Sleeve lobectomy for bronchogenic cancers: factors affecting survival

BACKGROUND: Sleeve lobectomy is a parenchyma-sparing procedure that is particularly valuable in patients with cardiac or pulmonary contraindications to pneumonectomy. The purpose of this study is to report our experience with sleeve lobectomy for bronchogenic cancer and to investigate factors associated with long-term survival. METHODS: Between January 1981 and June 2001, 169 patients underwent sleeve lobectomy for non-small-cell lung cancer (n = 139) or carcinoid tumor (n = 30), including 61 with a preoperative contraindication to pneumonectomy. Mean age was 59 +/- 14 years (range, 19 to 82 years). Vascular sleeve resection was performed in 11 patients. The remaining bronchial stump contained microscopic disease in 7 patients. RESULTS: Major bronchial anastomotic complications occurred in 6 (3.6%) patients: one was fatal postoperatively, three required reoperation, and two were managed conservatively. In the non-small-cell lung cancer group, operative mortality was 2.9% (4 of 139), and overall 5-year and 10-year survival rates were 52% and 28%, respectively. Six patients experienced local recurrence after complete resection. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0 or N1 versus N2; p = 0.01) and microscopic invasion of the bronchial stump (p = 0.02). In the carcinoid tumor group, there were no operative deaths, and overall 5-year and 10-year survival rates were 100% and 92%, respectively. CONCLUSIONS: Sleeve lobectomy achieves local tumor control and is associated with low mortality and bronchial anastomotic complication rates. Long-term survival is excellent for carcinoid tumors. For patients with non-small-cell lung cancer, N2 disease or incomplete resection is associated with a worse prognosis; outcome is not affected by presence of a preoperative contraindication to pneumonectomy.     

Subsequent pulmonary resection for bronchogenic carcinoma after pneumonectomy

BACKGROUND: Patients who have undergone a pneumonectomy for bronchogenic carcinoma are at risk of cancer in the contralateral lung. Little information exists regarding the outcome of subsequent lung operation for lung cancer after pneumonectomy. METHODS: The records of all patients who underwent lung resection after pneumonectomy for lung cancer from January 1980 through July 2001 were reviewed. RESULTS: There were 24 patients (18 men and 6 women). Median age was 64 years (range, 43 to 84 years). Median preoperative forced expiratory volume in 1 second was 1.47 L (range, 0.66 to 2.55 L). Subsequent pulmonary resection was performed 2 to 213 months after pneumonectomy (median, 23 months). Wedge excision was performed in 20 patients, segmentectomy in 3, and lobectomy in 1. Diagnosis was a metachronous lung cancer in 14 patients and metastatic lung cancer in 10. Complications occurred in 11 patients (44.0%), and 2 died (operative mortality, 8.3%). Median hospitalization was 7 days (range, 2 to 72 days). Follow-up was complete in all patients and ranged between 6 and 140 months (median, 37 months). Overall 1-, 3-, and 5-year survivals were 87%, 61%, and 40%, respectively. Five-year survival of patients undergoing resection for a metachronous lung cancer (50%) was better than the survival of patients who underwent resection for metastatic cancer (14%; p = 0.14). Five-year survival after a solitary wedge excision was 46% compared with 25% after a more extensive resection (p = 0.54). CONCLUSIONS: Limited pulmonary resection of the contralateral lung after pneumonectomy is associated with acceptable morbidity and mortality. Long-term survival is possible, especially in patients with a metachronous cancer. Solitary wedge excision is the treatment of choice.     

Prognostic factors for survival after pulmonary resection of metastatic renal cell carcinoma

BACKGROUND: Pulmonary resection in metastatic renal cell carcinoma is an accepted method of treatment. The purpose of this study was to determine the clinical course, outcome, and prognostic factors after surgery. METHODS: Between 1985 and 1999, 191 patients (145 men, 46 women) with pulmonary metastases from a renal cell carcinoma underwent surgical resection. Inclusion criteria for the study were the absence of primary tumor recurrence and other extrapulmonary metastases. Complete resection (CR) was achieved in 149 patients. RESULTS: The overall 5-year survival rate was 36.9%. The 5-year survival rate after complete metastasectomy and incomplete resection was 41.5% and 22.1%, respectively. In patients with pulmonary or mediastinal lymph node metastases, we observed after complete resection a 5-year survival rate of 24.4%, whereas the rate was 42.1% in patients without lymph node involvement. A significantly longer survival was observed for patients with fewer than seven pulmonary metastases compared with patients with more than seven metastases (46.8% vs 14.5%). For surgically rendered complete resection (CR) patients with a disease-free interval of 0 to 23 months, the 5-year survival rate was 24.7% compared with 47% for those with more than a 23-month disease-free interval. By multivariate analyses, we showed that the number of pulmonary metastases, the involvement of lymph node metastases, and the length of the disease-free interval were all predictors of survival after complete resection. CONCLUSIONS: We conclude that pulmonary resection in metastatic renal cell carcinoma is a safe and effective treatment that offers improved survival benefit. Prognosis-related criteria are identified that support patient selection for surgery.     

Long-term survival after resection for bronchogenic carcinoma.

Of 915 resections for bronchogenic carcinoma over a 25-year period (1945-1969), 249 patients survived over 5 years; 127 of the patients eligible survived over 10 years, 61 over 15 years, and 22 over 20 years. The case material was divided into three time periods: 1945-49, 1950-59 and 1960-69, as well as by extent of resection. Lobectomy became the operation of choice, pneumonectomy being reserved for the more extensive lesions. Observed survival rates at 5, 10 and 15 years for 561 patients in the lobetomy series were 35, 22 and 15%, respectively, but strikingly increased to 41, 28 and 19% in the 1960-69 period. Observed rates for 354 patients having pneumonectomies were similar for three time periods, being 16, 8 and 6% at 5, 10 and 15 years, respectively. Relative survival rates for the lobectomy series at 5, 10 and 15 years rose from 33, 28 and 26%, repectively, in the 1950-59 period to 50, 39 and 35% in the last time period, becoming a near horizontal curve segment after 5 years. Dominant factors in survival were extent of the lesion and stage of nodal involvement, histologic type and location being less significant.     

Long-term survival in bronchogenic carcinoma.

In this report, we shall review the clinical and pathological features of 64 patients who survived 10 years or longer after resection for bronchogenic carcinoma. Most of these patients had either adenocarcinoma or bronchioloalveolar carcinoma. None of them had oat cell carcinoma. In many of the long-term survivors, there were pathological findings generally considered to indicate a poor chance for survival. Thus we believe that curative resection for bronchogenic carcinoma should be attempted whenever feasible to offer the patient every hope of long-term survival.     

Long-term survival and prognostic factors of five-year survivors with complete resection of non-small cell lung carcinoma

OBJECTIVE: We analyzed the long-term follow-up data on cancer-related death in 5-year survivors of complete resection of their non-small cell lung cancer and examined the prognostic factors having an impact on subsequent survival. METHODS: Of 848 consecutive patients with proven primary non-small cell carcinoma who underwent complete removal of the primary tumor together with hilar and mediastinal lymph nodes, 421 patients (49.6%) survived 5 years or longer after the initial surgical treatment. Of all the data analyzed, only death related to cancer was treated as death. RESULTS: The median follow-up of 5-year survivors was 84 months from the original treatment (range, 60 to 200 months). Their overall survival rate at 10 years was 91.0%. Multivariable Cox analysis demonstrated that although advanced surgical-pathological stage (P =.0001), nodal involvement (P =.0245), male gender (P =.0313), and non-squamous type of the tumor (P =.0034) were significant, independent, unfavorable prognostic determinants in all patients, none of the variables investigated significantly influenced the long-term survival of 5-year survivors. The rate of recurrence beyond 5 years was much lower compared with that within 5 years. In contrast, the rate of occurrence of new malignancies was unchanged throughout the long-term postoperative period. CONCLUSIONS: Among 5-year survivors of complete resection of non-small cell lung cancer, neither stage, nodal status, sex, nor histologic condition further affected subsequent survival, suggesting that the 5-year interval might be sufficient to declare that a patient with lung cancer has been cured.     

Postpneumonectomy empyema does not improve survival in bronchogenic carcinoma

There is much disagreement in the literature about the beneficial effect of postpneumonectomy empyema on survival following operation for bronchogenic carcinoma. We had the opportunity to gather data on 407 patients with this serious complication. The survival data for a group of patients with postpneumonectomy empyema and fistula were compared with those for another group without such complications. Our statistical analysis confirms that postpneumonectomy empyema does not improve life expectancy.     

Bronchoplasty for bronchogenic carcinoma

This report details our experience in 34 patients with primary bronchogenic carcinoma who underwent broncho-plastic lobectomy between 1969 and 1981. Twenty-four had squamous cell carcinoma, 6 had adenocarcinonia, 2 large-cell carcinoma, 1 small-cell carcinoma, and 1 combined type. Twelve patients had no lymph node involvement, while 10 had hilar node metastasis and 12 had mediastinal node metastasis. Sleeve lobectomy was accomplished in 19 patients and wedge lobectomy in the remaining 15. Bronchoplasty was performed for direct tumorous invasion in 26 patients, whereas in 8 patients this procedure was done when metastatic cancer had involved the main bronchus. There were 3 operative deaths (8.8%). One was ascribed to tension pneumothorax, one to postoperative bleeding, and the other to myocardial infarction. One patient developed a bronchopleural fistula and died 44 days after completion pneumonectomy. Another died of massive hemorrhage from a bronchopulmonary artery fistula in the fourth postoperative month. Bronchial stenosis was observed in 4 patients: 3 granulation formation and 1 local recurrence. The 5-year survival rate was 17%, which was higher than that of pneumonectomy. Early postoperative pulmonary function studies revealed good function of the reconstructed lung. Bronchoplasty for bronchogenic carcinoma is an effective procedure for preserving pulmonary parenchyma and controlling the disease.

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Résumé Cet article rapporte notre expérience concernant 34 malades qui ont subi une lobectomie pulmonaire pour cancer bronchogénique primitif de 1969 à 1981. La série se compose de 24 cancers squamieux, de 6 adéno-carcinomes, de 2 cancers à larges cellules, de 1 cancer à petites cellules, de 1 cancer à cellules mixtes. 12 malades ne présentaient pas de métastase ganglionnaire, 10 avaient des métastases hilaires et 12 des métastases médiastinales.19 opérés subirent une lobectomie dite en manche et 15 une lobectomie cunéiforme. La bronchoplastie fut pratiquée chez 26 malades qui présentaient un envahissement tumoral direct alors qu'elle fut effectuée chez 8 malades dont la bronche principale était envahi par des métastases.Nous eûmes 3 morts à déplorer: l'une due à un pneumothorax suffocant, l'autre à une hémorragie post-opératoire, la troisième à un infarctus du myocarde.Un opéré présenta une fistule broncho-pulmonaire et mourut le 44ème jour après une tentative de pneumectomie, un autre fut emporté par une hémorragie massive au cours du 4ème mois qui suivit l'intervention, hémorragie due à une fistule artérielle bronchopulmonaire. Nous observames 4 cas de sténose bronchique, 3 formations granulomateuses et une récidive locale.Le taux de survie à 5 ans fut de 17 pour cent. Il est meilleur que celui de la pneumectomie.L'étude précoce des fonctions pulmonaires postopératoire montra qu'elles étaient bonnes.La bronchoplastie représente une méthode efficace de traitement du cancer bronchogénique. Elle respecte le parenchyme pulmonaire et permet de maîtriser la maladie.

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Presented at the XXIXth Congress of the Société Internationale de Chirurgie, Montreux, Switzerland, September, 1981.     

Resection of hepatocellular carcinoma in noncirrhotic liver: analysis of risk factors for survival

BACKGROUND: The aim of this study was to identify factors predictive of survival after curative resection of hepatocellular carcinoma (HCC) in noncirrhotic liver. STUDY DESIGN: Eighty-four patients underwent resection of HCC in noncirrhotic liver between January 1998 and December 2003. Univariate and multivariable analyses were used to retrospectively identify factors associated with overall survival and disease-free survival when resection was curative for the primary tumor. RESULTS: Overall 1-, 3-, and 5-year survival rates were 77.8%, 55.0%, and 44.4%, respectively, and 84.0%, 62.0%, and 50.0% when resection was curative for the primary tumor. HCC recurred in 27 patients (39.1%). Recurrence was intrahepatic in 14 patients (51.9%), extrahepatic in 3 patients (11.1%), and both intra- and extrahepatic in the remaining 10 patients (37.0%). In multivariable analysis, three independent factors were associated with poorer overall survival and recurrence-free survival, namely multiple tumors, macroscopic vascular invasion, and nonuse of adjuvant iodine-131-iodized oil. CONCLUSIONS: Aggressive operation is an effective treatment for HCC in noncirrhotic patients, whatever the degree of liver fibrosis. Multiple tumors and macroscopic vascular invasion are poor prognostic factors. Postoperative iodine-131-iodized oil injection appears to prevent recurrence and improve overall survival, although this needs to be confirmed in a prospective randomized trial.     

Risk factors predicting survival of liver transplantation

Prognostic models were developed for analyzing graft survival in a single-center study consisting of all 388 adult liver transplantations performed during 20 years. Proportional hazard models and generalized linear models were used to assess which risk factors, related to donor and recipient characteristics as well as graft preservation and operation, had an effect on graft survival. The prognostic modeling evidenced favorable trends in graft survival time during the successive quinquennials 1982-1987, 1988-1992, and 1993-1997, in comparison to the referent time period 1998-2002. Significant predictors of graft survival time were donor's age, recipient-donor gender compatibility, recipient's blood group, intraoperative blood transfusion, size of the transplanted organ, and indication for transplantation. Conventional histocompatibility matching did not correlate with graft outcome.     

Bronchoalveolar carcinoma: factors affecting survival

One hundred thirty-four consecutive patients (65 men and 69 women) underwent pulmonary resection for bronchoalveolar carcinoma. Mean age was 65 years. Lobectomy was done in 100 patients, pneumonectomy in 10, segmentectomy in 5, and wedge excision in 19. Only 10 patients had lymph node metastases (7.5%). The neoplasm was solitary in 111 patients (82.8%); 97 were in stage I, 4 were in stage II, 9 were in stage IIIa, and 1 was in stage IIIb. There were two operative deaths (1.5%). Thirty-nine complications occurred in 31 patients. Median follow-up was 5.1 years. Recurrent bronchoalveolar carcinoma developed in 45 patients. Five- and 10-year survival for patients in stage I was 75.2% and 62.0%, respectively. Survival for patients with T1 N0 M0 neoplasms was identical to expected survival and was 90.5% at 5 years, as compared with 55.4% for patients with T2 N0 M0 disease, only 35.9% for patients with multiple bilateral disease, and 0.0% for patients with bilateral disease (p less than 0.0001). Other significant factors adversely affecting survival included the presence of signs and symptoms, diffuse malignant invasion, mucin-producing tumors, and the histological absence of scar. We conclude that bronchoalveolar carcinoma has a unique natural history that is more influenced by local neoplastic processes than by lymph node metastases. Early aggressive pulmonary resection is safe and offers the potential for cure. The presence of bilateral cancer, however, is ominous.