Factors affecting early and long-term outcomes after completion pneumonectomy☆

The Impact of Postoperative Pulmonary Complications on Perioperative Outcomes in Patients Undergoing Pneumonectomy: A Multicenter Retrospective Cohort Study of the German Thorax Registry

Postoperative pulmonary complications have a deleterious impact in regards to thoracic surgery. Pneumonectomy is associated with the highest perioperative risk in elective thoracic surgery. The data from 152 patients undergoing pneumonectomy in this multicenter retrospective study were extracted from the German Thorax Registry database and presented after univariate and multivariate statistical processing. This retrospective study investigated the incidence of postoperative pulmonary complications (PPCs) and their impact on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs and in-hospital mortality were analyzed. A total of 32 (21%) patients exhibited one or more PPCs, and 11 (7%) died during the hospital stay. Multivariate stepwise logistic regression identified a preoperative FEV1 < 50% (OR 9.1, 95% CI 1.9-67), the presence of medical complications (OR 7.4, 95% CI 2.7-16.2), and an ICU stay of more than 2 days (OR 14, 95% CI 3.9-59) as independent factors associated with PPCs. PPCs (OR 13, 95% CI 3.2-52), a preoperative FEV1 < 60% in patients with previous pulmonary infection (OR 21, 95% CI 3.2-52), and continued postoperative mechanical ventilation (OR 8.4, 95% CI 2-34) were independent factors for in-hospital mortality. Our data emphasizes that PPCs are a significant risk factor for morbidity and mortality after pneumonectomy. Intensified perioperative care targeting the underlying risk factors and effects of PPCs, postoperative ventilation, and preoperative respiratory infections, especially in patients with reduced pulmonary reserve, could improve patient outcomes.

Completion Pneumonectomy for Non-Small-Cell Lung Cancer: Does Induction Treatment Influence Postoperative Outcomes?

Simple Summary

In recent years there have been important improvements in surgical and adjuvant therapy for lung cancer which have led to an increasing number of patients with non-small-cell lung cancer (NSCLC) which had been previously cured by surgery being identified as having a second primary NSCLC or a recurrence of the previous tumor. In these cases, a completion pneumonectomy (CP), defined as the complete removal of the remaining lung after an ipsilateral pulmonary resection, may be performed. Although this procedure has a higher morbidity and mortality than standard pneumonectomy due to the high degree of surgical difficulty strongly associated with the previous surgery, the number of patients undergoing CP is increasing with improvement in morbidity and mortality. To the best of our knowledge, there is no study evaluating the role of induction therapy (IT) on the outcomes of patients who have undergone CP. We reviewed our single-center experience in patients receiving CP for recurrent/second NSCLC after IT and analyzed perioperative results and long-term outcomes. Our results revealed that postoperative complications were not influenced by IT, and long-term survival was adversely influenced by the absence of IT, the presence of squamous cell carcinoma, and cancers at advanced stages. Correct patient selection is crucial to evaluating possible contraindications and adopting technical details to reduce the complication rate.

Abstract

Background: Completion pneumonectomy (CP) is associated with high morbidity and mortality. We reviewed our experience to evaluate whether induction treatment (IT) may affect postoperative outcomes and analyzed factors influencing long-term results. Methods: Between 1998 and 2020, 69 patients with lung cancer underwent CP (50 males, median age 63 years, right CP in 47 patients). A total of 23 patients (33.3%) received IT (chemotherapy in 15, chemoradiotherapy in 7, and radiation in 1). Surgery included 25 (36.2%) extended resections and five (7.2%) tracheal sleeve CP. Results: The 30-day mortality rate was 7.2% (5/69), and overall morbidity was 37.6%. Major complications occurred in five patients (7.2%): one cardiac dislocation, one diaphragmatic hernia, one transient ischemic attack (TIA), and two bronchopleural fistulas. Minor complications occurred in 21 cases (30.4%): pulmonary in 12, cardiac in 7, and neurological in 2. The median hospital stay was 8 days (range, 5–56 days). IT did not influence postoperative morbidity and mortality. Pathological staging included 19 (27.5%) stage I, 36 (52.2%) stage II, and 14 (20.3%) stage III. Overall 5-year survival was 51.7%. Factors influencing survival were IT (p = 0.01), extension of resection (p = 0.04), histology (p = 0.01), pathological stage (p = 0.03), and T and N factors (p = 0.2, respectively). Factors affecting survival in multivariate analysis included IT (p = 0.02) and histology (p = 0.03). Conclusions: In our experience, CP had a low mortality, acceptable morbidity, and good long-term survival, which justifies this surgical procedure. Postoperative complications were not influenced by IT. Long-term survival was adversely influenced by the absence of IT, the presence of extended resection, the presence of squamous cell carcinoma, and cancers at advanced stages.

Guiding Principles in the Management of Synchronous and Metachronous Primary Non-Small Cell Lung Cancer

Multiple lung cancers can be found simultaneously, with incidence ranging from 1% to 8%. Documentation of more than 1 pulmonary lesion can be challenging, because these solid, ground-glass, or mixed-density tumors may represent multicentric malignant disease or intrapulmonary metastases. If mediastinal nodal and distant deposits are excluded, surgery should be contemplated. After surgical treatment of lung cancer, patients should be followed closely for an undetermined period of time. Good clinical judgment is of outmost importance in deciding which individuals will benefit from those surgical interventions and which are candidates for alternate therapies. Every case should be discussed in a multidisciplinary meeting.

Completion Pneumonectomy for Second Primary/Primary Lung Cancer and Local Recurrence Lung Cancer

BACKGROUND

Completion pneumonectomy (CP) for second primary/primary lung cancer (SPLC) and local recurrence lung cancer (LRLC) is still controversial. Although several case series on such a practice exist, the oncological benefit is under debate. The purpose of this study was to review available literatures on CP for SPLC and LRLC and evaluate postoperative and long-term outcomes.

METHODS

MEDLINE, SCOPUS and Web of Science were reviewed for eligible studies in January 2021. Studies were included if they indicated outcomes of patients with lung cancer undergoing CP. Overall survival (OS) was defined as the primary end point; secondary end points included operative morbidity and 30-day mortality. Random-effects meta-analysis based on a binomial distribution was used to create pooled estimates.

RESULTS

Thirty-two eligible studies including 1,157 patients were identified. These studies were uniformly retrospective reports. Pooled estimates for 3- and 5-year OS were 50.6% [95% confidence interval (CI) 34.7-66.5] and 38.9% [95% CI 32.2-46.1] in SPLC patients. When the SPLC was a stage I tumor, pooled 5-year OS was favorable with 60.7% [95% CI 43.2-75.9]. In LRLC, pooled 3- and 5-year OS were 47.6% [95% CI 36.1-59.4] and 33.8% (95% CI 26.8-41.5). Pooled morbidity and 30-day mortality was reported in 38.2% (95% CI 32.0-44.9), and 10.0% (95% CI 8.1-12.3).

CONCLUSIONS

CP for SPLC and LRLC is a challenging procedure with significant perioperative morbimortality. However, published evidence indicates good long-term survival for selected patients. Further studies are needed to identify patient subgroups which benefit most from CP.

Long-term outcomes of completion pneumonectomy for non-small cell lung cancer

Background: Completion pneumonectomy (CP) is the removal of remaining lung tissue after initial resection. Our aim in this study was to investigate the factors affecting mortality, morbidity, and survival after CP. Methods: Patients who underwent CP in our clinic between January 2000 and December 2015 were evaluated retrospectively. The patients' demographic information, morbidity, mortality, histopathological characteristics, and 2-, 5-, and 10-year survival were evaluated. Results: Of the 32 non-small cell lung cancer patients in the study, 31 (96.9%) were male and one (3.1%) was female. The postoperative mortality rate was 9.4% and the morbidity rate was 46.9%. The most common complication was atrial fibrillation (31.3%). Median survival time was 67 ± 10.3 months; 5- and 10-year survival rates were 50.3 and 31.2%, respectively. Conclusion: Completion pneumonectomy involves an acceptable mortality rate but high morbidity rate. Based on the results of this study, the interval between initial resection and CP does not affect survival time.

Postpneumonectomy bronchopleural fistula: analysis of risk factors and the role of bronchial stump coverage

PURPOSE

Bronchopleural fistula (BPF) is a potentially fatal complication of pneumonectomy. We analyze its occurrence rate, risk factors, and the methods used for its prevention.

METHODS

We reviewed the medical records of patients who underwent pneumonectomy at our Institution between January, 1990 and March, 2016. The risk factors for postoperative BPF were analyzed by univariate analysis and multiple logistic regression.

RESULTS

Over the study period, 511 patients underwent pneumonectomy for non-small cell lung cancer (NSCLC) and had the bronchus closed by manual suturing. BPF developed in 23 patients (4.5%). Multiple logistic regression identified no coverage of the bronchial stump, right-sided pneumonectomy, residual tumor in the bronchial stump, postoperative ventilatory support, and completion pneumonectomy, as independent risk factors for BPF. The cumulative rate of BPF decreased significantly over time from 18% between 1990 and 1995 to 1% between 2011 and 2016 (p < 0.001). Concurrently, the data of several patients showed a significant positive trend over time, including bronchial stump coverage (BSC).

DISCUSSION

Several known risk factors for BPF were confirmed. The more frequent usage of tissue flaps for coverage of the bronchial stump may have contributed to the reduction in the rate of postoperative BPF over time.

Completion pneumonectomy: Indications and outcomes in non-small cell lung cancer

Background

This retrospective single-center study aims to review the indications and outcomes of completion pneumonectomy after primary resection due to non-small cell lung cancer.

Methods

Of a total of 452 patients who underwent pneumonectomy between January 2004 and August 2017 for non-small cell lung cancer, 29 (24 males, 5 females; mean age 59.9±7.1 years; range, 45 to 72 years) were performed completion pneumonectomy. Patients" indications, factors affecting early and late-term outcomes, operative mortality and survival rates were analyzed.

Results

Operative mortality rate was 24.1%, including two intraoperative and five postoperative deaths. Complication rate was 44.8% and the most frequent complication was bronchopleural fistula with 24.1%. Study population was divided into two groups. While elective completion pneumonectomy group (n=19) consisted of recurrent malignant tumor patients, rescue completion pneumonectomy group (n=10) consisted of patients performed urgent pneumonectomy due to a bronchopulmonary complication developing after an anatomic lung resection. The morbidity and mortality rates for elective completion pneumonectomy and rescue completion pneumonectomy were 26.3% and 21.1%; and 70% and 30%, respectively. The morbidity for rescue completion pneumonectomy was significantly higher than elective completion pneumonectomy (p=0.016). Advanced age and presence of any preoperative risk (comorbidity and neoadjuvant treatment) were related to higher operative mortality (p=0.019 and p=0.049, respectively). The median survival after completion pneumonectomy was 19.5 months (95% confidence interval 17.2 to 21.9 months).

Conclusion

The morbidity and mortality rates of completion pneumonectomy are higher than standard pneumonectomy. Rescue completion pneumonectomy is related to higher postoperative risk, but has better survival. The most significant complication after completion pneumonectomy is bronchopleural fistula. Advanced age and presence of any preoperative risk are related to statistically significantly higher mortality in completion pneumonectomy. Nevertheless, completion pneumonectomy is still a significant treatment option in selected patients.

Completion pneumonectomy: a valuable option for lung cancer recurrence or new primaries

Background

The preoperative selection of patients with lung cancer recurrence remains a major clinical challenge. Several aspects of this kind of surgery are still insufficiently evidence-based, with only a few series with more than 50 patients.

Methods

A retrospective study on 29 patients who underwent a completion pneumonectomy for postoperative lung cancer recurrence or new primary was done in the period between October 2004 and December 2015. Inclusion criteria include complete (R0) first and second resections, histologically proven recurrent or new malignancy, complete pathohistological report after both operations, and exact data about the treatment outcome at the time of the last contact with patients or their families.

Results

There were 25 (86.2%) males and 4 (13.8%) females (M:F 6.2:1). In 13/29 patients, the interval between the first and second operations was less than 2 years, while in the remaining 16 patients, it was longer than 2 years. Concerning the operative stage distribution, stage I was more frequent after the first operation (44.8 vs. 22%), while stage III was dominant after the second operation (40.7 vs. 10.3%). The same tumor histology after the first and second operations existed in 24 (82.8%) patients. Adjuvant treatment was given to 53.6% of patients after the first and to 45.5% of patients after the second operation. The overall 5-year survival was 30%, median survival being 35 ± 16.9 months (1.896, 68.104 95% CI). A median survival of patients in post-surgery stage I after re-do surgery was better in comparison with that in higher stages (35 ± 22.6 vs.17.2 ± 15.1 vs. 21 ± 6.7 months, p > 0.05). Patients with the same tumor type at both operations lived significantly longer (median survival 48 ± 21.5 vs. 7.7 ± 1.9 months) than patients with different tumor histology after the second operation. Patients under 60 years (42.9%) lived longer than patients older than 60 years (median survival 69 ± 4.5 vs. 17.2 ± 14.3 months). The Cox regression analysis revealed only the disease stage at first operation and the same/different tumor histology as significant prognostic factors. One patient died from cardiac insufficiency caused by bronchopleural fistula (3.4% operative mortality). Operative morbidity was 34.4%.

Conclusion

Completion pneumonectomy may be a reasonable option for postoperative lung cancer recurrence or new primaries only in carefully selected patients, in whom the potential oncological benefits overweigh the surgical risk.

Completion pneumonectomy after fenestration for empyema due to nontuberculous mycobacteriosis associated with destroyed lung as a result of cancer surgery

Long-term follow-up of post-operative lung cancer patients indicates that some patients develop lung complications. Destroyed lung cannot be ignored because it predisposes the patient to recurrent infection. We report a case of thoracic empyema with bronchopleural fistula that developed in lung tissue damaged due to cancer surgery and associated with an infection of Mycobacterium gordonae (M. gordonae); a class of bacterium responsible for nontuberculous mycobacterial infection. The patient's cancer did not recur after surgery and followed a typical course that began with sub-pleural cystitis followed by repeated infection. We performed fenestration because the patient developed fistulous empyema and the infection became difficult to control using antibiotics. The patient then underwent a radical pleuropneumonectomy and his postoperative course was excellent. Thus, in cases of impaired lung function due to cancer surgery and where pharmacologic control of infection is challenging, we suggest that radical surgical intervention should be considered.

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis

BACKGROUND

Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients.

METHODS

Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses.

RESULTS

The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95] (first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second meta-analysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled three- and five- year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability.

CONCLUSIONS

Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.

Analysis of Pneumonectomy for Benign Disease: A Single Institution Retrospective Study on 59 Patients

INTRODUCTION

Pneumonectomy is the only curative treatment for some benign diseases but the operation is a challenging procedure. Herein, we present our experiences of pneumonectomy for 59 patients.

METHODS

The medical records of 59 patients who undergone pneumonectomy for benign lung diseases from 2008 to 2013 at the Division of Thoracic Surgery in Beijing Chest Hospital were retrospectively reviewed.

RESULTS

There were 23 male and 36 female patients. Three procedures including pneumonectomy, pleuropneumonectomy and completion pneumonectomy were used. The operative time and intraoperative blood loss were statistically different in the patients who undergone different operations. The operative time of the patients with and without tuberculosis had no difference but the intraoperative blood loss was more in the patients with tuberculosis (P = 0.035). The operative type, age and operative blood loss were relevant with the morbidity, the P value were 0.024, 0.042 and 0.027 respectively.

CONCLUSIONS

Pneumonectomy for patients with benign disease may be more difficult than for patients with lung cancer, mean while pleuropneumonectomy and completion pneumonectomy may be greater challenges. But with careful patient selection and operative technique, it is a satisfactory treatment method for benign lung disease. The morbidity is acceptable and associated with operative type, age and operative blood loss.

Pulmonary metastasectomy: outcomes and issues according to the type of surgical resection

According to a recent report by the Committee for Scientific Affairs of the Japanese Association for Thoracic Surgery, pulmonary metastasectomy accounted for as many as 10.2 % of all entry cases of general thoracic surgery, and its use is increasing year by year. Accordingly, many studies have examined the surgical procedures used during pulmonary metastasectomy for metastases from primary tumors affecting various organs as well as the outcomes of and indications for such procedures, but some problems remain. In this article, the following questions related to the surgical approach and the type of resection used during pulmonary metastasectomy are reviewed: (1) Wedge resection--what is a safe margin for preventing local recurrence? (2) What is the clinical significance of node sampling/dissection during pulmonary metastasectomy? and (3) When is segmentectomy necessary? In addition, we discuss: (4) open thoracotomy vs. video-assisted thoracoscopic surgery (VATS), (5) repeated metastasectomy for pulmonary metastases, (6) the surgical approach for bilateral pulmonary metastasectomy, (7) pneumonectomy, and (8) pulmonary metastasectomy combined with resection of the neighboring organs.

Completion pneumonectomy and chemoradiotherapy as treatment options in local recurrence of non-small-cell lung cancer

INTRODUCTION

The selection of treatment for local recurrence in patients with non-small-cell lung cancer (NSCLC) depends on the possibility of performing a radical tumor resection, the patient's performance status, and cardiopulmonary efficiency. Compared with chemoradiotherapy, surgical treatment offers a greater chance of long-term survival, but results in completion pneumonectomy and is associated with a relatively high rate of complications.

AIM OF THE STUDY

Aim of the study was to evaluate early and long-term results of surgery and conservative treatment (chemoradiotherapy) in patients with local NSCLC recurrence.

MATERIAL AND METHODS

Between 1998 and 2011, 1697 NSCLC patients underwent lobectomy or bilobectomy at the Department of Thoracic Surgery in Poznań. Among them, 137 patients (8.1%) were diagnosed with cancer recurrence; chemotherapy or chemoradiotherapy was provided to 116 patients; 21 patients (15.3%) were treated with completion pneumonectomy. The median time from primary surgery to recurrence was 13.4 months. No metastases to N2 lymph nodes were observed among the patients undergoing surgery; in 7 patients N1 lymph node metastases were confirmed.

RESULTS

The rate of complications after surgery was significantly higher in comparison with conservative therapy (80.9% vs. 48.3%). Patients treated with surgery were most likely to suffer from complications associated with the circulatory system (80.9%), while hematologic complications were dominant in the group undergoing oncological treatment (41.4%). There were no perioperative deaths after completion pneumonectomy. The age of the patients was the only factor which significantly influenced the incidence of complications in both groups of patients. Analysis of the survival curves demonstrated statistically significant differences in survival between the groups treated with surgery, chemoradiotherapy, and chemotherapy (p = 0.00001). Five-year survival probability was significantly higher among patients treated surgically as compared to patients undergoing systemic therapy.

CONCLUSIONS

Despite the significant rate of postoperative complications (mostly circulatory), the long-term results of the surgical treatment of local NSCLC recurrence are more favorable than those achieved with chemoradiotherapy. The success of surgical treatment is conditioned on the exclusion of metastasis in N2 lymph nodes.

Pneumonectomy for benign disease: indications and postoperative outcomes, a nationwide study

OBJECTIVES

Pneumonectomy for benign disease is rare but is thought to have a higher more postoperative morbidity and mortality than when performed for lung cancer. We questioned this by assessing and analysing indications and postoperative outcomes of patients who underwent this type of resection.

METHODS

We used Epithor, the French national thoracic database including 91 public and private institutions with more than 220 000 procedures. We prospectively collected data of 5975 patients who underwent pneumonectomy between January 2003 and June 2013. The 321 patients (5.4%) who underwent pneumonectomy (n = 201) or completion pneumonectomy (n = 120) for benign disease were compared with those treated for malignant disease.

RESULTS

The patients' mean age was 55.2 years (53.5; 56.8) for benign indications vs 61.6 years (61.4; 61.9) for malignant disease; the sex ratio was 1.8 (207 males) and 4 (4543 males), respectively; 53% of patients (n = 169) had an American Society of Anesthesiologist (ASA) score of ≥3 vs 29% (n = 1598) for malignant disease. For benign disease, most frequent indications were infection or abscess (n = 114, 37.1%), post-tuberculosis destroyed lung (n = 47, 15.3%), aspergillosis or aspergilloma (n = 33, 10.7%), bronchiectasis (n = 41, 13.3%), haemorrhage (n = 26, 8.5%) and benign tumour (n = 20, 6.5%). Complications occurred in 53% (n = 170) of patients and the postoperative in-hospital mortality rate was 22.1% (n = 71). These results were significantly worse than those for malignant indications: 38.9% (n = 2198) of morbidity (P < 0.0001) and 5.1% (n = 288) of in-hospital mortality (P < 0.0001). For benign disease, there was no difference in fistula formation regarding side (P = 0.07) or type of resection (P = 0.6). Morbidity was higher for completion pneumonectomy: 62.5 vs 47.3% (P = 0.008). Mortality was significantly higher in case of resection for infection or abscess (P = 0.01) and for haemorrhage (P = 0.002). Emergency procedures were associated with worse postoperative outcomes (P < 0.0001).

CONCLUSIONS

Pneumonectomy for benign disease achieves cure with very high levels of morbidity and mortality. This type of surgical treatment should be considered as a salvage procedure.

The early and long-term outcomes of completion pneumonectomy: report of 56 cases

OBJECTIVES

The aim of this study was to analyse the early and long-term results of completion pneumonectomy (CP).

METHODS

A retrospective review of consecutive patients who underwent CP in the Shanghai Chest Hospital.

RESULTS

Fifty-six CP were performed between January 2003 and July 2013. There were 45 conventional CP (CCP) and 11 rescue CP (RCP) cases. CCP was defined as resection of the remaining lung because of the occurrence of new lesions in patients with previous lung resection. RCP was defined as resection of the remaining lung because of severe complication after primary lung surgery. The mortality and morbidity rates of CCP were 4.4 and 33.3%, respectively. For CCP, the morbidity was significantly higher in benign cases than in malignant cases (80.0 vs 27.5%, P = 0.04). The mortality and morbidity rates of RCP were 27.3 and 90.9%, respectively. For RCP, advanced age (P = 0.046) and preoperative mechanical ventilation (P = 0.03) were related to higher postoperative mortality. The overall 5-year survival rate was 80% for benign cases, whereas for lung malignancy cases, it was 30%. Survival varied (median 60.0 vs 35.0 vs 10.0 months, I vs II vs III, P < 0.01) for different TNM stages and was better for a time interval (between primary surgery and occurrence of lesion) of >2 years (median 60.0 vs 18.0 months, P < 0.01).

CONCLUSIONS

CP was an operation with high risk, especially for RCP. Advanced age and mechanical ventilation before the operation were related to higher mortality in RCP. CCP of benign cases was related to higher postoperative risk, but with good survival. For lung malignancy, survival was better for a time interval (between primary surgery and occurrence of lesion) of >2 years.

Completion pneumonectomy: outcomes for benign and malignant indications

BACKGROUND

Past series have identified completion pneumonectomy (CP) as a high-risk operation. We evaluated factors affecting outcomes of CP with a selective approach to offering this operation.

METHODS

We analyzed a prospective institutional database and abstracted information on patients undergoing pneumonectomy. Patients undergoing CP were compared with those undergoing primary pneumonectomy (PP).

RESULTS

Between January 2000 and February 2011, 211 patients underwent pneumonectomy, of which 35 (17%) were CPs. Ten of 35 (29%) CPs were for benign disease and 25 of 35 (71%) for cancer. Major perioperative morbidity was seen in 21 of 35 (60%) with 4 (11%) perioperative deaths. In univariate analysis, postoperative bronchopleural fistula (p = 0.05) and benign diagnosis (p = 0.07) tended to be associated with perioperative mortality. All 10 patients undergoing CP for benign disease developed a major complication compared with 11 of 25 (44%) with malignancy, p = 0.002. A bronchopleural fistula (4 of 35, 11%) was more likely to occur in patients undergoing CP shortly after the primary operation (interval between lobectomy and CP; 0.28 vs 4.5 years; p = 0.018) with a trend toward a benign indication for operation (p = 0.07). Median survival after CP for benign and malignant indications was 24.3 months and 36.5 months, respectively. Comparing CP patients to those undergoing PP (n = 176), CP patients were more likely to undergo an operation for benign disease (10 of 35, 29% vs 14 of 176, 8%, p = 0.001). Perioperative mortality for PP was 10 of 176 (5.7%), and was statistically similar to CP (11%).

CONCLUSIONS

Despite a selective approach, CP remains a morbid operation, particularly for benign indications. Rigorous preoperative optimization, ruling out contraindications to operation and attention to technical detail, are recommended.

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.

Completion pneumonectomy in patients with cancer: postoperative survival and mortality factors

OBJECTIVE

To describe postoperative complications and long-term outcomes of completion pneumonectomy and highlight prognostic factors.

METHOD

We retrospectively reviewed the records of 46 patients (38 men, 8 women) who underwent completion pneumonectomy for lung cancer between 1995 and 2009 in one of two thoracic surgery departments. Most were current or former smokers (n = 41; 89%) and did not undergo chemotherapy (n = 38; 83%) or radiotherapy (83%) before surgery.

RESULTS

Complications after surgery were respiratory failure (n = 11; 24.4%), bronchopleural fistula (n = 6; 13%, with no side preference), and empyema (n = 6; 13%). Blood transfusion was necessary for 43% of the cases (n = 20). The day 90 death rate was 15.2% (n = 7). Postoperative staging showed mostly limited disease. Ten patients (21.7%) underwent operation for a second primary cancer, 25 for local recurrence (54.3%), five for microscopically incomplete resection, and six for other reasons. Median overall survival after completion surgery was 30 months (median follow-up: 46.5 months). Among the 15 living patients (33%), 11 are free of disease (24%). In a Cox regression model, factors negatively influencing overall survival were: age older than 65 years (odds ratio [OR] = 2.47; p = 0.012), current smoker status (OR = 2.285; p = 0.033), postoperative pulmonary (OR = 5.144; p = 0.004), cardiac (OR = 3.404; p = 0.033), or parietal wound complications (OR = 5.439; p = 0.016).

CONCLUSION

Despite its increased postoperative complications and mortality compared with standard pneumonectomy, completion pneumonectomy offers encouraging long-term results. Five main factors seem predictive of shorter overall survival.

Surgical treatment for metachronous second primary lung cancer after radical resection of primary lung cancer

PURPOSE

We retrospectively reviewed our experience of surgical resection for second primary lung cancer (SPLC) in our institute. And to clarify whether periodic follow-up after resection of first primary lung cancer (FPLC) is associated with earlier detection of SPLC.

METHODS

From January 2003 to March 2011, a total of 386 patients underwent surgical resection for primary lung cancer in our institute. Of these patients, 21 (5.4%) with SPLC were observed during follow-up after surgery. Radiation therapy was selected instead of surgical resection in 7 patients to preserve respiratory function. The other14 patients are reviewed in this paper.

RESULTS

Histological types were different between FPLC and SPLC in only one patient(FPLC: adenosquamous carcinoma, SPLC: squamous cell carcinoma). The average SPLC tumor size (18±8 mm) was smaller (P = 0.07) than the average FPLC tumor size (26±14 mm). Recurrence was not observed in these patients.The follow-up period after resection of SPLC was 31±30 (5-94) months. During followup, 2 patients died of de novo malignancies, and the other 12 patients were alive without recurrence.

CONCLUSION

Systematic and periodic long-term follow-up after FPLC probably resulted in earlier detection of SPLC and yielded this good prognosis.

Completion pneumonectomy for lung cancer treatment: early and long term outcomes

Background

To analyze the experience of completion pneumonectomy for lung cancer at a single institution in China.

Methods

From January 1988 to December 2007, 92 patients underwent completion pneumonectomy for the treatment of lung cancer. The indications were second primary lung cancer (n = 51), Local metastasis (n = 37) and Lung metastasis (n = 4). The median interval between the primary operation and CP was 24.4 months (1.5-145 m).

Results

There was no intraoperative deaths. The CP procedure lasted 4.3 h (1.5-8 h). Blood loss in the CP performance was 1854.5 ml (200-9100 ml) 9 (9.78%) patients died in the postoperative period: pulmonary embolism (n = 2), disseminated intravascular coagulation (DIC) after the multisystem failure (n = 1), respiratory failure after contralateral pneumonia (n = 5), bronchopleural fistula (BPF) with acute respiratory distress syndrome (ARDS) (n = 1) 31(33.7%) patients had at least one major nonfatal complication. The 1, 3 and 5 year survival rates were 81%, 26% and 14% respectively.

Conclusions

Completion pneumonectomy for lung cancer is a safe surgical procedure for the skilled surgeon though it has a relatively higher complications and the long-term survival is acceptable.

Left lower apical segmentectomy after video-assisted left upper lobectomy for relapse in lung cancer: benefit to avoid completion pneumonectomy

Segmental resection is a useful procedure to preserve respiratory function. We report a case of lower apical segmentectomy for relapse after initial video-assisted left upper lobectomy to avoid completion pneumonectomy. After 4 years of follow-up, the patient is doing well with no evidence of disease.

Emergent completion pneumonectomy for postoperative hemorrhage from rupture of the infected pulmonary artery in lung cancer surgery

Completion pneumonectomy (CP) is one of the most difficult procedures and known to be associated with a high morbidity and mortality. A 74-year-old male underwent a left upper lobectomy for pulmonary adenocarcinoma (T3N0M0); six days later after the surgery, he had a sudden postoperative intrathoracic excessive hemorrhage with shock. Emergent redo thoracotomy was performed to treat the bleeding from the ablated interlobar pulmonary artery by suturing with prolene. However, 3 days later after the second operation, he had the second intrathoracic bleeding. Emergent CP was performed with cardiopulmonary bypass by anterior transpericarsial approach via a median sternotomy. The hemorrhage was caused by a rupture of the proximal fragile and infected pulmonary artery. We performed omentopexy for the infected intrathoracic cavity and for covering of the divided main bronchial stump. We had a rare experience of two times of postoperative life-threatening hemorrhage from rupture of the infected pulmonary artery after left upper lobectomy. Emergent CP as salvage surgery should have an advantage in control of infected proximal pulmonary arterial hemorrhage. We should take care of tearing off of adventitia of pulmonary artery in lobectomy because of a possibility of postoperative hemorrhage under a fragility of the injured pulmonary artery with infection.