Wedge resection for bronchogenic carcinoma in high-risk patients

Lung Resection in Patients With Preoperative FEV 1 < 35% Predicted

OBJECTIVES

To determine the morbidity, mortality, and feasibility of lung resection in patients with tumors and preoperative FEV1 < 35% predicted.

DESIGN

Retrospective review.

SETTING

A 734-bed, tertiary care, academic hospital with a dedicated general thoracic surgery unit performing > 2,000 operations per year.

PATIENTS

One hundred consecutive patients with discrete lung tumors and with preoperative FEV1 < 35% predicted undergoing lung resection between September 1997 and May 2003. Only operations with curative intent were included. Average preoperative predicted FEV1 was 26%. Sixteen percent of the patients were oxygen dependent prior to the operation.

RESULTS

Open and thoracoscopic wedge resections, segmentectomies, lobectomies, and combined lung resections with lung volume reduction were performed. Sixty-six of the lesions were malignant, and 57 were primary lung cancers. Only one patient left the operating room with positive margins. There was one in-hospital or 30-day mortality. Thirty-six percent of the patients had one or more complications. Twenty-two percent of the patients had prolonged air leaks requiring a chest tube for > 7 days. One patient left the hospital ventilator dependent, 3 additional patients required intubation > 48 h, and 11 patients were discharged with a new oxygen requirement. There were four pneumonias, one myocardial infarction, and two reoperations for bleeding. Male gender (p = 0.003), preoperative oxygen dependence (p = 0.03), and pack-year history (p = 0.006) were associated with a higher overall incidence of complications, while age, incision, diabetes, coronary artery disease, duration of smoking cessation, amount of lung resected, size of lesion, and preoperative percentage of predicted FEV1 did not correlate with the overall incidence of complications.

CONCLUSIONS

In a large academic center, minimally invasive surgical techniques, intensive pulmonary care, and advanced anesthetic techniques allow for curative lung tumor resections in patients with very low preoperative FEV1 with a very low mortality and very low incidence of ventilator dependence. Other serious complications such as pneumonia, myocardial infarction, and bleeding are uncommon. An extended hospital stay and a high incidence of prolonged air leak should be expected, especially in patients with preoperative FEV1 < or = 20% predicted.

Survival following lobectomy vs limited resection for stage I lung cancer: a meta-analysis

Extent of resection needed to treat lung cancer has long been an issue. The sole randomised controlled trial, reported by the Lung Cancer Study Group, advised against limited resection as standard surgery even for small peripheral non-small-cell lung cancers (⩽3 cm), because of frequent local recurrences. Elsewhere, conflicting results have been reported from different institutions. We therefore conducted a meta-analysis of reported studies to compare survival of stage I patients between limited resection and standard lobectomy. A MEDLINE web search for computer-archived bibliographic data yielded 14 articles suitable for analysis. Combined survival differences (survival rate with lobectomy minus that with limited resection) at 1, 3, and 5 years after resection according to the DerSimonian–Laird random effects model were 0.7% (95% CI, −0.8 to 2.1; P=0.3659), 1.9% (95% CI, −3.7 to 7.4; P=0.5088), and 3.6% (95% CI, −0.4 to 10.5; P=0.3603), respectively. None of these survival differences were significant, indicating that survival after limited resection for stage I lung cancer was comparable to that after lobectomy. However, since interstudy heterogeneity was detected, caution is required in interpretation of the results.

The spectrum of treatment and future diagnosis of early non-small cell lung carcinoma

PURPOSE

Review the surgical treatment of 56 patients at a single institution of early stage non-small cell lung carcinoma (NSCLC). Briefly review the literature to report the current indications for limited pulmonary resection. Discuss newer methods of assessing early stage NSCLC.

METHODS

We reviewed 56 lobectomies performed at the Biloxi Veterans Administration Medical Center from January 1992 to December 1997 for NSCLC to report the incidence of N1 positive lymph nodes and survival data. Additionally, a search of PubMed, Ovid, and MDConsult.com, using search parameters of non-small cell lung carcinoma, limited pulmonary resection, lobectomy, and comorbidity, were used to determine indications for treating non-small cell lung carcinoma.

RESULTS

N1 positive lymph nodes occurred in 11 out of 56 patients; 4 were identified preoperatively. In this sample, 21 patients were Stage IA, 21 Stage IB, 6 Stage IIA, and 8 Stage IIB, and their 4-year median survival was as follows: (IA) greater than 44.80 months, (IB) greater than 48.0 months, (IIA) greater than 25.28 months, and (IIB) = 11.18 months. Four-year survival rates by stage were IA= 10/21 (47.62%), IB= 14/21 (66.67%), IIA= 2/6 (33.33%), and IIB= 0/8 (0.0%).

CONCLUSIONS

The 4-year survival data we reviewed were less favorable than is reported by others. Patient medical comorbidity, patient age, and sample size are thought to account for this difference. According to our literature review, reasons for limited pulmonary resection include poor physical performance, marginal lung reserve, synchronous bilateral tumors, and superior sulcus tumors (T3) in which the tumor primarily invades the chest wall. Heavier consideration of these indications might have improved the outcomes seen in this population.

Surgery for early stage non-small cell lung cancer

Lung cancer accounts for 28.2% of all cancer-related deaths in the United States. Most patients present with advanced-stage disease, with only 15% having disease confined to the lung. Surgical resection is the optimal treatment for Stage I and II non-small cell lung cancer. Pre-resection staging includes various radiographic modalities, including PET scan and mediastinoscopy. Survival and local recurrence statistics favor full anatomic lobar resection over sublobar resection, although cases must be judged individually. Lobectomy via thoracoscopic approach appears to have equivalent outcome as lobectomy via thoracotomy. Characteristics of the counseling physician and the hospital volume at which the surgery is performed can also influence outcome. After surgical resection, stage IA patients have about 70% 5-year survival, but this falls below 50% for stage IIB patients. Methods that identify early-stage lung cancer patients at greatest risk for recurrence are needed to identify patients who may benefit from additional therapies.