Risk of pneumonectomy after induction therapy for locally advanced non-small cell lung cancer

Major pulmonary resection after neoadjuvant chemotherapy or chemoradiation in potentially resectable stage III non-small cell lung carcinoma

The aim of this study was to identify predictors of postoperative outcome and survival of locally advanced non-small cell lung carcinoma (NSCLC) resections after neoadjuvant chemotherapy or chemoradiation. Medical records of all patients with clinical stage III potentially resectable NSCLC initially treated by neoadjuvant chemotherapy or chemoradiation followed by major pulmonary resections were retrieved from the databases of four Israeli Medical Centers between 1999 to 2019. The 124 suitable patients included, 86 males (69.4%) and 38 females (30.6%), with an average age of 64.2 years (range 37-82) and an average hospital stay of 12.6 days (range 5-123). Complete resection was achieved in 92.7% of the patients, while complete pathologic response was achieved in 35.5%. The overall readmission rate was 16.1%. The overall 5-year survival rate was 47.9%. One patient (0.8%) had local recurrence. Postoperative complications were reported in 49.2% of the patients, mainly atrial fibrillation (15.9%) and pneumonia (13.7%), empyema (10.3%), and early bronchopleural fistula (7.3%). The early in-hospital mortality rate was 6.5%, and the 6-month mortality rate was 5.6%. Pre-neoadjuvant bulky mediastinal disease (lymph nodes > 20 mm) (p = 0.034), persistent postoperative N2 disease (p = 0.016), R1 resection (p = 0.027), preoperative N2 multistation disease (p = 0.053) and postoperative stage IIIA (p = 0.001) emerged as negative predictive factors for survival. Our findings demonstrate that neoadjuvant chemotherapy or chemoradiation in locally advanced potentially resectable NSCLC, followed by major pulmonary resection, is a beneficial approach in selected cases.

Sarcopenia on preoperative chest computed tomography predicts cancer-specific and all-cause mortality following pneumonectomy for lung cancer: A multicenter analysis

Background

Mortality risk prediction in patients undergoing pneumonectomy for non‐small cell lung cancer (NSCLC) remains imperfect. Here, we aimed to assess whether sarcopenia on routine chest computed tomography (CT) independently predicts worse cancer‐specific (CSS) and overall survival (OS) following pneumonectomy for NSCLC.

Methods

We included consecutive adults undergoing standard or carinal pneumonectomy for NSCLC at Massachusetts General Hospital and Heidelberg University from 2010 to 2018. We measured muscle cross‐sectional area (CSA) on CT at thoracic vertebral levels T8, T10, and T12 within 90 days prior to surgery. Sarcopenia was defined as T10 muscle CSA less than two standard deviations below the mean in healthy controls. We adjusted time‐to‐event analyses for age, body mass index, Charlson Comorbidity Index, forced expiratory volume in 1 second in % predicted, induction therapy, sex, smoking status, tumor stage, side of pneumonectomy, and institution.

Results

Three hundred and sixty‐seven patients (67.4% male, median age 62 years, 16.9% early‐stage) underwent predominantly standard pneumonectomy (89.6%) for stage IIIA NSCLC (45.5%) and squamous cell histology (58%). Sarcopenia was present in 104 of 367 patients (28.3%). Ninety‐day all‐cause mortality was 7.1% (26/367). After a median follow‐up of 20.5 months (IQR, 9.2–46.9), 183 of 367 patients (49.9%) had died. One hundred and thirty‐three (72.7%) of these deaths were due to lung cancer. Sarcopenia was associated with shorter CSS (HR 1.7, p = 0.008) and OS (HR 1.7, p = 0.003).

Conclusions

This transatlantic multicenter study confirms that sarcopenia on preoperative chest CT is an independent risk factor for CSS and OS following pneumonectomy for NSCLC.

Prognostic Factors and Long-Term Survival in Locally Advanced NSCLC with Pathological Complete Response after Surgical Resection Following Neoadjuvant Therapy

Simple Summary

Higher response may be achieved with induction therapy (IT) and better survival results could be expected after complete surgical resection for non-small-cell lung cancer (NSCLC) patients. Thus, locally advanced (LA)-NSCLC patients with pathological complete response (pCR) are optimal candidates to undergo surgery after IT, achieving good to very good long-term survival. Herein, we performed a retrospective analysis on a large cohort of locally advanced NSCLC patients who achieved pCR after IT and surgery, exploring long-term survival and factors affecting prognosis. We observed a rewarding 5-year overall survival (56%) with baseline N2 single-station disease and adjuvant therapy after surgery associated with better prognosis. These findings may be useful to better define the strategy of care in this highly selected subset of NSCLC patients.

Abstract

Background: Outcomes for locally advanced NSCLC with pathological complete response (pCR), i.e., pT0N0 after induction chemoradiotherapy (IT), have been seldom investigated. Herein, long-term results, in this highly selected group of patients, have been evaluated with the aim to identify prognostic predictive factors. Methods: Patients affected by locally advanced NSCLC (cT1-T4/N0-2/M0) who underwent IT, possibly following surgery, from January 1992 to December 2019, were considered for this retrospective analysis. Survival rates and prognostic factors have been studied with Kaplan-Meier analysis, log-rank and Cox regression analysis. Results: Three-hundred and forty-three consecutive patients underwent IT in the considered period. Out of them, 279 were addressed to surgery; among them, pCR has been observed in 62 patients (18% of the total and 22% of the operated patients). In the pCR-group, clinical staging was IIb in 3 (5%) patients, IIIa in 28 (45%) patients and IIIb in 31 (50%). Surgery consisted of (bi)lobectomy in the majority of cases (80.7%), followed by pneumonectomy (19.3%). Adjuvant therapy was administered in 33 (53.2%) patients. Five-year overall survival and disease-free survival have been respectively 56.18% and 48.84%. The relative risk of death, observed with the Cox regression analysis, was 4.4 times higher (95% confidence interval (CI): 1.632–11.695, p = 0.03) for patients with N2 multi-station disease, 2.6 times higher (95% CI: 1.066–6.407, p = 0.036) for patients treated with pneumonectomy and 3 times higher (95% CI: 1.302–6.809, p = 0.01) for patients who did not receive adjuvant therapy. Conclusions: Rewarding long-term results could be expected in locally advanced NSCLC patients with pCR after IT followed by surgery. Baseline N2 single-station disease and adjuvant therapy after surgery seem to be associated with better prognosis, while pneumonectomy is associated with poorer outcomes.

Surgical outcomes of segmental bronchial sleeve resection in central non-small cell lung cancer

Background

The purpose of this study was to present the clinical and surgical results in patients who underwent segmental bronchial sleeve reconstruction.

Methods

The clinical and pathological data of 16 patients with central non‐small cell lung cancer (NSCLC) who underwent segmental bronchial sleeve resection from April 2015 to May 2019 were retrospectively analyzed.

Results

According to the type of segmental bronchial reconstruction, procedures were divided into four types: right upper S6 sleeve lobectomy in three cases (type A); left lower lingular sleeve lobectomy in 10 cases (type B); left upper S6 sleeve lobectomy in two cases (type C); and left lower propriolateral superior sleeve lobectomy in one case (type D). A total of three patients (18.75%) experienced anastomotic complications, including two with anastomotic stenosis and one with anastomotic fistula. All patients achieved R0 resection. Apart from one patient who died of acute lung infection after surgery, the rest were successfully discharged. The average follow‐up time was 28 months, and the overall survival rates of patients at one, two, and three years were 80.0%, 53.3%, and 40.0%, respectively.

Conclusions

Segmental bronchial sleeve resection is complex in technique and may have an increased risk of complications compared to a standard sleeve resection, but it is an effective and safe procedure, especially for selected patients with central lung cancer.

International guidelines on stage III N2 nonsmall cell lung cancer: surgery or radiotherapy?

Stage III N2 nonsmall cell lung cancer (NSCLC) is a complex disease with poor treatment outcomes. For patients in whom the disease is considered technically resectable, the main treatment options include surgery (with neoadjuvant or adjuvant chemotherapy/neoadjuvant chemoradiotherapy (CRT)) or CRT followed by adjuvant immunotherapy (dependent on programmed death ligand 1 status). As there is no clear evidence demonstrating a survival benefit between these options, patient preference plays an important role. A lack of a consensus definition of resectability of N2 disease adds to the complexity of the decision-making process. We compared 10 international guidelines on the treatment of NSCLC to investigate the recommendations on preoperatively diagnosed stage III N2 NSCLC. This comparison simplified the treatment paths to multimodal therapy based on surgery or radiotherapy (RT). We analysed factors relevant to decision-making within these guidelines. Overall, for nonbulky mediastinal lymph node involvement there was no clear preference between surgery and CRT. With increasing extent of mediastinal nodal disease, a tendency towards multimodal treatment based on RT was identified. In multiple scenarios, surgery or RT-based treatments are feasible and patient involvement in decision-making is critical.

For many patients with stage III N2 NSCLC, radiotherapy or surgery are options and should be discussed with the patienthttp://bit.ly/2Z39MW5

Stereotactic Body Radiotherapy for Centrally Located Primary Non-Small-Cell Lung Cancer: A Meta-Analysis

BACKGROUND

The purpose of the study was to evaluate the efficacy and safety of stereotactic body radiotherapy (SBRT) for centrally located, primary non-small-cell lung cancer (NSCLC).

MATERIALS AND METHODS

Systematic search of 4 databases (PubMed, MEDLINE, EMBASE, and Cochrane Library) was performed for literature published until May 9, 2018. Primary (overall survival [OS] and local control [LC] rates) and secondary (Grade ≥3 toxicity) endpoints were reported.

RESULTS

Thirteen studies encompassing 599 patients with central NSCLCs were included. Median values of T1 tumor proportion, tumor size, and median survival were 55.3% (range, 0%-75%), 3.3 (range, 2.1-4.1) cm, and 26 (range, 14-68.9) months, respectively. Pooled rates of 1-, 2-, and 3-year OS rates were 84.3% (95% confidence interval [CI], 75.7-90.3), 64.0% (95% CI, 52.9-72.2), and 50.5% (95% CI, 39.4-61.5), respectively. Pooled rates of 1-, 2-, and 3-year LC rates were 89.4% (95% CI, 80.8-94.4), 82.2% (95% CI, 71.7-89.4), and 72.2% (95% CI, 55.0-84.7), respectively. Pooled rate of Grade ≥3 complication was 12.0% (95% CI, 7.3-19.0). Meta-regression analyses showed significant positive relationships between biologically equivalent dose using an α/β of 10 Gy in the linear quadratic model (BED_10Gy) and 1- and 2-year LC rates (P < .001 and P < .001), and 1- and 2-year OS rates (P = .0178 and P = .032), and Grade ≥3 complication rate (P = .0029). In subgroup comparisons between BED_10Gy <100 Gy versus ≥100 Gy, 1- and 2-year LC rates were significantly different but not for OS and Grade ≥3 complication rates.

CONCLUSION

Our results suggests that SBRT is potent for tumor control in central NSCLC, although complications should be further minimized through optimization of dose-fractionation scheme and accurate planning. Using BED_10Gy ≥100 Gy yielded higher LC rates, and dose escalation was related to OS, LC, and complications.

Pneumonectomy after induction chemoradiotherapy for locally advanced non-small cell lung cancer: should curative intent pulmonary resection be avoided?

PURPOSE

We conducted a retrospective analysis to assess the practicality of pneumonectomy, especially after concurrent induction chemoradiotherapy (i-CRT), for locally advanced non-small cell lung cancer (LA-NSCLC). The operative risks vs. the survival benefit of this procedure for such patients is a subject of controversy.

METHODS

The subjects of this retrospective study were 71 consecutive LA-NSCLC patients with cStage IIIA-C NSCLC, who underwent i-CRT followed by curative intent pulmonary resection between February, 2001 and March, 2013.

RESULTS

Thirty-two patients underwent pneumonectomy (group P) and 39 patients underwent lobectomy (group L). In group P, 17 (54.8%) patients underwent right pneumonectomy. There was no 30-day postoperative mortality in either group and no significant difference in 90-day postoperative mortality between the groups (3.1% vs. 2.6% in groups P and L, respectively). The 5-year overall survival (OS) rate was 58.7% (95% CI: 41.5-75.9%) in group P and 57.3% (95% CI 41.2-73.4%) in group L, without a significant difference between the groups.

CONCLUSION

Our findings suggest that i-CRT followed by pneumonectomy is feasible, with a similar survival benefit to lobectomy. Thus, pneumonectomy after i-CRT should not be avoided as it is a potentially curative intent strategy for carefully selected patients.

Neoadjuvant Therapy in Non-Small Cell Lung Cancer

Locally advanced (stage IIIA) non-small cell lung cancer (NSCLC) is confined to the chest, but requires more than surgery to maximize cure. Therapy given preoperatively is termed neoadjuvant, whereas postoperative therapy is termed adjuvant. Trimodality therapy (chemotherapy, radiation, and surgery) has become the standard treatment regimen for resectable, locally advanced NSCLC. During the past 2 decades, several prospective, randomized, and nonrandomized studies have explored various regimens for preoperative treatment of NSCLC. The evaluation of potential candidates with NSCLC for neoadjuvant therapy as well as the currently available therapeutic regimens are reviewed.

Morbidity and mortality after major pulmonary resections in patients with locally advanced stage IIIA non-small cell lung carcinoma who underwent induction therapy

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.

Neoadjuvant chemotherapy is a risk factor for bronchopleural fistula after pneumonectomy for non-small cell lung cancer

Introduction

Performing pneumonectomy after neoadjuvant chemotherapy is still controversial. Bronchopleural fistula is a major complication after pneumonectomy. In this study the effect of neoadjuvant chemotherapy on postpneumonectomy bronchopleural fistula was investigated.

Material and methods

A retrospective review of patients who underwent pneumonectomy for non-small cell lung cancer from January 2005 to December 2011 was undertaken. The major complications and operative mortality were analyzed and compared between the patients having neoadjuvant chemotherapy and patients having surgery only.

Results

One hundred and seventy-seven pneumonectomies (77 right and 100 left) were performed during the study period and 49 of these patients (27.7%) received neoadjuvant chemotherapy. Median age was 60 years (range, 32 to 80). The bronchopleural fistula rate was 26.5% (13/49) in the neoadjuvant group versus 3.1% (4/128) in the surgery alone group (p = 0.029). The bronchopleural fistula rate was 16.9% (13/77) in the right pneumonectomy group vs. 4% (4/100) in the left pneumonectomy group (p = 0.004). Overall operative mortality was 5.6%. Mortality in the neoadjuvant group was 8.2% vs. 4.7% in the surgery only group (p = 0.37).

Conclusions

Neoadjuvant chemotherapy and right pneumonectomy is a major risk factor for bronchopleural fistula. Especially right pneumonectomy should be avoided after induction therapy.

Pneumonectomy for node-positive non-small cell lung cancer: can it be a treatment option for N2 disease?

OBJECTIVE

The feasibility of multimodality therapy in patients with node-positive non-small cell lung cancer (NSCLC) requiring pneumonectomy and the role of pneumonectomy in N2 disease remain controversial. This study evaluated outcomes in patients with node-positive NSCLC undergoing pneumonectomy in a community hospital.

METHODS

Perioperative and long-term outcomes of 37 patients with node-positive (pN1-2) NSCLC undergoing pneumonectomy from September 1994 to April 2010 as a clinical practice were retrospectively analyzed.

RESULTS

Twenty patients received induction therapy, and 17 received preoperative chemoradiation (30-40 Gy). Fifteen patients and 22 patients underwent right and left pneumonectomy, respectively. A postoperative complication occurred in 8 patients. In-hospital mortality occurred in 1 patient. Induction therapy did not increase the operative risk including operative time, blood loss and postoperative complications. Nineteen patients were given a diagnosis of pN2. Although 7 bulky N2 patients and 10 multi-station N2 patients were included, 5-year overall survival was 34.3 % in pN1 and 28.0 % in pN2 (p = 0.998), respectively. Twenty-three patients received additional postoperative therapy. Five patients died within 3 months postoperatively due to distant metastases. Induction therapy and laterality did not influence survival. Extended resection, such as vagus nerve or chest wall resection, predicted an unfavorable outcome in multivariate analysis (Hazard ratio 2.81, p = 0.032).

CONCLUSIONS

The safety and acceptable long-term outcome of pneumonectomy as a general clinical practice were shown for both pN1 and pN2 patients with various preoperative or postoperative therapies. Extended resection due to the extrapleural or extranodal involvement of tumor was an unfavorable prognostic factor.

Does pneumonectomy have a role in the treatment of stage IIIA non-small cell lung cancer?

BACKGROUND

The role of surgical resection for stage IIIA non-small cell lung cancer (NSCLC) is unclear. We sought to examine outcomes after pneumonectomy for patients with stage IIIA disease.

METHODS

All patients with stage IIIA NSCLC who had pneumonectomy at a single institution between 1999 and 2010 were reviewed. The Kaplan-Meier method was used to estimate long-term survival and multivariable Cox proportional hazards regression was used to identify clinical characteristics associated with survival.

RESULTS

During the study period, 324 patients had surgical resection of stage IIIA NSCLC. Pneumonectomy was performed in 55 patients, 23 (42%) of whom had N2 disease. Induction treatment was used in 17 patients (31%) overall and in 11 of the patients (48%) with N2 disease. Perioperative mortality was 9% (n = 5) overall and 18% (n = 3) in patients that had received induction therapy (p = 0.17). Complications occurred in 32 patients (58%). Three-year survival was 36% and 5-year survival was 29% for all patients. Three-year survival was 40% for N0-1 patients and 29% for N2 patients (p = 0.59). In multivariable analysis, age over 60 years (hazard ratio [HR] 3.65, p = 0.001), renal insufficiency (HR 5.80, p = 0.007), and induction therapy (HR 2.17, p = 0.05) predicted worse survival, and adjuvant therapy (HR 0.35, p = 0.007) predicted improved survival.

CONCLUSIONS

Long-term survival after pneumonectomy for stage IIIA NSCLC is within an acceptable range, but pneumonectomy may not be appropriate after induction therapy or in patients with renal insufficiency. Patient selection and operative technique that limit perioperative morbidity and facilitate the use of adjuvant chemotherapy are critical to optimizing outcomes.

A retrospective study: platinum-based induction chemotherapy combined with gemcitabine or paclitaxel for stage IIB-IIIA central non-small-cell lung cancer

Background

Several encouraging phase III clinical trials have evaluated platinum-based induction chemotherapy against stage IIB-IIIA non-small-cell lung cancer (NSCLC). Chemotherapy efficacy was assessed using common regimens in this retrospective analysis.

Methods

From 2007 to 2011, the clinical records of stage IIB-IIIA NSCLC patients undergoing surgery after neoadjuvant chemotherapy were reviewed. Gathered data were tested for significance and variables impacting survival were assessed by univariate and Cox regression analyses.

Results

Overall, 84% of patients were male and 93% had central disease. Platinum-based chemotherapy protocols with gemcitabine or paclitaxel gave an overall response rate of 55% (45/82) and 6.1% pathological complete response (5/82). Clinical response was unassociated with regimen or histology, while more pneumonectomies were performed in the stable compared to partial response disease group (P =0.040). Postoperative mortality was 1.2% (1/82), and complications, unassociated with regimen or histology, were atelectasis (26.8%) and supraventricular arrhythmias (13.4%). Right-sided procedures appeared to increase the incidence of bronchopleural fistula (P =0.073). The median disease-free survival time was 18 months and median overall survival time was not reached. Disease-free survival rates at one, two, and three years were 54%, 47%, and 33%, while the overall survival rate was 73%, 69%, and 59%, respectively. Disease-free survival predictors were radiographic response and mediastinal lymphadenopathy before chemotherapy (P =0.012 and 0.002, respectively).

Conclusions

Two cycles of platinum-based chemotherapy with gemcitabine or paclitaxel is efficacious for patients with stage IIB-IIIA central disease. Patients achieving clinical response had improved disease-free survival times, while those with mediastinal lymphadenopathy had a higher postoperative recurrence risk.

Sleeve lobectomy after induction chemoradiotherapy

OBJECTIVES

The effect of induction chemoradiotherapy (CRT) on bronchial anastomoses remains uncertain. This prospective study aimed to assess the impact of neoadjuvant CRT on mortality, morbidity and survival following circular sleeve lobectomy (SL).

METHODS

All consecutive patients undergoing SL between June 2005 and December 2010 were prospectively included. Clinico-demographic variables were sex, age, clinical and pathologic TNM staging, comorbidities, pulmonary function, SL type, complications, neoadjuvant CRT and mortality.

RESULTS

Of 79 patients, who underwent SL during this period, 53 (67%) patients were directly assigned to surgery and 26 (33%) patients had pre-induction treatment for N2 pathologically confirmed. Induction treatment (CRT) was based on platinum-based chemotherapy and radiation (range 45-60 Gy). Twenty-one (80%) patients of the CRT group achieved a complete mediastinal pathological response. Mortality occurred in only three cases in the non-CRT [bronchovascular fistula, pulmonary artery thrombosis (reoperation and pneumonectomy and exitus due to pneumonia) and ADRS]. There were no differences with respect to complication rate between the non-CRT and CRT patients (33 versus 37%, P > 0.05), and overall 5-year survival was 69 and 33%, respectively (P = 0.017). Overall survival in the subgroup of CRT patients with mediastinal complete response after induction resulted significantly worse than the non-CRT group (43 versus 69%, P < 0.01). The rate of distant metastases was similar in both groups and only one patient experienced local recurrence.

CONCLUSIONS

Neoadjuvant CRT does not increase surgical morbidity, anastomotic complications or mortality in SL. Complete mediastinal response after induction therapy overcomes a significant independent prognostic factor for better survival. Although SL following induction CRT carries a good prognosis, the long-term results shows significantly lower survival compared with SL without induction CTR. In addition, patients who had complete pathological responses have a better prognosis than non-responders. SL appears to be safe and reliable after neoadjuvant concurrent CRT and can be considered the primary surgical option to save the complications related to pneumonectomy in central tumours.

Multidisciplinary approach in stage III non-small-cell lung cancer: standard of care and open questions

Lung cancer is the most frequent cause of cancer death worldwide and its global incidence has been steadily increasing during recent decades. A third of patients with newly diagnosed non-small-cell lung cancer (NSCLC) present with locally advanced disease. There is not a single widely accepted standard of care for these patients because of the wide spectrum of presentation of the disease. Although feasible and safe in experienced hands, evidence that surgical resection after induction treatment improves overall survival (OS) is lacking. For resectable or potentially resectable stage III, the findings of two phase III trials suggest that surgical resection should not be considered a standard of care but rather reserved for selected patients after critical multidisciplinary assessment, in whom surgery improves survival after downstaging if pneumonectomy can be avoided or in some T4N0-1 resectable tumours. For unresectable stage III NSCLC the standard of care is a combination of chemotherapy and radiotherapy. In those patients with good performance status and minimal weight loss, the concurrent approach has resulted in a statistically significant improvement in OS rates compared with a sequential approach in randomised clinical trials, although several questions remain unresolved.

Impact of laterality on early and late survival after pneumonectomy

BACKGROUND

This study evaluated the effect of laterality on survival in patients who underwent pneumonectomy for lung cancer.

METHODS

We reviewed the Surveillance, Epidemiology, and End Results (SEER) database for patients who underwent pneumonectomy for lung cancer from 1988 through 2006. Predictors of survival were determined by univariate and multivariable analysis.

RESULTS

A total of 9746 patients had pneumonectomies. Left pneumonectomies (56%) were more common than right; 67% of patients were men with mean age of 63 years (range, 12 to 92 years). Tumor pathology was squamous cell in 49% and adenocarcinoma in 34%. Stage distribution was stage I, 28%; stage II, 28%; stage IIIA, 19%; stage IIIB, 18%; and stage IV, 6%. Overall survival was 67% and 40%, respectively, at 1 and 3 years; with 63% and 39% for right vs 70% and 41% for left (p<0.001). Mortality at 1 and 3 months was 8% and 16% for right pneumonectomies and 4% and 9% for left (p<0.001). Multivariate predictors of worse survival were right pneumonectomy, age, stage, male sex, tumor size, grade, prior malignancy, not married, number of positive lymph nodes, and fewer lymph nodes evaluated (all p<0.05). The adjusted hazard ratio for right pneumonectomy was 1.12 (95% confidence interval, 1.07 to 1.18; p<0.00001). For 3-month survival, right pneumonectomy had an adjusted odds ratio of 2.01 (95% confidence interval, 1.77 to 2.29; p<0.001). Neoadjuvant radiotherapy did not affect 3-month survival (adjusted odds ratio, 0.88; 95% confidence interval, 0.1 to 7.03, p=0.9).

CONCLUSIONS

A right pneumonectomy is associated with approximately twice the perioperative mortality as a left pneumonectomy. However, neoadjuvant radiotherapy does not appear to add incremental risk, and long-term survival is not affected by laterality.