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Subotic D, Savic M, Atanasijadis N, Gajic M, Stojsic J, Popovic M, Milenkovic V, Garabinovic Z. Standard versus extended pneumonectomy for lung cancer: what really matters? World J Surg Oncol 2014; 12:248. [PMID: 25086948 PMCID: PMC4244073 DOI: 10.1186/1477-7819-12-248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is still not clear whether an intrapericardial pneumonectomy indicates a more advanced stage of the disease compared to a standard pneumonectomy. METHODS This was a retrospective study of 164 patients who underwent a pneumonectomy for lung cancer. The first group consisted of 82 patients who had a standard pneumonectomy and the second group was 38 patients who had a intrapericardial pneumonectomy, for both groups in the latest 5-year period. The third group was 44 patients with had a sleeve pneumonectomy in the latest 10-year period. The groups were compared in relation to the overall and stage-related survival, influence of T and N factors, operative morbidity and mortality. The statistics used were Kaplan-Meier, U-test, t-test, χ2 test. RESULTS There was no statistically significant difference in stage distribution between standard and intrapericardial pneumonectomies; stages I, II, IIIA and IIIB occurred for 10.9% vs. 2.6%, 30.5% vs. 26.3%, 46.4% vs. 65.8% and 12.2% vs. 5.3% of patients, respectively. For patients who had a sleeve pneumonectomy, stage IIIA was significantly more frequent. Although the overall survival (63.5% vs. 57.6%) and stage-related 5-year survival were better in the first compared to the second group, especially for stage IIIA (58.6% vs. 42.6%), these differences were not statistically significant. There were no significant differences in operative morbidity and mortality between groups 1 and 2, but both were significantly higher in the third group (35.7% and 15.9%). CONCLUSIONS An intrapericardial pneumonectomy does not always indicate a more advanced stage of the disease. The need for an intrapericardial pneumonectomy, either established preoperatively or during the operation, as a single factor, even for marginal surgical candidates, is not strong enough to reject these patients for surgery.
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Affiliation(s)
- Dragan Subotic
- Clinic for Thoracic Surgery, Clinical Center of Serbia, University of Belgrade School of Medicine, Koste Todorovica 26, 11000 Belgrade, Serbia.
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Current status of induction treatment for N2-Stage III non-small cell lung cancer. Gen Thorac Cardiovasc Surg 2014; 62:651-9. [PMID: 25355643 DOI: 10.1007/s11748-014-0447-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Indexed: 12/25/2022]
Abstract
Locally advanced non-small cell lung cancer (NSCLC), particularly clinical Stage IIIA NSCLC with mediastinal lymph node metastasis, is known to be quite heterogeneous, comprising approximately one-fourth of cases of NSCLC. In this subset, patients with a minor tumor load in the mediastinal lymph nodes, such as microscopically or pathologically proven N2 in the resected specimens, are treated with surgery followed by adjuvant chemotherapy. Meanwhile, the current standard of care for patients with bulky or infiltrative N2 disease is concurrent chemoradiotherapy. The potential role of surgery in multi-modality treatment for clinical N2-Stage IIIA remains controversial. Several prospective clinical trials of this subset have been conducted; however, the heterogeneity of the N2 status and differences in chemotherapy regimens and/or radiation modalities between clinical trials make the results difficult to compare. No optimal chemotherapy regimen has been established to control possible micrometastasis, and radiotherapy is often used to achieve maximum local disease control and minimize post-surgical complications. This review summarizes the findings of prospective clinical trials that assessed the role of surgery in treating clinical N2-Stage IIIA patients within the last two decades and discusses the present status of induction treatment followed by surgery for clinical N2-Stage IIIA NSCLC.
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Peer M, Stav D, Cyjon A, Sandbank J, Vasserman M, Haitov Z, Sasson L, Schreiber L, Ezri T, Priel IE, Hayat H. Morbidity and mortality after major pulmonary resections in patients with locally advanced stage IIIA non-small cell lung carcinoma who underwent induction therapy. Heart Lung Circ 2014; 24:69-76. [PMID: 25086910 DOI: 10.1016/j.hlc.2014.07.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 06/25/2014] [Accepted: 07/02/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal treatment for patients with locally advanced stage IIIA non-small cell lung carcinoma (NSCLC) remains controversial, but induction therapy is increasingly used. The aim of this study was to evaluate mortality, morbidity, hospital stay and frequency of postoperative complications in stage IIIA NSCLC patients that underwent major pulmonary resections after neoadjuvant chemotherapy or chemoradiation. METHODS We conducted a retrospective analysis of all patients who underwent major pulmonary resections after induction therapy for locally advanced NSCLC from October 2009 to February 2014. Forty-one patients were included in the study. RESULTS Complete resection was achieved in 40 patients (97.5%). A complete pathologic response was seen in 10 patients (24.4%). Mean hospital stay was 17.7 days (ranged 5-129 days). Early (in-hospital) mortality occurred in 2.4% (one patient after bilobectomy), late (six months) mortality in 4.9% (two patients after right pneumonectomy and bilobectomy), and overall morbidity in 58.5% (24 patients). Postoperative complications included: bronchopleural fistula (BPF) with empyema - three patients, empyema without BPF - five patients, air leak - eight patients, atrial fibrillation - eight patients, pneumonia - eight patients, and lobar atelectasis - four patients. CONCLUSION Following neoadjuvant therapy for stage IIIA NSCLC, pneumonectomy can be performed with low early and late mortality (0% and 5.8%, respectively), bilobectomy is a high risk operation (16.7% early and 16.7% late mortality); and lobectomy a low risk operation (0% early and late mortality). The need for major pulmonary resections should not be a reason to exclude patients from a potentially curative procedure if it can be performed with acceptable morbidity and mortality rates at an experienced medical centre.
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Affiliation(s)
- Michael Peer
- Department of Thoracic Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel.
| | - David Stav
- Department of Pulmonology, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Arnold Cyjon
- Department of Oncology, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Judith Sandbank
- Department of Pathology, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Margarita Vasserman
- Institute of Diagnostic Imaging, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Zoya Haitov
- Department of Anesthesiology, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Lior Sasson
- Department of Cardiothoracic Surgery, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Letizia Schreiber
- Department of Pathology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tiberiu Ezri
- Department of Anesthesiology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel E Priel
- Department of Pulmonary Medicine, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Henri Hayat
- Department of Oncology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Azzoli CG, Pisters KM. Neoadjuvant Chemotherapy for Resectable Non-Small Cell Lung Cancer. Lung Cancer 2014. [DOI: 10.1002/9781118468791.ch19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kim AW, Boffa DJ, Wang Z, Detterbeck FC. An analysis, systematic review, and meta-analysis of the perioperative mortality after neoadjuvant therapy and pneumonectomy for non–small cell lung cancer. J Thorac Cardiovasc Surg 2012; 143:55-63. [PMID: 22056364 DOI: 10.1016/j.jtcvs.2011.09.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 07/30/2011] [Accepted: 09/13/2011] [Indexed: 11/16/2022]
Affiliation(s)
- Anthony W Kim
- Section of Thoracic Surgery, School of Medicine, Yale University, New Haven, Conn 06520, USA.
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Contemporary results of surgical resection of non-small cell lung cancer after induction therapy: a review of 549 consecutive cases. J Thorac Oncol 2011; 6:1530-6. [PMID: 21792074 DOI: 10.1097/jto.0b013e318228a0d8] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We previously reported a high mortality after induction therapy and pneumonectomy for non-small cell lung cancer. Recent reports suggest that operative mortality in these patients is declining. We analyzed our contemporary results to define operative mortality and factors determining surgical risk. METHODS Eligible patients were identified from our prospective surgical database. Complications were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events 3.0. Uni- and multivariate logistic regression models assessed the association of preoperative tests and clinical characteristics with outcome. Receiver operating characteristic curves and area under the receiver operating characteristic curve (AUC) statistics were calculated in a leave-one-out crossvalidation scheme to evaluate the predictive value of various models. RESULTS From January 2000 to December 2006, 549 patients underwent surgery after induction therapy. Median patient age was 64 years (range: 30-86), and 54% were women (298/549). All received chemotherapy, and 17% also had radiation. Lobectomy (388/549, 71%) and pneumonectomy (70/549, 13%) were the most common procedures. Complications occurred in 250 patients (46%), with grade 3 or higher in 23% (126/549). Inhospital mortality was 1.8% (10/549), with only one death after right pneumonectomy (1/30, 3%). Multivariate analysis showed that predicted postoperative (PPO) pulmonary function was associated with postoperative morbidity. By receiver operating characteristic curves, PPO product (AUC = 0.75, p < 0.001), PPO diffusion capacity (AUC = 0.70, p < 0.001), and preoperative % predicted PPO diffusion capacity (AUC = 0.66, p < 0.001) predicted mortality. CONCLUSION Our current experience shows that resection of non-small cell lung cancer after induction therapy, including pneumonectomy, is associated with low mortality. PPO pulmonary function is the strongest predictor of operative risk and should be used to select patients for surgery.
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Impact of Neoadjuvant Radiation on Survival in Stage III Non–Small-Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2011; 79:1388-94. [DOI: 10.1016/j.ijrobp.2009.12.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Revised: 12/21/2009] [Accepted: 12/21/2009] [Indexed: 10/19/2022]
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Saito H, Minamiya Y, Nanjo H, Ito M, Ono T, Motoyama S, Hashimoto M, Ogawa JI. Pathological finding of subclinical interstitial pneumonia as a predictor of postoperative acute respiratory distress syndrome after pulmonary resection. Eur J Cardiothorac Surg 2010; 39:190-4. [PMID: 20598898 DOI: 10.1016/j.ejcts.2010.05.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 04/28/2010] [Accepted: 05/18/2010] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Post-surgical interstitial pneumonia (IP) is a part of postoperative acute respiratory distress syndrome (ARDS). Some cases of ARDS may be an acute exacerbation of idiopathic pulmonary fibrosis (IPF) that is generally not recognised as IPF prior to surgery. In this study, we evaluated IP on preoperative computed tomography (CT) and histopathological findings in patients who underwent thoracic surgery, and attempted to identify high-risk patients who might develop postoperative ARDS. METHODS A retrospective review of preoperative CT and histopathological examination was performed in 487 patients who underwent lobectomy for primary lung cancer at our institute. RESULTS The incidence of ARDS was 2.05%, and histopathological finding of IP was the only predictor of ARDS (P = 0.038, odds ratio (OR) = 6.89). The incidence of IP on histopathological examination was 9.7% for all cases of lung cancer; and the incidence of ARDS in the IP-positive group (31.8%) was significantly different from that in the IP-negative group (1.5%) (P<0.05). However, in 85.7% of patients with ARDS, who were histologically IP-positive, IP was masked by emphysematous findings and thus not detected on preoperative CT. CONCLUSIONS In this study, histopathological finding of IP was the only predictor of ARDS; however, it was difficult to identify preoperatively because emphysematous change was also present in the majority of cases, which masks the findings of IP on CT. If identification of the high-risk case of ARDS is insisted upon, screening the presence or absence of IP (e.g., just in the patients with emphysema or IP finding on CT) by histopathological examination, as the need arises, after surgery using resected lung might be one of the additional methods of identifying those at high risk of ARDS.
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Affiliation(s)
- Hajime Saito
- Department of Surgery, Akita University School of Medicine, Hondo, Akita City 010-8543, Japan.
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Amar D, Munoz D, Shi W, Zhang H, Thaler HT. A Clinical Prediction Rule for Pulmonary Complications After Thoracic Surgery for Primary Lung Cancer. Anesth Analg 2010; 110:1343-8. [DOI: 10.1213/ane.0b013e3181bf5c99] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Weder W, Collaud S, Eberhardt WEE, Hillinger S, Welter S, Stahel R, Stamatis G. Pneumonectomy is a valuable treatment option after neoadjuvant therapy for stage III non-small-cell lung cancer. J Thorac Cardiovasc Surg 2010; 139:1424-30. [PMID: 20416887 DOI: 10.1016/j.jtcvs.2010.02.039] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Revised: 01/27/2010] [Accepted: 02/20/2010] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The mortality of pneumonectomy after chemotherapy or chemoradiotherapy for locally advanced non-small-cell lung cancer is reported to be as high as 26%. We retrospectively reviewed the medical records of patients undergoing these procedures in 2 specialized thoracic centers to determine the outcome. METHODS Retrospective analyses were performed of all patients who underwent pneumonectomy after neoadjuvant chemotherapy or chemoradiotherapy for locally advanced non-small-cell lung cancer from 1998 to 2007. Presurgical treatment consisted of 3-4 platin-based doublets alone in 20% of patients or combined with radiotherapy (45Gy) to the tumor and mediastinum in 80% of patients. RESULTS Of 827 patients who underwent neoadjuvant therapy, 176 pneumonectomies were performed, including 138 (78%) extended resections. Post-induction pathologic stages were 0 in 36 patients (21%), I in 33 patients (19%), II in 38 patients (21%), III in 57 patients (32%), and IV in 12 patients (7%). Three patients died of pulmonary embolism, 2 patients of respiratory failure, and 1 patient of cardiac failure, resulting in a 90 postoperative day mortality rate of 3%; 23 major complications occurred in 22 patients (13%). For the overall population, 3-year survival was 43% and 5-year survival was 38%. CONCLUSION Pneumonectomy after neoadjuvant therapy for non-small-cell lung cancer can be performed with a perioperative mortality rate of 3%. Thus, the need of a pneumonectomy for complete resection alone should not be a reason to exclude patients from a potentially curative procedure if done in an experienced center. The 5-year survival of 38%, which can be achieved, justifies extended surgery within a multimodality concept for selected patients with locally advanced non-small-cell lung cancer.
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Affiliation(s)
- Walter Weder
- Division of Thoracic Surgery, University Hospital Zurich, CH-8091 Zurich, Switzerland.
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Eichenbaum KD, Neustein SM. Acute lung injury after thoracic surgery. J Cardiothorac Vasc Anesth 2010; 24:681-90. [PMID: 20060320 DOI: 10.1053/j.jvca.2009.10.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Indexed: 01/11/2023]
Abstract
In this review, the authors discussed criteria for diagnosing ALI; incidence, etiology, preoperative risk factors, intraoperative management, risk-reduction strategies, treatment, and prognosis. The anesthesiologist needs to maintain an index of suspicion for ALI in the perioperative period of thoracic surgery, particularly after lung resection on the right side. Acute hypoxemia, imaging analysis for diffuse infiltrates, and detecting a noncardiogenic origin for pulmonary edema are important hallmarks of acute lung injury. Conservative intraoperative fluid administration of neutral to slightly negative fluid balance over the postoperative first week can reduce the number of ventilator days. Fluid management may be optimized with the assistance of new imaging techniques, and the anesthesiologist should monitor for transfusion-related lung injuries. Small tidal volumes of 6 mL/kg and low plateau pressures of < or =30 cmH2O may reduce organ and systemic failure. PEEP may improve oxygenation and increases organ failure-free days but has not shown a mortality benefit. The optimal mode of ventilation has not been shown in perioperative studies. Permissive hypercapnia may be needed in order to reduce lung injury from positive-pressure ventilation. NO is not recommended as a treatment. Strategies such as bronchodilation, smoking cessation, steroids, and recruitment maneuvers are unproven to benefit mortality although symptomatically they often have been shown to help ALI patients. Further studies to isolate biomarkers active in the acute setting of lung injury and pharmacologic agents to inhibit inflammatory intermediates may help improve management of this complex disease.
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Pisters K. Adjuvant and Neoadjuvant Therapy of NSCLC. Lung Cancer 2010. [DOI: 10.1007/978-1-60761-524-8_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Is Pneumonectomy After Induction Chemotherapy for Non-small Cell Lung Cancer a Reasonable Procedure? A Multicenter Retrospective Study of 228 Cases. J Thorac Oncol 2009; 4:1496-503. [PMID: 19745768 DOI: 10.1097/jto.0b013e3181b9e966] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kim AW, Faber LP, Warren WH, Basu S, Wightman SC, Weber JA, Bonomi P, Liptay MJ. Pneumonectomy After Chemoradiation Therapy for Non-Small Cell Lung Cancer: Does “Side” Really Matter? Ann Thorac Surg 2009; 88:937-43; discussion 944. [PMID: 19699924 DOI: 10.1016/j.athoracsur.2009.04.102] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 04/20/2009] [Accepted: 04/22/2009] [Indexed: 11/28/2022]
Affiliation(s)
- Anthony W Kim
- Division of Thoracic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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van Meerbeeck JP, Surmont VF. Stage IIIA-N2 NSCLC: A review of its treatment approaches and future developments. Lung Cancer 2009; 65:257-67. [DOI: 10.1016/j.lungcan.2009.02.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 01/10/2009] [Accepted: 02/07/2009] [Indexed: 11/29/2022]
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Gaissert HA, Keum DY, Wright CD, Ancukiewicz M, Monroe E, Donahue DM, Wain JC, Lanuti M, Allan JS, Choi NC, Mathisen DJ. POINT: Operative risk of pneumonectomy—Influence of preoperative induction therapy. J Thorac Cardiovasc Surg 2009; 138:289-94. [PMID: 19619768 DOI: 10.1016/j.jtcvs.2008.11.069] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 10/01/2008] [Accepted: 11/15/2008] [Indexed: 02/06/2023]
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Alan S, Jan S, Tomas H, Robert L, Jan S, Pavel P. Does chemotherapy increase morbidity and mortality after pneumonectomy? J Surg Oncol 2009; 99:38-41. [DOI: 10.1002/jso.21181] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Zhou X, Wang J, Wang J, Pan Y, Li J, Wang W, Zhao F. Analysis of prognostic factors for surgery after neo-adjuvant therapy for stage III non-small cell lung cancer. ACTA ACUST UNITED AC 2008; 28:677-80. [DOI: 10.1007/s11596-008-0614-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Indexed: 11/27/2022]
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Results of Surgical Treatment After Neoadjuvant Chemotherapy for Stage III Non-Small Cell Lung Cancer. World J Surg 2008; 32:2636-42. [DOI: 10.1007/s00268-008-9774-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gudbjartsson T, Gyllstedt E, Pikwer A, Jönsson P. Early Surgical Results After Pneumonectomy for Non-Small Cell Lung Cancer are not Affected by Preoperative Radiotherapy and Chemotherapy. Ann Thorac Surg 2008; 86:376-82. [PMID: 18640300 DOI: 10.1016/j.athoracsur.2008.04.013] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Revised: 04/01/2008] [Accepted: 04/02/2008] [Indexed: 11/27/2022]
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Kakizaki T, Kohno M, Watanabe M, Tajima A, Izumi Y, Miyasho T, Tasaka S, Fukunaga K, Maruyama I, Ishizaka A, Kobayashi K. Exacerbation of bleomycin-induced injury and fibrosis by pneumonectomy in the residual lung of mice. J Surg Res 2008; 154:336-44. [PMID: 19118846 DOI: 10.1016/j.jss.2008.06.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2008] [Revised: 06/06/2008] [Accepted: 06/12/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Lung resection after induction chemotherapy and/or radiotherapy for down-staging of locally advanced lung cancer can be complicated with lethal interstitial pneumonia. We studied the effects of pneumonectomy on bleomycin-induced lung injury and fibrosis in mice. METHODS The mice underwent left pneumonectomy or a sham thoracotomy after intratracheal administration of saline or bleomycin. Lung permeability index, wet-to-dry weight ratio, histological changes, collagen contents, and concentrations of inflammatory mediators and cell counts in broncho-alveolar lavage (BAL) fluid were assessed in the residual right lung 7 d after surgery. RESULTS The index of capillary permeability, lung water content, and inflammatory cell counts in BAL fluid were significantly increased by pneumonectomy. These measurements were highest in the mice with both pneumonectomy and intratracheal administration of bleomycin. Similarly, fibrotic change in lung pathology, as well as an increase in lung collagen content, was most prominent in the mice exposed to both interventions. The BAL fluid concentrations of interleukin-1beta, interleukin-6, RANTES, and high mobility group box 1 were significantly increased by pneumonectomy and enhanced by the additional administration of bleomycin. CONCLUSIONS The results of this study indicate that pneumonectomy alone causes noncritical lung injury, which amplifies the inflammatory response to bleomycin and promotes lung fibrosis. Several inflammatory mediators appear to be involved in the exacerbation of bleomycin-induced lung injury and fibrosis.
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Affiliation(s)
- Toru Kakizaki
- Department of Surgery, National Hospital Organization Kanagawa Hospital, Kanagawa, Japan
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Abstract
On the basis of the evidence available, the authors would suggest a decision making algorithm to determine the need for ICU admission postoperatively similar to that shown in Fig. 1. First, patients should quit smoking at least 1 month and preferably 2 months before surgery. Those over the age of 70 years should receive elective ICU admission. Second, those at increased risk of general anesthesia, as judged by ASA and performance status scores and cardiovascular risk assessment, should be prebooked into the ICU in the postoperative period. A ppo FEV1 of less than 44% should warrant additional monitoring rather than mandate ICU admission. Pre-existing fibrotic lung disease mandates ICU admission. Third, perioperatively, protective (low tidal volume) ventilatory strategies should be applied during one lung ventilation. Patients undergoing one lung ventilation, and especially those undergoing extensive lymphatic dissection, should be monitored closely for signs of ALI in the first 5 days postoperatively. This, together with any indication of postoperative complications such as POP, BPF or empyema, should mandate immediate transfer to the ICU.
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Affiliation(s)
- Simon Jordan
- Department of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
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Inoue M, Okumura M, Minami M, Shiono H, Sawabata N, Utsumi T, Ohno Y, Sawa Y. Cardiopulmonary co-morbidity: a critical negative prognostic predictor for pulmonary resection following preoperative chemotherapy and/or radiation therapy in lung cancer patients. Gen Thorac Cardiovasc Surg 2007; 55:315-21. [PMID: 17867276 DOI: 10.1007/s11748-007-0140-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Preoperative therapy is an optional strategy for locally advanced lung cancer, although the indication for pulmonary resection is often marginal, when considering the survival benefit and perioperative risks. The aim of the present study was to identify prognostic predictors by assessing clinical factors including pre-thoracotomy co-morbidity. METHODS This was a retrospective analysis of 54 patients who underwent complete resection after preoperative therapy was performed. RESULTS The overall 5-year survival rate was 38%. In patients without cardiopulmonary co-morbidity the 5-year survival rate was 49%, whereas it was 0% for those who had associated cardiopulmonary co-morbidity (P = 0.004). When analyzing only those who died from lung cancer, the group without cardiopulmonary comorbidity showed a tendency for longer survival than those in the co-morbidity group (P = 0.092). The 5-year survival rate for patients--evaluated with a Charlson Co-morbidity Index (CCI)--with a CCI score of 0, was 45%, which tended to be better than that for those with a CCI score of 1-2 (P = 0.066). Furthermore, patients with a normal prethoracotomy level of carcinoembryonic antigen (CEA) had a 5-year survival rate of 44%, which was better than the 22% for patients with elevated CEA (P = 0.013). The 5-year survival rate for patients without lymph node metastasis was 52%, whereas it was 14% for those with residual node involvement (P = 0.002). Lymph node metastasis and cardiopulmonary co-morbidity were shown to be independent poor prognostic predictors by multivariate analysis. CONCLUSION In addition to nodal status, preoperative cardiopulmonary co-morbidity should be noted when considering the operative indications following preoperative therapy for lung cancer patients.
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Affiliation(s)
- Masayoshi Inoue
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Osaka University Graduate School of Medicine, E1-2-2 Yamadaoka, Suita, Osaka 565-0871, Japan
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Massard G. Critères de qualité de la chirurgie d’exérèse des cancers bronchiques non microcellulaires. Rev Mal Respir 2007. [DOI: 10.1016/s0761-8425(07)78133-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Venuta F, Anile M, Diso D, Ibrahim M, De Giacomo T, Rolla M, Liparulo V, Coloni GF. Operative complications and early mortality after induction therapy for lung cancer. Eur J Cardiothorac Surg 2007; 31:714-7. [PMID: 17317200 DOI: 10.1016/j.ejcts.2007.01.017] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2006] [Revised: 12/20/2006] [Accepted: 01/15/2007] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Induction therapy for advanced lung cancer allows improvement of completeness of resection and survival. However, predictive risk factors for postoperative complications and early mortality remain controversial. We report our 14-year experience with this combined approach. METHODS One hundred and thirty-nine patients (100 males and 39 females) underwent induction therapy and surgery for stage IIIA and B lung cancer. The mean age was 58.4+/-7.7 years. We retrospectively collected demographic data, preoperative functional parameters, type of operation, associated disorders, staging, induction regimen (chemotherapy alone or associated with radiotherapy). Univariate and multivariate analyses were performed to identify predictors of postoperative complications and early mortality. RESULTS One hundred and nine patients received chemotherapy (mainly based on cisplatin and gemcitabine) and 30 received chemoradiotherapy (median dose 50Gy). Complications developed in 49 patients (35%). The most frequent was persistent air leakage (23-30% of the lobectomies), followed by cardiac complications, respiratory failure, and infections. Five patients (3.5%) died in the postoperative period and four of them had received pneumonectomy (mortality for pneumonectomy: 12.5%). The statistical analysis demonstrated that only pneumonectomy was associated with an increased mortality risk with no differences between intra- and extrapericardial dissection or right and left pneumonectomy. CONCLUSIONS Induction therapy seems to be associated with an increased incidence of air leakage; the risk of other complications is acceptable. Pneumonectomy is associated with an increased risk of mortality and should be performed in selected patients.
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Affiliation(s)
- Federico Venuta
- Cattedra di Chirurgia Toracica, Policlinico Umberto I, Università di Roma La Sapienza, V.le del Policlinico, 00100 Rome, Italy.
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Sánchez PG, Vendrame GS, Madke GR, Pilla ES, Camargo JDJP, Andrade CF, Felicetti JC, Cardoso PFG. Lobectomia por carcinoma brônquico: análise das co-morbidades e seu impacto na morbimortalidade pós-operatória. J Bras Pneumol 2006; 32:495-504. [PMID: 17435899 DOI: 10.1590/s1806-37132006000600005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2005] [Accepted: 03/24/2006] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: Analisar o impacto das co-morbidades no desempenho pós-operatório de lobectomia por carcinoma brônquico. MÉTODOS: Estudaram-se retrospectivamente 493 pacientes submetidos a lobectomia por carcinoma brônquico e 305 preencheram os critérios de inclusão. A técnica cirúrgica foi sempre semelhante. Analisaram-se as co-morbidades categorizando-se os pacientes nas escalas de Torrington-Henderson e de Charlson, estabelecendo-se grupos de risco para complicações e óbito. RESULTADOS: A mortalidade operatória foi de 2,9% e o índice de complicações de 44%. O escape aéreo prolongado foi a complicação mais freqüente (20,6%). A análise univariada mostrou que sexo, idade, tabagismo, terapia neo-adjuvante e diabetes apresentaram impacto significativo na incidência de complicações. O índice de massa corporal (23,8 ± 4,4 kg/m²), volume expiratório forçado no primeiro segundo (74,1 ± 24%) e relação entre volume expiratório forçado no primeiro segundo e capacidade vital forçada (0,65 ± 0,1) foram fatores preditivos da ocorrência de complicações. As escalas foram eficazes na identificação de grupos de risco e na relação com a morbimortalidade (p = 0,001 e p < 0,001). A análise multivariada identificou que o índice de massa corporal e o índice de Charlson foram os principais determinantes de complicações; o escape aéreo prolongado foi o principal fator envolvido na mortalidade (p = 0,01). CONCLUSÃO: Valores reduzidos de volume expiratório forçado no primeiro segundo, relação entre volume expiratório forçado no primeiro segundo e capacidade vital forçada, índice de massa corporal e graus 3-4 de Charlson e 3 de PORT associaram-se a mais complicações após lobectomias por carcinoma brônquico. O escape aéreo persistente associou-se fortemente à mortalidade.
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Scotte F, Fabre-Guillevin E, Dujon A, Riquet M. [Postoperative risk after induction treatment on surgery in non-small cell lung cancer]. Cancer Radiother 2006; 11:41-6. [PMID: 16920376 DOI: 10.1016/j.canrad.2006.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Induction treatments in non-small cell lung cancer are usually discussed. Long-term survival after surgery and resecability are enhanced in locally advanced cancers. Morbidity and mortality observed after surgery limit the use of these treatments, despite they depend on many other factors: comorbidities in patient, smoking status, cancer staging, and type of surgery. Right pneumectomy enhances this risk more than left pneumectomy or other limited resections allowed by neoadjuvant treatments, especially in case of downstaging.
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Affiliation(s)
- F Scotte
- Service d'oncologie médicale, hôpital européen Georges-Pompidou, 20-40, rue Leblanc, 75015 Paris, France
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Dulu A, Pastores SM, Park B, Riedel E, Rusch V, Halpern NA. Prevalence and Mortality of Acute Lung Injury and ARDS After Lung Resection. Chest 2006. [DOI: 10.1016/s0012-3692(15)50955-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Brunelli A, Xiume' F, Al Refai M, Salati M, Marasco R, Sabbatini A. Gemcitabine-Cisplatin Chemotherapy Before Lung Resection: A Case-Matched Analysis of Early Outcome. Ann Thorac Surg 2006; 81:1963-8. [PMID: 16731114 DOI: 10.1016/j.athoracsur.2006.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 12/23/2005] [Accepted: 01/03/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND The objective of the present study was to assess whether neoadjuvant chemotherapy with gemcitabine and cisplatin was associated with an increased incidence of morbidity and mortality after major lung resection for lung cancer. METHODS We analyzed 570 patients who underwent lobectomy or pneumonectomy for nonsmall-cell lung cancer at our institution from January 2000 through June 2005. Of these, 70 patients underwent three cycles of gemcitabine-cisplatin chemotherapy before operation for locally advanced disease. Propensity scores were constructed to match those patients undergoing neoadjuvant chemotherapy and lung resection with those undergoing surgery alone. The propensity score analysis yielded two groups of 70 well-matched pairs that were compared in terms of baseline characteristics and early outcome (morbidity, mortality, length of postoperative stay, intensive care unit admission). RESULTS The two case-matched groups had similar morbidity (p = 0.8), mortality (p = 0.4), perioperative blood transfusions (p = 0.8) and intensive care unit admission rates (p = 0.8). Likewise, the length of postoperative stay did not differ between the groups (p = 0.9). CONCLUSIONS Gemcitabin-cisplatin neoadjuvant chemotherapy appears to be safe before major lung resection. This finding warrants its use for efficacy studies of locally advanced and even early-stage lung cancer.
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Leo F, Borri A, Petrella F, Gasparri R, Galetta D, Veronesi G, Spaggiari L. Preoperative chemotherapy and postoperative complications: a closer look. Ann Thorac Surg 2006; 81:2335. [PMID: 16731194 DOI: 10.1016/j.athoracsur.2005.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2005] [Revised: 10/18/2005] [Accepted: 11/07/2005] [Indexed: 10/24/2022]
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Kozian A, Schilling T, Strang C, Hachenberg T. Anesthetic considerations in patients with previous thoracic surgery. Curr Opin Anaesthesiol 2006; 19:26-33. [PMID: 16547430 DOI: 10.1097/01.aco.0000192782.40021.88] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF THE REVIEW This review presents an overview of the different problems and challenges after thoracic surgery. It covers the pathophysiological changes that may occur regularly in the early and late period following surgery. In addition, surgical complications with anesthesiological implications for diagnosis, treatment and prevention are discussed, and consequences for anesthesia in further major and thoracic surgical procedures are shown. RECENT FINDINGS During the last decade, complications in the early period following surgery after thoracotomy have increasingly moved into the focus caused by their high morbidity and mortality. These problems, such as hemorrhagia and bronchopleural fistulas, are important because they call for a prompt revision or even an emergency operation. The therapy of acute bleeding follows general anesthesiological guidelines whereas the bronchopleural fistula demands methods to prevent aspiration pneumonia as a first priority. In the late period following surgery, typical cardiac and pulmonary modifications can be described that persist and have anesthesiological implications in the case of further surgery. Recent literature, however, lacks clear recommendations regarding anesthesiological management and practice for these cases. SUMMARY Current literature presents no general recommendations on how to manage patients after recent thoracic surgery. Therefore it is necessary to find an individual strategy to handle possible complications and well known pathophysiological changes. Knowledge and understanding of the etiology, the pathophysiology and the risk factors of the perioperative period, allows prevention and target intervention aimed at reducing morbidity and mortality following surgery.
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Affiliation(s)
- Alf Kozian
- Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University, Magdeburg, Germany.
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