Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung cancer

The Short-Term Impact of Neoadjuvant Chemotherapy on the Outcome of Patients Undergoing Pneumonectomy for Lung Cancer: Is It Acceptable Nowadays?

Objective: We aimed at assessing our experience at the European Institute of Oncology in order to evaluate the peri- and immediately post-operative impact of neoadjuvant chemotherapy in patients who underwent pneumonectomy for NSCLC. Materials and methods: We retrospectively reviewed the outcomes and medical records of patients undergoing pneumonectomy (2010-2024). We compared pre-, peri- and post-operative outcomes of patients treated with induction chemotherapy and subsequent pneumonectomy with patients who underwent surgery directly. Differences in their distribution between study arms were assessed using the chi-square test for categorical variables or the Mantel-Haenszel test for trend for ordinal variables. We tested normality of the distribution of continuous variables using the Shapiro-Wilk test. We used logistic regression to quantify the risk of various outcomes (complications, 30-day and 12-day mortality) in patients who received neoadjuvant chemotherapy. Risks were expressed as odds ratios (ORs) with 95% confidence intervals (CIs adjusted for age (<60, 60-64, 65-69, ≥70 years), sex and comorbidities (cardiovascular, pulmonary or previous cancer). Results: We observed a higher frequency of post-operative respiratory complications in patients who underwent neoadjuvant therapy and pneumonectomy compared to those who only underwent surgery (11.4% vs. 18.5%; p = 0.05). After adjustment for age, sex and comorbidities we observed a significantly higher rate of pulmonary complications (OR 1.95; 95% CI 1.09-3.47; p = 0.02), ARDS (OR 2.88; 95% CI 1.26-6.59; p = 0.02) and 30-day mortality rate (OR 8.19; 95% CI 1.33-50.3; p = 0.02) in pre-treated patients. Conclusions: It is therefore strongly recommended to study and select potentially eligible patients in an extremely meticulous way before starting the neoadjuvant treatment, and to thoroughly re-evaluate the cardiorespiratory status after inductive therapy, before surgery.

Salvage lung resection after immunotherapy is feasible and safe

Objectives

Patients with non-small cell lung cancer treated with immunotherapy and modern chemoradiation regimens show improved progression-free and overall survival. However, patients with limited oligo-progression represent a potential population in which local therapy such as surgery may have a potential role as salvage treatment. The objectives of our study were to evaluate the feasibility and safety of salvage lung resection after immunotherapy in patients with non-small cell lung cancer.

Methods

The National Cancer Database was queried for patients diagnosed and treated for non-small cell lung cancer stage I to IV, from 2013 to 2020. Patients who underwent surgery as salvage after immunotherapy were defined as undergoing surgery >5 months from the initiation of immunotherapy. As a sensitivity analysis, patients who underwent surgery as salvage after chemoradiation were also analyzed in a similar fashion. Surgical outcomes such as type of surgery, complete resection (R0) rates, and complete pathologic response rates were determined for feasibility. Length of stay, 30-day readmission rates, and 30-day mortality rates were determined and overall survivals were estimated with Kaplan-Meier analysis to evaluate for safety.

Results

Of the 934,093 patients diagnosed with non-small cell lung cancer stage I to IV from 2013 to 2020, 164 patients received immunotherapy and after 5 months underwent surgery. Lobectomy was the most commonly performed operation (74%) and pneumonectomy was required in 9% (n = 15). R0 resection was achieved in 89% (n = 146) and of these patients, 23% (n = 37) had complete pathologic response. Median length of stay was 4 days, 30-day readmission was 5%, and 30-day mortality was 0.6%. In our sensitivity analysis of chemoradiation patients (n = 445), the above data were similar to previously reported cohort studies of patients undergoing chemoradiation and subsequently salvage surgery.

Conclusions

Lung resection after immunotherapy appears to be a feasible salvage treatment option, with lobectomy being most common and with high R0 resection rates. Low patient morbidity and mortality rates also suggest the safety of this approach. Salvage surgery may be considered in patients who have oligo-progression after immunotherapy within the context of a comprehensive multidisciplinary treatment plan.

Risk Factor Analysis of Morbidity and 90-Day Mortality of Curative Resection in Patients with Stage IIIA-N2 Non-Small Cell Lung Cancer after Induction Concurrent Chemoradiation Therapy

Background

Major pulmonary resection after neoadjuvant concurrent chemoradiation therapy (nCCRT) is associated with a substantial risk of postoperative complications. This study investigated postoperative complications and associated risk factors to facilitate the selection of suitable surgical candidates following nCCRT in stage IIIA-N2 non-small cell lung cancer (NSCLC).

Methods

We conducted a retrospective analysis of patients diagnosed with clinical stage IIIA-N2 NSCLC who underwent surgical resection following nCCRT between 1997 and 2013. Perioperative characteristics and clinical factors associated with morbidity and mortality were analyzed using univariable and multivariable logistic regression.

Results

A total of 574 patients underwent major lung resection after induction CCRT. Thirty-day and 90-day postoperative mortality occurred in 8 patients (1.4%) and 41 patients (7.1%), respectively. Acute respiratory distress syndrome (n=6, 4.5%) was the primary cause of in-hospital mortality. Morbidity occurred in 199 patients (34.7%). Multivariable analysis identified significant predictors of morbidity, including patient age exceeding 70 years (odds ratio [OR], 1.8; p=0.04), low body mass index (OR, 2.6; p=0.02), and pneumonectomy (OR, 1.8; p=0.03). Patient age over 70 years (OR, 1.8; p=0.02) and pneumonectomy (OR, 3.26; p<0.01) were independent predictors of mortality in the multivariable analysis.

Conclusion

In conclusion, the surgical outcomes following nCCRT are less favorable for individuals aged over 70 years or those undergoing pneumonectomy. Special attention is warranted for these patients due to their heightened risks of respiratory complications. In high-risk patients, such as elderly patients with decreased lung function, alternative treatment options like definitive CCRT should be considered instead of surgical resection.

Risk factors for pulmonary complications after neoadjuvant chemoradiotherapy followed by surgery for non-small cell lung cancer

Background

We aimed to investigate the characteristics and pretreatment risk factors for postoperative pulmonary complications (PPCs) after neoadjuvant concurrent chemoradiotherapy (CRTx) in patients with non‐small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed data of 122 patients who underwent curative resection after neoadjuvant CRTx for NSCLC between 2007 and December 2019. Clinical data, including pulmonary function and body mass index (BMI) at the time of concurrent CRTx initiation, were analyzed. We performed logistic regression analyses to identify the risk factors for PPCs and built a nomogram with significant factors.

Results

Of the 122 patients included (mean age, 60.1 ± 9.7 years; 69.7% male), 27 experienced PPCs (severity grade ≥ 2). The most common PPCs were pneumonia (n = 17). Patients with PPCs had a significantly longer hospital stay (median 6.0 vs. 17 days, p < 0.001) and a higher in‐hospital mortality rate (1.1% vs. 29.6%, p < 0.001). In multivariable analysis, lower BMI (odds ratio [OR] 0.796, 95% confidence interval [CI] 0.628–0.987, p = 0.038), no comorbidity (OR 0.220, 95% CI: 0.059–0.819, p = 0.048), smoking history (OR 4.362, 95% CI: 1.210–15.720, p = 0.024), and %predicted DLCO <60% (OR 3.727, 95% CI: 1.319–10.530, p = 0.013) were independent risk factors for PPCs. The predictive accuracy of the nomogram built with factors was excellent (concordance index: 0.756).

Conclusions

The nomogram constructed with factors identified in multivariable analysis could serve as a reliable tool for evaluating the risk of PPCs in the patients who underwent neoadjuvant CRTx for NSCLC.

18FDG-PET/CT Specificity for the Detection of Lymphoma Recurrence in the Tonsils

Objective

In patients with a history of lymphoma who demonstrate palatine tonsil uptake on posttreatment PET/CT (positron emission tomography/computed tomography), tonsillectomy is often performed to evaluate for lymphoma recurrence. However, predictive clinical and imaging factors for true tonsil recurrence in this setting are not well established; this will be explored herein.

Study Design

Retrospective case series.

Setting

Patients treated at a tertiary medical center from January 2008 to May 2020.

Methods

Chart review was performed on all patients with a history of treated lymphoma in clinical remission who presented for evaluation of abnormal PET/CT imaging findings and subsequently underwent tonsillectomy.

Results

Among 15 patients who met inclusion criteria, 14 had benign findings on surgical pathology, yielding a false-positive rate of 93%. The patient with malignancy was identified on biopsy after inconclusive surgical pathology and is the only documented case of recurrence in this specific patient population throughout the literature. The patient presented with B symptoms, irregularly shaped tonsils, increased lymph node activity on PET/CT, and uptrending bilateral tonsil activity but with one of the lowest maximum standardized uptake values of the cohort. The singular distinguishing feature for the patient with recurrent disease was a prior tonsil biopsy suspicious for recurrence, which prompted the otolaryngology referral.

Conclusion

PET/CT lacks specificity in identifying lymphoma recurrence in the oropharynx. Clinical and radiographic features that were previously considered concerning for recurrence are most likely not indicative of malignancy in this patient population. Our findings call into question whether tonsillectomy should be routinely performed in this patient population.

Induction therapy is not associated with improved survival in large cT4N0 non-small cell lung cancers

BACKGROUND

The 8^th edition staging for non-small cell lung cancer reclassified tumors >7 cm as stage IIIA (T4N0); previously, such tumors without nodal disease were considered stage IIB (T3N0). This study tested the hypothesis that induction chemotherapy for these stage IIIA patients does not improve survival compared to primary surgery.

METHODS

The National Cancer Database was queried for non-small cell lung cancer patients with tumor size >7 cm who underwent surgical resection from 2010 - 2015. Patients with clinically node-positive disease or tumor invasion of major structures were excluded. Patients undergoing induction chemotherapy followed by surgery (IC) were compared to patients undergoing primary surgery (PS). Propensity-score matching was performed.

RESULTS

In total, 1,610 patients with cT4N0 disease based on tumor size >7 cm and no tumor invasion underwent surgical resection: 1,346 (83.6%) comprised the PS group and 264 (16.4%) the IC group. After propensity-score matching, IC had a higher rate of pN0 (78.4% vs 66.0%, p<0.001) and less lymphovascular invasion (13.9% vs 26.3%, p<0.001), but longer postoperative stay (6 vs 5 days, p<0.001) and higher 30-day mortality (3.5% vs 0%, p=0.002). Median 5-year survival was similar between IC and PS (53.5% vs 62.2%, p=0.075), and IC was not independently associated with survival (HR 1.45, p=0.146).

CONCLUSIONS

Patients with cT4N0 non-small cell lung cancer based on tumor size >7 cm and no tumor invasion of major structures have similar overall survival with either IC or PS. IC should not be routinely given for this subset of stage IIIA patients.

Morbidity and mortality of lobectomy or pneumonectomy after neoadjuvant treatment: an analysis from the ESTS database

OBJECTIVES

To evaluate the postoperative complications and 30-day mortality rates associated with neoadjuvant chemotherapy before major anatomic lung resections registered in the European Society of Thoracic Surgeons (ESTS) database.

METHODS

Retrospective analysis on 52 982 anatomic lung resections registered in the ESTS database (July 2007-31 December 2017) (6587 pneumonectomies and 46 395 lobectomies); 5143 patients received neoadjuvant treatment (9.7%) (3993 chemotherapy alone and 1150 chemoradiotherapy). To adjust for possible confounders, a propensity case-matched analysis was performed. The postoperative outcomes (morbidity and 30-day mortality) of matched patients with and without induction treatment were compared.

RESULTS

8.2% of all patients undergoing lobectomies and 20% of all patients undergoing pneumonectomies received induction treatment. Lobectomy analysis: propensity score analysis yielded 3824 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the neoadjuvant group (626 patients, 16% vs 446 patients, 12%, P < 0.001), but 30-day mortality rates were similar (71 patients, 1.9% vs 75 patients, 2.0%, P = 0.73). The incidence of bronchopleural fistula and prolonged air leak >5 days were similar between the 2 groups (neoadjuvant: 0.5% vs 0.4%, P = 0.87; 9.2% vs 9.9%, P = 0.27). Pneumonectomy analysis: propensity score analysis yielded 1312 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the treated patients compared to those without neoadjuvant treatment (neoadjuvant 275 cases, 21% vs 18%, P = 0.030). However, the 30-day mortality was similar between the matched groups (neoadjuvant 68 cases, 5.2% vs 5.3%, P = 0.86). Finally, the incidence of bronchopleural fistula was also similar between the 2 groups (neoadjuvant 1.8% vs 1.4%, P = 0.44).

CONCLUSIONS

Neoadjuvant chemotherapy is not associated with an increased perioperative risk after either lobectomy or pneumonectomy, warranting a more liberal use of this approach for patients with locally advanced operable lung cancer.

Extended Robotic Pulmonary Resections

While lung cancer remains the most common cause of cancer-related mortality in the United States, surgery for curative intent continues to be a mainstay of therapy. The robotic platform for pulmonary resection for non-small cell lung cancer (NSCLC) has been utilized for more than a decade now. With respect to more localized resections, such as wedge resection or lobectomy, considerable data exist demonstrating shorter length of stay, decreased postoperative pain, improved lymph node dissection, and overall lower complication rate. There are a multitude of technical advantages the robotic approach offers, such as improved optics, natural movement of the operator's hands to control the instruments, and precise identification of tissue planes leading to a more ergonomic and safe dissection. Due to the advantages, the scope of robotic resections is expanding. In this review, we will look at the existing data on extended robotic pulmonary resections, specifically post-induction therapy resection, sleeve lobectomy, and pneumonectomy. Additionally, this review will examine the indications for these more complex resections, as well as review the data and outcomes from other institutions' experience with performing them. Lastly, we will share the strategy and outlook of our own institution with respect to these three types of extended pulmonary resections. Though some controversy remains regarding the use and safety of robotic surgery in these complex pulmonary resections, we hope to shed some light on the existing evidence and evaluate the efficacy and safety for patients with NSCLC.

Evaluation of Risk for Thoracic Surgery

Modern surgical practice places increased emphasis on treatment outcomes. There has been a paradigm shift from paternalistic ways of practicing medicine to patients having a major involvement in decision making and treatment planning. The combination of these two factors undoubtedly leaves the surgeon open to greater scrutiny in respect of results and outcomes. In dealing with this it is important that the surgeon, wider multidisciplinary team, and patient appreciate the idea of surgical risk. This article reviews the latest evidence relating to risk assessment in thoracic surgery and suggests how this should be incorporated into clinical practice.

Feasibility of Surgical Resection After Induction Epidermal Growth Factor Receptor-Tyrosine Kinase Inhibitor Therapy for N2 Lung Adenocarcinomas

BACKGROUND

Prognosis of patients with stage IIIA-N2 lung adenocarcinoma is still not optimistic. The aim of this study was to evaluate safety, feasibility, and outcomes of surgery after induction epidermal growth factor receptor-tyrosine kinase inhibitor therapy in a clinical trial setting.

METHODS

Fourteen patients with IIIA-N2 lung adenocarcinoma and epidermal growth factor receptor mutation received erlotinib induction followed by surgery in a phase II clinical trial. Perioperative outcomes and survival results were compared with a control group of 15 patients receiving neoadjuvant chemotherapy during the same time period.

RESULTS

Thirteen patients showed partial response to induction, whereas 16 patients remained stable. Serum carcinoembryonic antigen level in the erlotinib group was significantly higher than in the chemotherapy group before treatment but was reduced to similar levels after induction. Operation time, blood loss, resection extents, complete resection rates, postoperative drainage, complication rates, and length of hospital stay were all comparable between the 2 groups. Thoracoscopic resection was accomplished in 78.6% of patients in the erlotinib group and 80.0% of patients in the chemotherapy group (P = .924) but was higher in patients who responded to induction than those who did not (92.3% vs 68.8%, P = .119). A resection extent greater than lobectomy and incomplete resections were only seen in stable disease after induction. No significant difference was detected in 1-year and 3-year overall or disease-free survivals between the 2 groups.

CONCLUSIONS

Pulmonary resection is safe and feasible after induction treatment with erlotinib for stage IIIA-N2 lung adenocarcinomas. Better surgical and oncologic outcomes may be expected in patients who respond to effective induction therapies.

Wine cup stoma anastomosis after extended sleeve lobectomy for central-type squamous cell lung cancer

BACKGROUND

Extended sleeve lobectomy is rarely applied to pulmonary surgery for primary lung cancer to avoid a pneumonectomy. As there is a size discrepancy between main bronchus and peripheral bronchus, ingenuity to improve anastomosis is required in the bronchoplasty. We report herein a case in which successful reconstruction of extended sleeve lobectomy with bronchial wall flap.

CASE PRESENTATION

We report on a 64-year-old man suffering from hemoptysis, cough, mild fever and dyspnea. His computed tomography (CT) scan showed solid tumor of 40 mm in diameter in left lower bronchus, which obstructed the lower bronchus and caused obstructive pneumonia of left lower lobe and expanded to second carina and pulmonary artery. His bronchoscopy showed that tumor was exposed in the bronchial lumen and infiltrated to left main bronchus and upper bronchus even though the scope could pass through the exposed tumor of upper bronchus. Transbronchial lung biopsy showed squamous cell carcinoma. He had undergone left sleeve lingular segmentectomy and left lower lobectomy. Reconstruction was performed with bronchial wall flap. Pathological findings revealed pT3N0M0 stage IIB according to UICC 8th edition. Postoperative bronchoscopic findings showed no troubles at the anastomotic site. He has been well for eighteen months without recurrence after surgery.

CONCLUSIONS

We experienced a successful case who was reconstructed with bronchial wall flap (wine cup stoma) after extended sleeve lobectomy. This technique might be also useful for other types of extended sleeve lobectomy and lung transplantation to adjust caliber changes of bronchi.

Comparison of surgical outcomes after pneumonectomy and pulmonary function-preserving surgery for non-small cell lung cancer

BACKGROUND

According to previous reports, lobectomy with bronchoplasty or angioplasty is a more feasible surgery than pneumonectomy for central-type non-small cell lung cancer. However, few studies have compared both the short- and long-term outcomes between pneumonectomy and pulmonary function-preserving surgery.

METHODS

From January 2004 to December 2015, 18 patients underwent pneumonectomy (Group PN) and 12 patients underwent pulmonary function-preserving surgery (group PS) at Fukushima Medical University Hospital. Clinicopathological factors were statistically compared between the two groups.

RESULTS

The operation times in Group PN and Group PS were 285.9±27.9 and 271.3±99.2 min, respectively (p=0.613), while the amounts of intraoperative bleeding were 324.8±248.9 and 164.5±116.6 g, respectively (p=0.020). The duration of chest drainage and hospitalization after surgery in both groups were not significantly different but there was a tendency toward shorter periods of these durations in Group PS. The 5-year disease-free survival (DFS) rate in Group PN and PS was 51.4% and 74.1%, respectively, without a significant difference (p=0.298). The 5-year overall survival (OS) rate in Group PN and PS was 52.5% and 56.6%, respectively, also without a significant difference (p=0.748). The 5-year OS rate was inferior to the 5-year DFS rate in Group PS, and the 5-year OS rate was not better than the 5-year DFS rate in Group PN.

CONCLUSIONS

The short-term results were better in Group PS than PN. However, the long-term results in both groups were similar. Other causes of death influenced OS in both groups; this result might have been affected by the surgical procedures.

Preoperative functional workup for patients with advanced lung cancer

Locally advanced lung cancer remains a surgical indication in selected patients. This condition often demands larger resections. As a consequence preoperative functional workup is of paramount importance to stratify the risk and choose the most appropriate treatment. We reviewed the current evidence on functional evaluation with a special focus on specific aspects related to locally advanced lung cancer stages (i.e., risk after neoadjuvant treatment, pneumonectomy). Evidence is discussed to provide information that could assist clinicians in their preoperative workup of these challenging patients.

Bronchial colonization and complications after lung cancer surgery

PURPOSE

Infectious complications occur following pulmonary resections preceded or not by induction chemoradiotherapy. We aimed to investigate whether bacterial colonization of the bronchial tree at the time of surgery was associated with postoperative complications.

PATIENTS AND METHODS

A retrospective analysis of all patients who underwent open anatomical pulmonary resections for malignancies at a single center was performed. Demographical data of the included patients, intraoperative data, and data on the postoperative course of patients were collected. Outcome of patients with a positive intraoperative bronchial culture was compared to patients with a negative bronchial culture. Relations between the presence of potential bacterial pathogens in the bronchial tree and other possible risk factors for the development of postoperative infectious and non-infectious complications, were analyzed using uni- and multivariate analysis.

RESULTS

Between January 2010 and January 2012, a total of 121 consecutive patients underwent open anatomical pulmonary resections for malignancy, of whom 45 were preceded by induction chemoradiotherapy and 5 by induction chemotherapy. Intraoperative bronchial cultures were taken from 58 patients (48 %). Patients with a positive bronchial culture developed significantly more infectious (88 % vs. 20 %, p < 0.001) and non-infectious complications (63 % vs. 12 %, p = 0.001). Positive intraoperative bronchial cultures showed the strongest association with the development of infectious and non-infectious postoperative complications (OR 24.8 and 12.2, respectively). After multivariate analysis, only BMI less than 20 kg/m(2) and the presence of a positive intraoperative bronchial culture were found to be independent risk factors for the development of infectious complications. Chemoradiotherapy was not associated with postoperative complications in the present study.

CONCLUSIONS

Bacterial colonization of the bronchial tree assessed intraoperatively, appears to be associated with higher rates of infectious and non-infectious complications after pulmonary resection. Whether early starting of appropriate antibiotics based on intraoperative-taken culture findings will reduce the infectious complication rate in a subcategory of patients needs to be investigated.

Surgical outcomes of pulmonary resection for lung cancer after neo-adjuvant treatment

AIM: To evaluate the outcomes of surgery for lung cancer after induction therapy.

METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012), we identified 4063 patients who underwent a pulmonary resection for lung cancer. Two hundred and thirty-six (5.8%) received neo-adjuvant therapy prior to surgery (64 chemo-radiation, 103 radiation alone, 69 chemotherapy alone). The outcomes were compared to 3827 patients (94.2%) treated with surgery alone. Primary outcome was 30-d mortality, and secondary outcomes included length of stay, operative time and NSQIP measured postoperative complications.

RESULTS: Lung cancer patients who received preoperative treatment were younger (66 vs 69, P < 0.001), were more likely to have experienced recent weight loss (6.8% vs 3.5%; P = 0.011), to be active smokers (48.3 vs 34.9, P < 0.001), and had lower preoperative hematological cell counts (abnormal white blood cell: 25.6 vs 13.4; P < 0.001; low hematocrit 53% vs 17.3%, P < 0.001). On unadjusted analysis, neo-adjuvant patients had significantly higher 30-d mortality, overall and serious morbidity (all P < 0.001). Adjusted analysis showed similar findings, while matched cohorts comparison confirmed higher morbidity, but not higher early mortality.

CONCLUSION: Our data suggest that patients who receive neo-adjuvant therapy for lung cancer have worse early surgical outcomes. Although NSQIP does not provide stage information, this analysis shows important findings that should be considered when selecting patients for induction treatment.

Extrapleural pneumonectomy after induction chemotherapy: perioperative outcome in 251 mesothelioma patients from three high-volume institutions

BACKGROUND

Several publications have suggested that induction chemotherapy followed by extrapleural pneumonectomy (EPP) for patients with malignant pleural mesothelioma (MPM) patients is associated with exceedingly high morbidity and mortality, and the role of EPP is controversially debated. The present retrospective study analyzed the perioperative outcome in 251 consecutively treated patients at three high-volume mesothelioma centers.

METHODS

251 MPM patients completed EPP after platinum-based induction chemotherapy at three institutions for thoracic surgery over more than 10 years. The rates of 30-day and 90-day mortality and of major morbidities (pulmonary embolism, postoperative bleeding, acute respiratory distress syndrome, empyema, bronchopleural fistula (BPF), chylothorax, patch failure) were recorded. Perioperative outcome was correlated to risk factors such as smoking history (pack years), age at operation, body mass index, spirometry results, C-reactive protein, American Society of Anesthesiologists classification, chemotherapy regimen used, blood loss during operation, duration of operation, and characteristics of the tumor (laterality, histologic subtype, pT and pN stage) to find factors predicting 30-day and 90-day mortality or major morbidity.

RESULTS

The overall 30-day mortality was 5%. Within 90 days after operation, 8% of the patients died. The rates of 30-day and 90-day mortality were significantly higher in patients with high preoperative C-reactive protein values (p=0.001 and p<0.0005). The spirometry values forced expiratory volume in 1 second and forced vital capacity exhaled (FVCex) were both associated with 30-day and 90-day mortality (p=0.001 and p<0.0005; and p=0.002 and p<0.0005). Major morbidity occurred in 30% of the patients, significantly more often after right-sided EPP (p=0.01) and after longer operations (p<0.0005). Empyema (p<0.0005) and acute respiratory distress syndrome (p=0.02) were associated with longer duration of operation.

CONCLUSIONS

EPP after induction chemotherapy is a demanding procedure but can be performed with acceptable morbidity and mortality if patients are well selected and treated at dedicated high-volume MPM centers.

Role of adjuvant chemotherapy after pneumonectomy for non-small cell lung cancer

Adjuvant chemotherapy is used as an alternative treatment for non-small cell lung cancer (NSCLC); however, the efficiency of post-pneumonectomy adjuvant chemotherapy in NSCLC has not been clarified. In the present study, patients who benefited from adjuvant chemotherapy with TP/NP/GP were identified. A total of 217 patients who underwent pneumonectomy were identified in this study. Of these, 87 underwent pneumonectomy combined with adjuvant chemotherapy (TP/NP/GP regimen) and 130 underwent pneumonectomy only in the initial management. The primary endpoint of the present study was overall survival. Actuarial survival analysis was conducted using the Kaplan-Meier method. Postoperative adjuvant chemotherapy significantly improved the survival rate of patients who underwent left pneumonectomy and in patients with a preoperative forced expiratory volume in 1 sec (FEV1) greater than or equal to 21. Age had no effect on the survival rate of patients with or without postoperative adjuvant therapy. Post-pneumonectomy adjuvant chemotherapy is an efficient therapy in NSCLC for patients with preoperative FEV1 greater than or equal to 21 or who received left pneumonectomy.

Nutritional status of patients undergoing chemoradiotherapy for lung cancer

Impaired nutrition is an important predictor of perioperative complications in lung cancer patients, and preoperative chemoradiotherapy increases the risk of such complications. The goal of this study was to assess the effect of an immune-enhancing diet on nutritional status in patients undergoing lung resection after chemoradiotherapy. We compared the preoperative nutritional status in 15 patients with lung cancer undergoing lung resection without chemoradiotherapy and 15 who had chemoradiotherapy. Body mass index and lymphocyte counts were lower in patients who had chemoradiotherapy. Although there was no difference in the rate of postoperative morbidity between groups, the chemoradiotherapy patients were more likely to have severe complications postoperatively. After chemoradiotherapy in 12 patients, 6 received oral Impact for 5 days, and 6 had a conventional diet before surgery. Oral intake of Impact for 5 days before surgery modified the decrease in transferrin and lymphocytes after the operation. Preoperative immunonutrition may improve the perioperative nutritional status after induction chemoradiotherapy in patients undergoing lung cancer surgery, and reduce the severity of postoperative complications. These potential benefits need to be confirmed in a randomized controlled trial.

Contemporary results of surgical resection of non-small cell lung cancer after induction therapy: a review of 549 consecutive cases

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.

Oral nutritional supplements containing (n-3) polyunsaturated fatty acids affect the nutritional status of patients with stage III non-small cell lung cancer during multimodality treatment

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), (n-3) fatty acids from fish oil, have immune-modulating effects and may improve nutritional status in cancer. The objective of this study was to investigate the effects of an oral nutritional supplement containing (n-3) fatty acids on nutritional status and inflammatory markers in patients with non-small cell lung cancer (NSCLC) undergoing multimodality treatment. In a double-blind experiment, 40 patients with stage III NSCLC were randomly assigned to receive 2 cans/d of a protein- and energy-dense oral nutritional supplement containing (n-3) fatty acids (2.0 g EPA + 0.9 g DHA/d) or an isocaloric control supplement. EPA in plasma phospholipids, energy intake, resting energy expenditure (REE), body weight, fat free mass (FFM), mid-upper arm circumference (MUAC), and inflammatory markers were assessed. Effects of intervention were analyzed by generalized estimating equations and expressed as regression coefficients (B). The intervention group (I) had a better weight maintenance than the control (C) group after 2 and 4 wk (B = 1.3 and 1.7 kg, respectively; P < 0.05), a better FFM maintenance after 3 and 5 wk (B = 1.5 and 1.9 kg, respectively; P < 0.05), a reduced REE (B = -16.7% of predicted; P = 0.01) after 3 wk, and a trend for a greater MUAC (B = 9.1; P = 0.06) and lower interleukin-6 production (B = -27.9; P = 0.08) after 5 wk. After 4 wk, the I group had a higher energy and protein intake than the C group (B = 2456 kJ/24 h, P = 0.03 and B = 25.0 g, P = 0.01, respectively). In conclusion, a protein- and energy-dense oral nutritional supplement containing (n-3) fatty acids beneficially affects nutritional status during multimodality treatment in patients with NSCLC.

The impact of induction therapy on morbidity and operative mortality after resection of primary lung cancer

OBJECTIVE

Use and operative results of neoadjuvant therapy before major elective resection for primary lung cancer were examined in the Society of Thoracic Surgeons General Thoracic Surgical Database.

METHODS

Lobectomy and pneumonectomy for primary lung cancer were identified in 12,201 patients between January 2002 and June 2008. After excluding procedures for missing clinical staging or end points; institutions with more than 10% missing data for clinical stage, discharge mortality, or length of stay; and patients treated with chemotherapy or radiation for unrelated disease, there remained 5376 resections. Study end points were discharge mortality, length of stay more than 14 days, and major morbidity. Multivariate analysis using propensity scores stratified into quintiles measured the effect of induction therapy.

RESULTS

In 525 of 5376 procedures (9.8%), chemotherapy (n = 153), radiotherapy (23), or chemoradiotherapy (349) preceded resection. Compared with resection only, patients receiving induction therapy were younger and had fewer comorbidities, more reoperative surgery, and higher rates of pneumonectomy. Clinical IIIA-N2 disease was treated with induction therapy in only 203 of 397 patients (51.1%). Propensity-adjusted rates detected no difference in discharge mortality, prolonged length of stay, or a composite of major morbidity for patients receiving induction therapy. Similar results were obtained in a logistic regression model (discharge mortality P = .9883; prolonged hospital stay P = .9710; major morbidity P = .9678).

CONCLUSION

Less than 10% of all major lung resections for primary carcinoma and just more than half of all resections for clinical stage IIIA-N2 disease are preceded by neoadjuvant chemotherapy or radiation. This study does not support concerns over excessive operative risk of induction therapy.

Trimodality therapy for malignant pleural mesothelioma

BACKGROUND

Malignant pleural mesothelioma is a fatal disease. The optimal modality and sequence of therapy are controversial. We analyzed the outcomes of a cohort of mesothelioma patients treated with induction chemotherapy, followed by extrapleural pneumonectomy (EPP) and adjuvant radiation.

METHODS

The study comprised a retrospective cohort of 46 patients treated with induction chemotherapy, followed by EPP, during a 10-year period. Of these, 24 completed adjuvant external beam radiotherapy (EBRT), and 14 had intensity-modulated radiotherapy (IMRT).

RESULTS

Mean follow-up was 20.6 months (range, 0.5 to 75 months). Operative mortality after EPP was 4.3% (n = 2). Pathologic stage was p0, 4.3%; pII, 23.9%; pIII, 56.5%; and pIV, 15.2%. Median overall survival was 24 months. On univariate analysis and Cox proportional hazards model, only nodal metastases (hazard ratio, 3.7; 95% confidence interval, 1.6 to 8.7; p = 0.002) was a significant predictor of survival. First site of recurrence was local in 12, the contralateral chest in 5, abdominal in 8, and distant in 5. The incidence of local recurrence was 14.3% with IMRT vs 41.7% with EBRT (p = 0.03). The time to local recurrence with the use of IMRT was 12 months vs 7 for EBRT (p = 0.19).

CONCLUSIONS

Induction chemotherapy, followed by EPP and adjuvant radiotherapy for selected patients with mesothelioma, is safe, with acceptable operative mortality. Adjuvant IMRT may be more effective in terms of local control than EBRT.

The Surgical Management of Lung Cancer

Since the introduction of the pneumonectomy as a technically feasible strategy for the treatment of lung cancer, surgical resection has played a pivotal role in the management of early stage non-small cell lung carcinoma (NSCLC). In the last two decades, surgical, medical, and radiation oncologists have produced a growing body of evidence to support the combination of neoadjuvant or adjuvant treatments with standard surgical resection, to improve disease-free and overall survival for specific patient subgroups. Furthermore, alternatives to aggressive surgical management have evolved for patients who are medically inoperable due to compromised pulmonary function or other comorbidities. In this review, surgical options and multimodal treatment strategies are discussed, as well as completed and ongoing clinical trials addressing the surgical management of NSCLC.

Structural lung damage after chemotherapy fact or fiction?

BACKGROUND

The hypothesis that chemotherapy increases morbidity after pneumonectomy remains under debate, as the results of previous surgical series remain controversial. The hypothesis of the study is that patients who received preoperative chemotherapy may have subclinical parenchymal damage, increasing their risk of respiratory complications.

METHODS

The study population was composed of 10 patients who underwent pneumonectomy after chemotherapy for lung cancer (cisplatin+gemcitabine) randomly selected from our database and compared with 10 matched patients who underwent pneumonectomy without previous chemotherapy during the same period. Healthy lung tissue was obtained from surgical specimens, processed according to standard methods and evaluated on ematossilin and eosin-stained sections. Two pathologists without information on the preoperative treatment were asked to review the slides in order to reach a consensus on the type and extent of lung damage. Relevant information was then compared with functional tests and postoperative outcome.

RESULTS

Severe and diffuse (more than 50% of lung parenchyma) interstitial alterations were detected in the lungs of eight patients, seven of which belonged to the chemotherapy group (70%, p 0.02). Six of these patients developed postoperative respiratory complications. In the chemotherapy group, patterns of interstitial involvement were variable interstitial inflammation and fibrosis associated with obliterative bronchiolitis [Roberts JR, Eustis C, Devore R, et al. Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung carcinoma. Ann Thorac Surg 2001;72:885-8], bronchiolitis obliterans-organizing pneumonia [Leo F, Solli P, Veronesi G, et al. Does chemotherapy increase the risk of respiratory complications after pneumonectomy? J Thorac Cardiovasc Surg 2006;132:519-23], diffuse alveolar damage [Novoa N, Varela G, Jimenez MF. Morbidity after surgery for non-small cell lung carcinoma is not related to neoadjuvant chemotherapy. Eur J Cardiothor Surg 2001;20:700-4], DIP (desquamative interstitial pneumonia)-like reaction [Roberts JR, Eustis C, Devore R, et al. Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung carcinoma. Ann Thorac Surg 2001;72:885-8] and UIP (usual interstitial pneumonia)-like changes [Roberts JR, Eustis C, Devore R, et al. Induction chemotherapy increases perioperative complications in patients undergoing resection for non-small cell lung carcinoma. Ann Thorac Surg 2001;72:885-8]. The only preoperative clinical predictor of severe diffuse damage was preoperative diffusion by carbon monoxide (Dlco).

CONCLUSIONS

Preoperative chemotherapy is associated with an increased risk of severe and diffuse pulmonary disease even in the presence of normal spirometric parameters. These alterations may play an important role in the occurrence of postoperative respiratory complications.

Long term follow-up of neoadjuvant-adjuvant combination treatment of IIIA stage non-small-cell-lung cancer: results of neoadjuvant carboplatin/vinorelbine and carboplatin/paclitaxel regimens combined with selective adjuvant chemotherapy according to in-vitro chemoresistance test

AIM

A prospective study investigated survival of patients with stage IIIA non-small-cell-lung cancer (NSCLC) treated with a combination of neoadjuvant and adjuvant chemotherapy.

METHODS

Consecutive chemo-naive patients with potentially operable stage IIIA NSCLC received carboplatin-based neoadjuvant treatment. Tumor cells harvested during surgery underwent methylthiazolyl tetrazolium blue (MTT) cytotoxic assay. After surgery, adjuvant chemotherapy was selected, where possible, according to MTT results.

RESULTS

A total of 65 patients were evaluated (31 received carboplatin/vinorelbine, 34 carboplatin/paclitaxel). The overall response rate was 67.7 % (95% confidence interval [CI]: 56.3-79.1 %) with downstaging in 52.3 % (95% CI: 40.2-64.5 %) and no significant differences between regimens. Median follow-up was 86 months: median overall survival (OS) was 32.1 months (95% CI: 7.4-46.5), median time to progression was 25.1 months (95% CI: 15.1-34.9 months) and five-year overall survival was 35.7 % (95% CI: 23.7-47.7 %). Forty-seven patients (72.3 %) underwent surgery and 43 patients received adjuvant chemotherapy. Five-year survival after tumor resection was 49.5 % (95% CI: 34.2-64.8%), median OS was 59.0 months (95% CI: 34.2-83.1) and median disease free survival after surgery was 57.3 months (95% CI: 29.5-84.4). With MTT-directed therapy, median OS was 85.1 months (95% CI: 15.4-148.6) and the 5-year survival rate was 57.0 % (95% CI: 34.5-79.5 %); the trend for longer survival failed to reach statistical significance.

CONCLUSIONS

A combination of carboplatin-based neoadjuvant chemotherapy, surgical resection and adjuvant chemotherapy achieved satisfactory survival rates in stage IIIA NSCLC, especially in patients with complete resection of tumor and those given MTT-directed adjuvant treatment. Our results suggest MTT testing may help optimise adjuvant chemotherapy.

Exacerbation of bleomycin-induced injury and fibrosis by pneumonectomy in the residual lung of mice

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.

Mortality related to neoadjuvant therapy and surgery for stage III non-small-cell lung cancer

BACKGROUND

Neoadjuvant chemotherapy alone or with concurrent radiation is often used for stage IIIA non-small-cell lung cancer but is often tried in patients with stage IIIB and at times in patients with stage I or II disease. Newer neoadjuvant regimens would need to be compared with currently used programs to see if they increased toxicity. For such a comparison, a baseline estimate is needed of the mortality of currently used regimens.

PATIENTS AND METHODS

In this review, we searched PubMed and associated references, and data on mortality were identified in 34 publications.

RESULTS

The mortality of neoadjuvant chemotherapy or chemotherapy plus radiation has been estimated in 2015 patients was 0.7%, and the postsurgical mortality in 2195 patients was 4.3%.

CONCLUSION

These estimates might provide a benchmark for comparison for innovative trials.

Oxygen toxicity during one-lung ventilation: is it time to re-evaluate our practice?

Lung cancer remains one of the leading causes of cancer-related mortality. Surgical resection remains the mainstay of non-small cell lung cancer therapy, but an increasing number of patients receive preoperative adjuvant chemotherapy that may predispose these patients to unique organ toxicities. This chemotherapy, along with exposure to high oxygen concentrations, may combine to increase the risk of reactive oxygen species-mediated lung injury. Continued efforts are needed to improve overall outcome in these patients, including a reevaluation of our management of oxygen therapy.

Complete mediastinal lymphadenectomy: the core component of the multidisciplinary therapy in resectable non-small cell lung cancer

There is a great deal of concern about metastasis of lung cancer to regional lymph nodes, due partly to the work of groups of thoracic surgeons in Japan and North America beginning in the 1970s. The classification of regional lymph node stations for lung cancer staging published by Mountain and Dresler has been widely adopted for more than ten years. Anatomic landmarks for 14 levels of intrapulmonary, hilar, and mediastinal lymph nodes stations are designated. Skip transfer and occult lymph node metastasis, confirmed by studies regarding the mode of spread of intrathoracic lymphatic metastasis, are two theoretical bases for complete mediastinal lymphadenectomy of lung cancer. However, whether or not the degree of the dissection influences prognosis, the role of systematic nodal dissection (SND) vs mediastinal lymph node sampling (MLD) in resectable non-small cell lung cancer (NSCLC) remains controversial. A systematic literature search was performed to identify relevant reports, making full use of the 'Cited by,' 'Related Records,' 'References,' and 'Author Index' functions in the PubMed and ISI Web of Science databases. This paper presents a review of the role of mediastinal lymph node distribution and methods of determining suitability for hilar and mediastinal lymphadenectomy based on the four subsets of stage IIIA-N2, balancing the cost vs effect of mediastinal lymph node dissection in resectable NSCLC, focusing on the stage migration bias in clinical trials comparing SND and MLS, recommending a reasonable node dissection sequence, improving the prospects for the perioperative anti-tumor therapy based on mediastinal lymphadenectomy, and evaluating the various preoperative staging techniques. Finally, we believe that, besides the role of complete resection and accurate staging, the complete mediastinal lymphadenectomy is the core component of the lung cancer multidisciplinary therapy, and suggest that the values of lymphadenectomy should be further assessed using decision-tree analysis based on large-scale prospective randomized trials and pooled analysis to evaluate the costs vs effects.

Treatment of Non-small Cell Lung Cancer-Stage IIIA

STUDY OBJECTIVES

Stage IIIA non-small cell lung cancer represents a relatively heterogeneous group of patients with metastatic disease to the ipsilateral mediastinal (N2) lymph nodes and also includes T3N1 patients. Presentations of disease range from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky multistation nodal disease. This review explores the published clinical trials to make treatment recommendations in this controversial subset of lung cancer.

DESIGN, SETTING, AND PARTICIPANTS

Systematic searches were made of MEDLINE, HealthStar, and Cochrane Library databases up to May 2006, focusing primarily on randomized trials, with inclusion of selected metaanalyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.

MEASUREMENT AND RESULTS

The evidence derived from the literature now appears to support routine adjuvant chemotherapy after complete resection of stage IIIA lung cancer encountered unexpectedly at surgery. However, using neoadjuvant therapy followed by surgery for known stage IIIA lung cancer as a routine therapeutic option is not supported by current published randomized trials. Combination chemoradiotherapy, especially delivered concurrently, is still the preferred treatment for prospectively recognized stage IIIA lung cancer with all degrees of mediastinal lymph node involvement. Current and future trials may modify these recommendations.

CONCLUSIONS

Multimodality therapy of some type appears to be preferable in all subsets of stage IIIA patients. However, because of the relative lack of consistent randomized trial data in this subset, the following evidence-based treatment guidelines lack compelling evidence in most scenarios.

Impact of Induction Treatment on Postoperative Complications in the Treatment of Non-small Cell Lung Cancer

INTRODUCTION

A main drawback of neoadjuvant chemotherapy is that it may increase operative morbidity and mortality. The aim of this study was to determine the impact of chemotherapy on these complications.

METHODS

Patient data were collected from the Epithor database. From June 2002 to June 2004, 3888 successive observations of surgery for lung cancer have been reported from 51 thoracic surgery departments throughout France. Logistic regression analysis was performed to identify preoperative clinical characteristics of patients with significant postoperative complications.

RESULTS

Of 3888 patients, 555 (14.3%) received induction chemotherapy. The groups were similar with respect to sex and the number of comorbidities. The in-hospital mortality rate was 3.01%. The multivariate analysis allows us to identify age (older than 65 years), sex (male), preoperative clinical score (moderate and severe), surgical procedure (right pneumonectomy and bilobectomy) as significantly associated with in-hospital mortality. No statistical difference was observed according to the delivery or preoperative chemotherapy. In total, 1219 patients (31.4%) had at least one postoperative complication. Using a multivariate analysis, we observed a significant correlation between morbidity and age (older than 65 years), sex (male), presence of comorbidities (two or more), clinical score (moderate), and type of operation (bilobectomy). Preoperative administration of chemotherapy did not significantly influenced postoperative morbidity.

CONCLUSIONS

Preoperative chemotherapy is not associated with an increase in either the mortality rate or major surgical complications. Future randomized trials are warranted to confirm the survival benefit of this strategy.

Multicenter trial of neo-adjuvant chemotherapy followed by extrapleural pneumonectomy in malignant pleural mesothelioma

BACKGROUND

The aim of this multicenter trial was to prospectively evaluate neo-adjuvant chemotherapy followed by extrapleural pneumonectomy (EPP) and radiotherapy, including quality of life as outcome.

PATIENTS AND METHODS

Eligible patients had malignant pleural mesothelioma of all histological types, World Health Organization performance status of zero to two and clinical stage T1-T3, N0-2, M0 disease considered completely resectable. Neo-adjuvant chemotherapy consisted of three cycles of cisplatin and gemcitabine followed by EPP. Postoperative radiotherapy was considered for all patients.

RESULTS

In all, 58 of 61 patients completed three cycles of neo-adjuvant chemotherapy. Forty-five patients (74%) underwent EPP and in 37 patients (61%) the resection was complete. Postoperative radiotherapy was initiated in 36 patients. The median survival of all patients was 19.8 months [95% confidence interval (CI) 14.6-24.5]. For the 45 patients undergoing EPP, the median survival was 23 months (95% CI 16.6-32.9). Psychological distress showed minor variations over time with distress above the cut-off score indicating no morbidity with 82% (N = 36) at baseline and 76% (N = 26) at 3 months after surgery (P = 0.5).

CONCLUSIONS

The observed rate of operability is promising. A median survival of 23 months for patients undergoing EPP compares favourably with the survival reported from single center studies of upfront surgery. This approach was not associated with an increase in psychological distress.

Operative complications and early mortality after induction therapy for lung cancer

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.