operative mortality was 4%, the recurrence rate was 8%, and the postsurgical 5-year survival rate was 74%. In the elderly group, 25% had postoperative respiratory complications, 6% had postoperative cardiac complications, operative mortality was 3%, the recurrence rate was 6%, and the postsurgical 5-year survival rate was 80%.

Conclusions: Thoracoscopic surgery for treatment of primary non-small-cell lung cancer can be performed with similar postoperative complication rates, operative mortality, and survival in octogenarians when compared to elderly patients.

Changes in lung function parameters after wedge resections: a prospective evaluation of patients undergoing metastasectomy

BACKGROUND

Pulmonary metastasectomy with lung-sparing local excisions is a widely accepted method of treating stage IV malignancies in selected cases. The ability to predict postoperative lung function is an unresolved issue, especially when multiple wedge resections are planned. To help develop a method to predict postoperative lung function after wedge resections, we present this prospective observational study.

METHODS

A total of 77 patients who underwent one or more wedge resections to remove lung metastases completed the study protocol. Spirometry results, diffusion capacity of lung for carbon monoxide (Dlco), and blood gases and potential confounding factors were measured prior to, immediately following, and 3 months after the procedure and were analyzed.

RESULTS

Seventy-seven patients with a median age of 61.3 years underwent up to 22 wedge resections. The mean lung function losses were FVC (-7.5%), total lung capacity (TLC) (-7.9%), FEV(1) (-9.2%), and Dlco (-8.8%), and all were statistically significant (P < .001). The lung function losses also differed significantly between those having a single and those with more than eight wedge resections. Using regression analysis, we found that for every additional wedge resection, there was a reduction in FVC of 30 mL (0.7%), in TLC of 44 mL (0.65%), and in FEV(1) of 23 mL (0.58%).

CONCLUSIONS

Metastasectomy by wedge resection significantly reduces lung function parameters. As a benchmark, we can predict a 0.6% decrease in spirometry values and Dlco for every additional wedge resection, and a decrease of approximately 5% that may be attributed to thoracotomy.

Clinicopathological characteristics and prognosis of non-small cell lung cancer patients associated with a family history of lung cancer

INTRODUCTION

Clinicopathological characteristics and prognosis of non-small cell lung cancer (NSCLC) patients with a family history of lung cancer (FHLC) have not been well established.

METHODS

Clinical records of patients with NSCLC treated at our institute from 1982 to 2010 were reviewed with special reference to family history of lung cancer and clinicopathological factors including patient's outcome. Univariate analyses of the factors between the groups of FHLC and non-FHLC were performed using unpaired two-tailed t tests or the chi-square test. The Cox proportional hazards model was used to evaluate the hazard ratio of death.

RESULTS

Of the 1013 NSCLC patients, 124 (12.2%) had a FHLC of whom 119 (96%) were the first-degree relatives. The frequency of early stages of lung cancer was high in both groups of FHLC and non-FHLC patients. Patients with FHLC had a significantly higher frequency of early pathological stages and a prepomderance of adenocarcinoma, and a hazard ratio of death of 0.870 (95% confidence interval: 0.599-1.263, p value: 0.465) compared with the non-FHLC patients.

CONCLUSIONS

NSCLC patients with FHLC could be characterized by early pathological stages and preponderance of adenocarcinoma, however they were not at a decreased hazard ratio of death. These findings emphasize the importance of early detection of lung cancer and employment of less invasive therapeutic interventions.

Aging is associated with an increased susceptibility to ischaemic necrosis due to microvascular perfusion failure but not a reduction in ischaemic tolerance

In the present study in a murine model of chronic ischaemia, we analysed: (i) whether aging was associated with an increased susceptibility to ischaemic necrosis, and (ii) whether this was based on microvascular dysfunction or reduced ischaemic tolerance. An ischaemic pedicled skin flap was created in the ear of homozygous hairless mice. The animals were assigned to three age groups, including adolescent (2±1 months), adult (10±2 months) and senescent (19±3 months). Microvascular perfusion of the ischaemic flap was assessed over 5 days by intravital microscopy, evaluating FCD (functional capillary density), capillary dilation response and the area of tissue necrosis. Expression of the stress-protein HO (haem oxygenase)-1 was determined by immunohistochemistry and Western blotting. Induction of chronic ischaemia stimulated a significant expression of HO-1 without a significant difference between the three age groups. This was associated with capillary dilation, which, however, was more pronounced in adolescent (10.5±2.8 μm compared with 3.95±0.79 μm at baseline) and adult (12.1±3.1 μm compared with 3.36±0.45 μm at baseline) animals compared with senescent animals (8.5±1.7 μm compared with 3.28±0.69 μm at baseline; P value not significant). In senescent animals, flap creation further resulted in complete cessation of capillary flow in the distal area of the flap (FCD, 0±0 cm/cm2), whereas adult (11.9±13.5 cm/cm2) and, in particular, adolescent animals (58.4±33.6 cm/cm2; P<0.05) were capable of maintaining residual capillary perfusion. The age-associated microcirculatory dysfunction resulted in a significantly increased flap necrosis of 49±8% (P<0.05) and 42±8% (P<0.05) in senescent and adult animals respectively, compared with 31±6% in adolescent mice. Of interest, functional inhibition of HO-1 by SnPP-IX (tin protoporphyrin-IX) in adolescent mice abrogated capillary dilation, decreased functional capillary density and aggravated tissue necrosis comparably with that observed in senescent mice. Thus aging is associated with an increased susceptibility to tissue necrosis, which is due to a loss of vascular reactivity to endogenous HO-1 expression, rather than a reduction in ischaemic tolerance.

Analysis of Risk Factors for Postpneumonectomy Bronchopleural Fistulas in Patients with Lung Cancer

BACKGROUND

Bronchopleural fistula is a potentially fatal complication of pulmonary resections, especially pneumonectomy.

METHODS

Univariate and multivariate analyses of the development of bronchopleural fistula were performed in 12 patients with bronchopleural fistula and 102 patients without bronchopleural fistula who had undergone pneumonectomy from January 1983 through December 2005.

RESULTS

Bronchopleural fistula developed after pneumonectomy in 12 patients (8.5%). Seven (58.7%) of the 12 patients died of bronchopleural fistula. Univariate analysis showed that preoperative infection, right pneumonectomy, and pathological N2, 3 disease significantly contributed to the development of postpneumonectomy bronchopleural fistula (p=0.0002, p=0.0043, and p=0.0387, respectively). Multivariate analysis also showed that preoperative infection, right pneumonectomy, and pathological N2, 3 disease were significant risk factors for postpneumonectomy bronchopleural fistula.

CONCLUSIONS

Bronchopleural fistula is strongly associated with preoperative infection, right pneumonectomy, and pathological N2, 3 disease. Bronchial stump coverage with pedicled tissue flaps and preservation of the bronchial arteries during mediastinal lymph node dissection are recommended to maintain the blood supply to the bronchial stump in patients at risk.

Reliability of quantitative computed tomography to predict postoperative lung function in patients with chronic obstructive pulmonary disease having a lobectomy

OBJECTIVE

To verify the reliability of quantitative computed tomography (CT) to estimate the postoperative lung function in patients with mild to severe chronic obstructive pulmonary disease (COPD) who underwent a lobectomy.

METHODS

Nine COPD patients with lung cancer having a lung lobectomy with preoperative CT were enrolled. By applying a density mask technique and a specific equation, predicted postoperative forced expiratory volume in 1 second (FEV1) and vital capacity (VC) were calculated. Predicted values were correlated with postoperative measured values.

RESULTS

Estimated FEV1 and VC were always significantly lower than the corresponding postoperative values; however, CT-estimated postresection FEV1 values were better than the postresection VC values (biases between estimated and measured values were -0.14 and -0.536 L, respectively, according to the Bland-Altman method). Quantitative CT predicted postoperative FEV1 (r = 0.97, P < 0.001) and VC (r = 0.93, P < 0.001) well in all patients, however.

CONCLUSIONS

Quantitative CT may be an alternative tool to perfusion scan to predict postresection lung function, even in patients with borderline pulmonary function undergoing a lobectomy.

Outcome of Surgery for Lung Cancer in Young and Elderly Patients

PURPOSE

It has been suggested that lung cancer follows a more aggressive course and has a poorer prognosis in young patients than in elderly patients. We conducted this study to determine whether the basal characteristics and survival of young patients undergoing surgical resection of lung cancer differ from those of elderly patients.

METHODS

Eighty patients who underwent surgery for lung cancer at our hospital between 1989 and 2004 were divided into two groups according to age. Group 1 comprised 50 patients aged 45 years or younger and group 2 comprised 30 patients aged 70 years or older. The patients' medical records were reviewed with respect to age, gender, histological diagnosis, coexisting diseases, smoking history, postoperative staging, type of operation, and postoperative morbidity, mortality, and survival results.

RESULTS

The average ages were 40.2 +/- 3.77 years (range, 29-45 years) in group 1 and 72.2 +/- 2.53 years (range, 70-80 years) in group 2. The incidence of postoperative complications was significantly higher in group 2 (P = 0.02). However, the 5-year survival rates for patients who underwent surgery for non-small cell lung cancer did not differ between groups 1 and 2, at 33.3% versus 21.3%, respectively (P = 0.09).

CONCLUSIONS

The incidence of adenocarcinoma was higher in the young patients, whose prognosis was slightly better than that of the elderly patients. Coexisting diseases and postoperative complications were the major factors that adversely affected the prognosis of the elderly patients.

Optimization of lung function before pulmonary resection: pulmonologists' perspectives

Many risk factors for morbidity and mortality with lung resection have been identified. Factors such as age, gender, and cancer stage cannot be altered, but lung function can be optimized by treating COPD or asthma with bronchodilators, corticosteroids, or antibiotics (when indicated) and by inspiratory muscle training. Although smoking cessation 2 months in advance of surgery may not be feasible, cessation nevertheless should be encouraged because it may decrease postoperative inflammation and in the long-term may decrease the risk of recurrence. In addition, morbidity and mortality can be minimized by careful patient selection using lung scanning or CT to determine predicted postoperative functions (FEV1% and DLco%) and some form of exercise testing, such as cardiopulmonary exercise testing or simple stair climbing. When the risk of surgery is high, any benefit from possible cure must be weighed against the risk of long-term disability or death. Although much data are available to guide clinicians in these decisions, there still is no one test that provides the answer in individual cases. The art and science of medicine must merge at this point.

Postoperative Respiratory Complications of Video-assisted Thoracic Surgery for Lung Cancer

PURPOSE

We analyzed the risk factors predisposing patients to develop postoperative respiratory complications (PRCs) in VATS lobectomy and segmentectomy for lung cancer, retrospectively.

METHODS

Both univariate and multivariate analyses of PRCs were performed in seventy-five patients who had undergone VATS lobectomy and segmentectomy for lung cancer from November 1994 to December 2000.

RESULTS

Univariate analysis of the development of PRCs revealed that the significant risk factors were age, ppo%VC, ppo%FEV, ppoFEV, poor pulmonary function, and duration of surgery. Multivariate logistic regression test in regard to the development of PRCs revealed that duration of surgery was the most significant risk factor. On the basis of the receiver operator characteristic analysis, duration of surgery more than 297 min had a sensitivity of 70% and a specificity of 66% for the development of PRCs.

CONCLUSIONS

The duration of surgery should be less than five hours not to lose advantages of VATS lobectomy and segmentectomy. Therefore, if the duration of surgery is more than five hours for any reasons, conversion to limited thoracotomy or muscle-sparing methods is recommended.