Management of traumatic lung injury: a Western Trauma Association Multicenter review.

BACKGROUND: Improved outcomes following lung injury have been reported using "lung sparing" techniques. METHODS: A retrospective multicenter 4-year review of patients who underwent lung resection following injury was performed. Resections were categorized as "minor" (suture, wedge resection, tractotomy) or "major" (lobectomy or pneumonectomy). Injury severity, Abbreviated Injury Scale (AIS) score, and outcome were recorded. RESULTS: One hundred forty-three patients (28 blunt, 115 penetrating) underwent lung resection after sustaining an injury. Minor resections were used in 75% of cases, in patients with less severe thoracic injury (chest AIS scores "minor" 3.8 +/- 0.9 vs. "major" 4.3 +/- 0.7, p = 0.02). Mortality increased with each step of increasing complexity of the surgical technique (RR, 1.8; CI, 1.4-2.2): suture alone, 9% mortality; tractotomy, 13%; wedge resection, 30%; lobectomy, 43%; and pneumonectomy, 50%. Regression analysis demonstrated that blunt mechanism, lower blood pressure at thoracotomy, and increasing amount of the lung resection were each independently associated with mortality. CONCLUSION: Blunt traumatic lung injury has higher mortality primarily due to associated extrathoracic injuries. Major resections are required more commonly than previously reported. While "minor" resections, if feasible, are associated with improved outcome, trauma surgeons should be facile in a wide range of technical procedures for the management of lung injuries.     

Factors Affecting Postoperative Morbidity and Mortality in Destroyed Lung

Background. The presence of specific risk factors can increase the postoperative complication rate of pneumonectomy for destroyed lung.

Methods. Our experience in 118 consecutive patients who underwent pneumonectomy for destroyed lung over a 10-year period was retrospectively analyzed to evaluate the effect of specific risk factors on postoperative complications. The significance of tuberculosis, right pneumonectomy, preoperative empyema, and duration of illness longer than 36 months was examined by univariate analyses.

Results. The most common underlying diseases were nonspecific bronchiectasis (n = 52) and tuberculosis (n = 43). Sixty-day or in-hospital morbidity and mortality rates were 11.9% and 5.9%, respectively. The combined morbidity and mortality rate was significantly higher in patients with preoperative empyema (p < 0.003), tuberculosis (p < 0.03), and right pneumonectomy (p < 0.03). The prevalence of bronchopleural fistula was higher in patients with preoperative empyema (p < 0.02) and patients with tuberculosis (p < 0.03).

Conclusions. The postoperative complication rate of pneumonectomy for destroyed lung is acceptably low. However, it is increased by preoperative empyema, tuberculosis, and right-sided resection.     

Operative management and outcomes of traumatic lung resection

BACKGROUND: To analyze the presentation, injury patterns, and outcomes among a large cohort of patients requiring lung resection for trauma, and to compare outcomes stratified by the extent of resection. STUDY DESIGN: Review of all adult patients undergoing lung resections in the National Trauma Data Bank. Patients were categorized by extent of lung resection; wedge resection, lobectomy, or pneumonectomy. Patient factors, injury data, and outcomes were compared between groups using univariate and multivariable analysis for the entire sample, and after excluding patients with severe associated injuries. RESULTS: There were 669 patients who had a lung resection after trauma identified for an overall prevalence of 0.08%, with 325 undergoing wedge resection (49%), 244 had a lobectomy (36%), and 100 underwent complete pneumonectomy (15%). Blunt mechanism was associated with worse outcomes in terms of prolonged hospital stay, complications, disability, and a trend toward higher mortality (38% versus 30%, p = 0.07). Patients undergoing pneumonectomy had a higher mortality (62%) and more complications (48%) compared with patients undergoing lobectomy (35% mortality, 33% complications) and wedge resection (22% and 8%, all p < 0.05). After excluding patients with severe associated injuries (head, abdomen, heart, great vessels), there were 535 patients with "isolated" lung injury. There was again a stepwise increase in mortality by extent of resection, 19% for wedge resection, 27% for lobectomy, and 53% for pneumonectomy. Extent of lung resection remained an independent predictor of mortality for both the entire sample and for patients with isolated lung injury. CONCLUSIONS: Lung resection is infrequently required for traumatic injury, but carries substantial associated morbidity and mortality. The extent of lung resection is an independent predictor of hospital mortality, even after exclusion of patients with severe associated injuries. The worst outcomes were seen after complete pneumonectomy.     

Cancer Resection on the Residual Lung After Pneumonectomy for Bronchogenic Carcinoma

Background. After pneumonectomy for bronchogenic carcinoma, the residual lung may be the site of a new lung cancer or metastatic spread.

Methods. From 1989 to 1995, 13 patients with carcinoma on the residual lung after pneumonectomy for lung cancer were operated on. Three segmentectomies and 7 simple wedge resections were performed, 2 patients had multiple wedge resections, and 1 patient had an exploratory thoracotomy. Nine patients had a primary metachronous bronchogenic carcinoma, 3 had metastases from bronchogenic carcinoma, and no definite conclusion was reached in 1 case.

Results. No postoperative mortality was observed. Four patients had postoperative complications. The mean postoperative hospital stay was 14 days. Seven patients are alive, including 5 patients without evidence of disease. Six patients died of their disease, all with pulmonary recurrences. The overall median survival was 19 months, with a probability of survival at 3 years (Kaplan-Meier) of 46% (95% confidence interval, 22% to 73%).

Conclusions. Limited pulmonary resection for lung cancer after pneumonectomy for bronchogenic carcinoma is feasible with very low morbidity. In highly selected patients, surgical resection might prolong survival.     

Favorable results after sleeve lobectomy or bronchoplasty for bronchial malignancies

Background. Sleeve lobectomy and bronchoplasty are established alternatives to pneumonectomy for bronchial malignancies involving a main bronchus. However, potential bronchial anastomotic complications have deterred the general application of these types of resection. Some reports have contained a mixture of non-small cell lung cancer (NSCLC) and tumors of low-grade malignancy, making it difficult to assess the long-term results of these procedures as an alternative to pneumonectomy for lung cancer.

Methods. We retrospectively reviewed our experience with sleeve lobectomy and bronchoplasty for bronchial malignancies from January 1988 to September 1998 separating NSCLC (n = 58) from tumors of low-grade malignancy (n = 19). We compared the overall results between sleeve lobectomy and pneumonectomy (n = 142) performed for NSCLC over the same time interval.

Results. For NSCLC, after sleeve lobectomy, the operative mortality was 5.2% (3 of 58 patients) and the overall 5-year actuarial survival was 37.5%. After pneumonectomy, the operative mortality was 4.9% (7 of 142 patients) and the overall 5-year actuarial survival was 35.8%. For tumors with low-grade malignancy, there was no operative mortality after sleeve lobectomy or bronchoplasty and the 5-year actuarial survival was 100%. Major bronchial anastomotic complications occurred in 3 patients among the 77 patients who underwent sleeve resection.

Conclusions. Sleeve resection can be performed with a low risk of bronchial anastomotic complication. The long-term survival after sleeve resection for NSCLC is similar to pneumonectomy. Excellent results are obtained after sleeve resection for low-grade malignancies.     

Operative mortality, mortality and late results in bronchial carcinoma]

457 patients with a bronchial carcinoma of the years 1947--1962 are compared with 126 patients of the years 1969--1970 and set up in comparison to the whole clinical material of the years 1960--1975. In the period between 1969 and 1970 radical resections were performed in 20% more patients than in the first period (1947--1962). Older patients were in the last period (1970--1974) more frequent. 8% of all patients in which lobectomy was performed and 5.5% of the patients in which pneumonectomy was performed were older than 70 years of age. Overall mortality has remained unchanged for exploratory thoracotomy (19%), palliative resection (17.5%) and "radical" resection (14%). For simple pneumonectomy the overall mortality went down from 19.2% (1960--1964) to 9.6% (1970-1974) and for simple lobectomy from 14.4% to 3.8%. The five-year survival rate after radical resections was 8% (first period 0%) and after simple resections 26% (26.2%). Patients with stage I epidermoid carcinoma had a five-year survival rate of 46%. Those with stage II (spread to ipsilateral hilar nodes) a five-year survival rate of 14.3% Patients with palliative resections and exploratory thoracotomy died within 16 months.     

Thoracotomy for blunt trauma: traditional indications may not apply

The indications for performing as urgent thoractomy after trauma are based on the criteria used for penetrating injuries. However, few data are available on the use of these indications for patients with blunt injuries. In a retrospective study (June 1996 to July 2001), we compared the indications of urgent thoracotomy after blunt injury and penetrating injury in patients who underwent thoracotomy within 24 hours of hospital admission at our institution. Patients with blunt aortic injuries or emergency department thoracotomies were excluded from evaluation. Fifty-nine patients were identified (37 penetrating injuries, 22 blunt injuries). Blunt trauma victims had a higher mortality rate than penetrating trauma victims (73% vs. 22%). Chest tube output was the indication for nontherapuetic thoracotomy in 5 patients with blunt injuries whereas this occurred in only 1 penetrating injury victim (P = 0.04). All 5 blunt injury patients underwent a prior procedure and were coagulopathic when thoracotomy was performed. In conclusion, thoracotomy following blunt trauma is associated with a high rate of mortality. The rate of nontherapeutic exploration is increased when chest tube output is the indication for thoracotomy after blunt trauma. Since the majority of such patients have multicavitary injuries that require prior operation and are commonly coagulopathic, caution should be exercised when deciding whether to proceed with thoracotomy based solely on chest tube output.     

Is there a role for pneumonectomy in pulmonary metastases?

Background. Although sublobar and lobar resections are accepted operations for pulmonary metastases, pneumonectomy is viewed as a major incursion on Stage IV patients. We considered it important to ascertain the current results of pneumonectomy for pulmonary metastases since little information is available.

Methods. Of the 5,206 patients with pulmonary metastasectomy reported by the International Registry of Lung Metastases, 133 (3%) underwent primary, and 38 (1%) completion pneumonectomy between 1962 and 1994. Data were analyzed to determine the operative mortality rates, survival rates, and determinants of survival.

Results. Primary pneumonectomy was performed for metastatic disease mainly from epithelial (49%, 65 of 133) and sarcomatous (33%, 43 of 133) tumors. Indications were central lesion, eg, proximal endobronchial or hilar nodal metastases. Operative mortality was 4% (4 of 112) and a 5-year survival rate of 20% was achieved following complete resection (R0) in 112 patients. In contrast, the 21 incompletely resected patients had an operative mortality rate of 19% (4 of 21), and the majority did not survive beyond 2 years (p = 0.02). Survival was determined by the completeness of resection and not histology of the primary tumor, number of metastases, nodal status, and disease-free interval. In the 38 completion pneumonectomy patients, 35 were operated for recurrent disease and 3 for residual disease. Sarcomatous secondaries predominated in 28 patients. Complete resection was achieved in 31 patients (82%). The operative mortality rate was 3% (1 of 38 patients) and the 5-year survival rate was 30%.

Conclusions. Pneumonectomies for pulmonary metastases, albeit infrequently performed, were associated with acceptable operative mortality and long-term survival when performed in selected patients amenable to complete resection.     

Management of penetrating pancreatic trauma: an 11-year experience of a level-1 trauma center

Introduction: We present our experience in the management of penetrating pancreatic injuries, focusing on factors related to complications and death.

Methods: Retrospective trauma registry-based analysis of 62 consecutive patients with penetrating pancreatic injuries during an 11-year period. Overall injury severity was assessed by the injury severity score (ISS) and the penetrating abdominal trauma index (PATI). Pancreatic injuries were graded according to the American Association for the Surgery of Trauma (AAST) Organ Injury Scaling (OIS). Complications were characterised using standardised definitions. Mortality was recorded as early (within 48 h after admission) and late (after 48 h).

Results: Thirty patients suffered gunshot wounds and 24 had grade I pancreatic injuries. Shotgun and gunshot wounds were more destructive than stab wounds (higher PATI, number of intraabdominal injuries and mortality). Seventeen patients died. Most deaths occurred within 1 h after admission due to massive bleeding and severe associated injuries. Only one death was potentially related to the pancreatic injury. Mortality rate also correlated with pancreatic injury grading. Sixty-one patients had associated intraabdominal injuries. Combined pancreaticoduodenal injuries were present in 13 patients, and five died. Simple drainage was the most common procedure performed. Pancreas-related complications were found in 12 out of 47 patients who survived more than 48 h; intraabdominal abscess (n=7) that was associated with colon injuries, and pancreatic fistula (n=5).

Conclusion: An approach based on injury grade and location is advised. Routine drainage is recommended; distal resection is indicated in the presence of main duct injury, and the management of severe injuries will be tailored according to the overall physiologic status, presence of associated injuries, and duodenal viability. Morbidity and mortality is mainly due to associated injuries.     

Pulmonary tractotomy versus lung resection: viable options in penetrating lung injury.

BACKGROUND: Emergency lung resection following penetrating chest trauma has been associated with mortality rates as high as 55-100%. Pulmonary tractotomy is advocated as a rapid alternative method of dealing with deep lobar injuries. We reviewed our experience with resection and tractotomy to determine whether method of management affects mortality or if patient presentation is more critical in determining outcome. METHODS: A retrospective review of all patients with chest injury seen at an urban Level I trauma center from 2/89-1/99 was performed. All patients undergoing parenchymal surgery were included. Records were abstracted for grade of injury, type of resection, presenting systolic blood pressure (SBP), temperature, Injury Severity Score (ISS), operative time, and estimated blood loss (EBL). Mortality and thoracic complications were compared between groups. RESULTS: Two hundred forty-six of 2736 patients with penetrating chest trauma underwent thoracotomy, with 70 (28%) requiring some form of lung resection. There were 11 (15.7%) deaths. Patients who died had lower SBP (53 +/- 32 mm Hg vs 77 +/- 28 mm Hg), lower temperature (32.5 degrees +/- 1.3 degrees C vs 34.3 degrees +/- 1.2 degrees C), higher ISS (33 +/- 13 vs 23 +/- 9), and greater EBL (9.8 +/- 4.3 liters vs 2.8 +/- 2.1 liters) compared with survivors (p < 0.05 for all). Mortality was also increased in the presence of cardiac injury (33% with vs 12% without) and the need for laparotomy (26% with vs 9% without) (p < 0.05 for all). Tractotomy was associated with an increased incidence of chest complications (67% vs 24%, p = 0.05) compared with lobectomy with no difference in presenting physiology, operative time, or mortality. CONCLUSION: Lung resection for penetrating injuries can be done safely with morbidity and mortality rates lower than previously reported. Patient outcome is related to severity of injury rather than type of resection. Tractotomy is associated with a higher incidence of infectious complications and is not associated with shortened operative times or survival.     

Prognostic implication of Ki-67 immunostaining in treating subclinical pleural cancer found at thoracotomy in lung cancer patients

Background. Therapeutic principles for managing subclinical pleural cancer found unexpectedly during intraoperative examination are unclear. We analyzed prognostic factors including the tumor proliferative marker Ki-67 in these circumstances.

Methods. The cases of 65 surgically treated patients with lung cancer and subclinical T4 pleural cancer, microscopic in 25 and macroscopic in 40, were reviewed.

Results. The overall 5-year survival rate of patients undergoing lobectomy was 14.3%. For patients with T4 N0 disease, the 5-year survival rate was 46.7%. In patients with a low Ki-67 labeling index, the 5-year survival rate was 28.6%. The Ki-67 labeling index was a significant (p < 0.05) indicator of survival. Multivariate analysis demonstrated Ki-67 labeling index, lymph node involvement, and tumor differentiation to be the most influential prognostic factors for postoperative survival (p < 0.01).

Conclusions. In the treatment of lung cancer patients with subclinical pleural cancer found at thoracotomy, tumor resection is not necessarily contraindicated. Resection appears to be beneficial in patients with no nodal involvement or a low tumor Ki-67 labeling index. This index is a good therapeutic indicator for lung cancer patients.     

Reperfusion injury significantly impacts clinical outcome after pulmonary transplantation

Background. Reperfusion injury after pulmonary transplantation can contribute significantly to postoperative pulmonary dysfunction. We hypothesized that posttransplantation reperfusion injury would result in an increase in both in-hospital mortality and morbidity. We also hypothesized that the incidence of reperfusion injury would be dependent upon the cause of recipient lung disease and the interval of donor allograft ischemia.

Methods. We performed a retrospective study of all lung transplant recipients at our institution from June 1990 until June 1998. One hundred patients received 120 organs during this time period. We compared two groups of patients in this study: those experiencing a significant reperfusion injury (22%) and those who did not (78%).

Results. In-hospital mortality was significantly greater in patients experiencing reperfusion injury (40.9% versus 11.7%, p < 0.02). Posttransplantation reperfusion injury also resulted in prolonged ventilation (393.5 versus 56.8 hours, p < 0.001) and an increased length of stay in both the intensive care unit (22.2 versus 10.5 days, p < 0.01) and in the hospital (48.8 versus 25.6 days, p < 0.03). The incidence of reperfusion injury could not be attributed to length of donor organ ischemia (221.5 versus 252.9 minutes, p < 0.20). The clinical impact of reperfusion injury was significantly greater in patients undergoing transplantation for preexisting pulmonary hypertension (6/14) than those with chronic obstructive pulmonary disease or emphysema alone (6/54) (42.9% versus 11.1%, p < 0.012).

Conclusions. Clinically significant pulmonary reperfusion injury increased in-hospital mortality and morbidity resulting in prolonged ventilation, length of stay in the intensive care unit, and cost of hospitalization. The incidence of reperfusion injury was not dependent upon the duration of donor organ ischemia but increased with the presence of preoperative pulmonary hypertension. These findings suggest that recipient pathophysiology and donor allograft quality may play important roles in determining the incidence of reperfusion injury.     

Staging and resection of lung cancer with minimal invasion of the adjacent lobe

Objective: Correct staging, optimal resection type, and prognosis for non-small cell lung cancer (NSCLC) with invasion of the adjacent lobe through the fissure have seldom been reported. Methods: We retrospectively evaluated 351 completely resected NSCLC patients between 1994 and 2004. Of these, 152 patients had T2 and 139 had T3 NSCLC confined in one lobe and 60 patients had T2 NSCLC that shows a limited growth through the interlobar fissure into the adjacent lobe (NSCLC-ALI). Types of resections performed in patients who have NSCLC-ALI were: pneumonectomy in 40, bilobectomy in 10, and lobectomy plus partial adjacent lobe resection (LPR) in 10. Survival rates of all patients were determined and factors affecting the survival were evaluated by univariate and multivariate analyses. A multivariate survival analysis of NSCLC-ALI patients including the resection type as a prognostic factor was also performed. Results: Survival of the patients with NSCLC-ALI was not statistically different from those with T3 disease (p = 0.67, log rank test) but was significantly poorer than remaining patients with simple T2 disease (p = 0.049, log-rank test). T status was found as a prognostic factor at multivariate analysis too (p = 0.037). The survival of patients who underwent pneumonectomy was significantly worse than the patient group who underwent bilobectomy or LPR (p = 0.04). There was no statistically significant difference between survival of the patients who underwent LPR and the patient group who underwent pneumonectomy or bilobectomy (p = 0.16). Hospital mortality was 6.6% (4/60) and they all underwent a pneumonectomy. During follow-up there was no local recurrence encountered in patients in LPR group. Conclusions: The prognosis of NSCLC with limited invasion of an adjacent lobe was found to be similar with that of T3 tumors. A resection type lesser than a pneumonectomy may be considered in these tumors.     

Surgical management of metachronous bronchial carcinoma

Objective: To assess the results of surgery for the treatment of metachronous bronchial carcinoma. Methods: From 1985 to 1999, 38 patients were operated on for a metachronous lung carcinoma, accordingly to the criteria of Martini. All tumors were staged using the new International Classification System revised in 1997. Results: Diagnosis of the second cancer was done at radiological follow-up in 30 asymptomatic patients. Seventeen metachronous locations were ipsilateral. Histology of the metachronous lesion was the same as that of the first tumour in 23 patients (60%). The first resection was a lobectomy (n=35), a pneumonectomy (n=2) and a carinal resection (n=1). The second one was a wedge resection (n=7), a segmentectomy (n=3), a lingulectomy (n=2), a lobectomy (n=9), a bilobectomy (n=1), and a pneumonectomy (n=16). There were five in-hospital deaths (13%). Completion pneumonectomy was performed in 15 patients, with one postoperative death (7%). The overall estimated 5 and 10-years actuarial survival rates from the treatment of the first cancer were 70 and 47% respectively. The 5-year survival rate after the treatment of the second cancer was 32% (median survival: 31 months), including the operative mortality. Survival was negatively affected by a resection interval of less than 2 years and the performance of atypical lung sparing pulmonary resection for the treatment of the second cancer. Conclusions: Good long-term results are achievable by the means of a second pulmonary resection in selected patients with metachronous lung cancer. Optimal cancer operations should be applied whenever functionally possible.     

Pulmonary resection for Mycobacterium xenopi pulmonary infection.

Background. Results of medical therapy for Mycobacterium xenopi pulmonary infection remain unreliable. Pulmonary resection may be beneficial to patients whose disease is localized and who can tolerate a resectional operation.

Methods. Eighteen patients underwent pulmonary resection between 1991 and 2000: 14 men and 4 women, with a mean age of 50 ± 12 years (range 27 to 68 years). Indications for operation were either therapeutic (n = 9) or diagnostic (n = 9). Four patients received antimycobacterial chemotherapy before their operation and 2 patients were HIV positive.

Results. Therapeutic procedures included completion pneumonectomy (n = 1), lobectomy (n = 6), segmentectomy (n = 1), and bilateral wedge resection (n = 1). Diagnostic procedures included lobectomy (n = 1) and wedge resection (n = 8). Complete resection could be achieved in 15 patients (83%). There was no in-hospital mortality. Postoperative complications included prolonged air leak (5 of 18 patients, 27.7%) and pleural effusion requiring insertion of a new chest tube (3 of 18 patients, 16.6%). Mean hospital stay was 14 ± 8 days. Follow-up was 100% complete. Eleven patients received antimycobacterial chemotherapy for 4 to 24 months, postoperatively. Late mortality was 11% and was unrelated to progression of mycobacterial disease. After the operation, the sputum remained positive in only 2 patients (11%) with incomplete resections. Fourteen patients were asymptomatic with no relapse at a mean follow-up of 38 ± 22 months (range 85 to 13 months).

Conclusions. Resection represents an important adjunct to chemotherapy for the treatment of M xenopi pulmonary disease. In the setting of localized nodular or cavitary disease, failure to respond to medical therapy, relapse after treatment discontinuation, coexistent aspergilloma or polymicrobial contamination, or patient intolerance of medical therapy, pulmonary resection can be undertaken with acceptable morbidity and mortality.     

Surgical management of traumatic pulmonary injury

BACKGROUND: Surgical treatment of traumatic pulmonary injuries requires knowledge of multiple approaches and operative interventions. We present a 15year experience in treatment of traumatic pulmonary injuries. We hypothesize that increased extent of lung resection correlates with higher mortality. METHODS: Surgical registry data of a level 1 trauma center was retrospectively reviewed from 1984 to 1999 for traumatic lung injuries requiring operative intervention. Epidemiologic, operative, and hospital mortality data were obtained. RESULTS: Operative intervention for traumatic pulmonary injuries was required in 397 patients, of whom 352 (89%) were men. Penetrating trauma was seen in 371 (93%) patients. Location of the injuries was noted in the left side of the chest in 197 (50%), right side of the chest in 171 (43%), and bilateral in 29 (7%). Operative interventions included pneumonorraphy (58%), wedge resection or lobectomy in (21%), tractotomy (11%), pneumonectomy (8%), and evacuation of hematoma (2%). Overall mortality was 27%. If concomitant laparotomy was required, mortality increased to 33%. The mortality rate in the pneumonectomy group was 69.7%. CONCLUSIONS: The majority of lung injuries occurred in males due to penetrating trauma. Surgical treatment options ranged from simple oversewing of bleeding injury to rapid pneumonectomy. Mortality increased as the complexity of the operative intervention increased. Rapid intraoperative assessment and appropriate control of the injury is critical to the successful management of traumatic lung injury.     

Principles and practice of thoracic anaesthesia

Thoracic anaesthesia is a large field. This review concentrates on anaesthesia for major thoracotomy and lung resection, which is most usually carried out for malignant disease. This is a relatively small patient population, but procedures carry significant mortality of up to 6% for pneumonectomy. Physiological changes that occur during anaesthesia and one lung ventilation (OLV) are discussed, and the optimal ventilatory management of these patients is covered. Postoperative management of analgesia and chest drains is also discussed, as is the pathophysiology of acute lung injury (ALI) which may occur after lobectomy or pneumonectomy. Aspects of video-assisted thoracoscopy (VATS) and lung volume reduction surgery (LVRS) are also mentioned.     

Concurrent cisplatin/etoposide plus 3D-conformal radiotherapy followed by surgery for stage IIB (superior sulcus T3N0)/III non-small cell lung cancer yields a high rate of pathological complete response

Introduction: Optimal preoperative treatment of stage IIB (Pancoast)/III non-small cell lung cancer (NSCLC) remains undetermined and a subject of controversy. The goal of our study is to confirm feasibility and pathological response rates after induction chemoradiation (CRT) in our community-based treatment center. Patients and methods: Patients were selected according to functional and resectability criteria. Induction treatment comprised 3D conformal 4500 cGy radiotherapy delivered to the primary tumor and pathologic hilar and/or mediastinal lymph nodes on CT scan with an extra-margin of 1–1.5 cm. Concurrent chemotherapy regimen was cisplatinum 20 mg/m² d1–d5 and etoposide 50 mg/m² d1–d5, d1–5 d29–33. Within 3–4 weeks after CRT completion, operability was re-assessed accordingly. Surgery was performed 4–6 weeks after CRT completion in patients (pts) deemed resectable. Inoperable pts were referred for a 20–25 Gy boost ±1 extra-cycle of cisplatinum + etoposide. Results: From 1996 to 2005, 107 pts were initially selected for treatment and received induction chemoradiation (stage IIB-Pancoast 18, IIIA 58 and IIIB 31, squamous cell carcinoma 48%, adenocarcinoma 44%, large-cell undifferentiated carcinoma 14%). After preoperative evaluation, 72 pts (67%) had a thoracotomy (pneumonectomy 21, lobectomy 45, bilobectomy 5) and all but one (unresectable tumor) had a macroscopic complete resection. During the 3-month postoperative time, five patients (6.9%) died, four after pneumonectomy (right 3, left 1). The analysis of tumoral samples showed a pathological complete response rate or microscopic residual foci of 39.5%. Median follow-up time was 22.3 months (survivors: 36.8 months), 2-year and 3-year overall survival rates were 55% and 40%, respectively (median = 26.7 months) for all the intention-to-treat population (n = 107), 62% and 51% (median = 36.5 months) for 71 resected pts, 41% and 16% for 36 non-resected pts (median = 19.1 months). On multivariate analysis, surgical resection and tumoral necrosis >50% (or pathological complete response) were the most pertinent predictive factors of the risk of death (hazard ratio = 0.50 and 0.48, p = 0.006 and 0.038, respectively). Conclusion: Surgery was feasible after induction chemoradiation, particularly lobectomy in PS 0–1, stage IIB (Pancoast)/III NSCLC pts but pneumonectomy carries a high risk of postoperative death (particularly, right pneumonectomy). Pathological response to induction chemoradiation was complete in 39.5% of patients and was a significant predictive factor of overall survival.     

Lung-sparing techniques are associated with improved outcome compared with anatomic resection for severe lung injuries

BACKGROUND: Pulmonary tractotomy was introduced in 1994 as a novel concept for lung salvage after penetrating wounds. Recently, tractotomy has been suggested to increase morbidity and, thus, its practice has been challenged. The purpose of this study was to compare the morbidity and mortality associated with nonanatomic and anatomic lung resection in the management of severe pulmonary injuries. METHODS: Using our trauma registry, patients admitted to an urban Level I trauma center during an 11-year period with thoracic injuries requiring thoracotomy and pulmonary operation were identified. A chart review was performed with attention to patient demographics, operative treatment, and outcome. Pulmonary operations performed were classified as either nonanatomic (wedge resection and tractotomy) or anatomic resection (lobectomy and pneumonectomy). Statistical analysis was performed using Student's test, Fisher's exact test, and logistic regression as appropriate. RESULTS: There were 34 men and 2 women, with a mean age of 29 +/- 2 years. Mechanism of injury was predominantly penetrating, with 26 (72%) gunshot wounds and 8 (22%) stab wounds. Intraoperative blood loss and early red blood cell transfusion requirement were lower in patients undergoing nonanatomic resection (3.85 L vs. 11.90 L and 17.4 U vs. 27.9 U, respectively; p < 0.05). Mortality was 4% in the nonanatomic resection group versus 77% in the anatomic resection group. CONCLUSION: Nonanatomic resection is associated with an improved morbidity and mortality compared with anatomic resection in the management of severe lung injuries. Although not a randomized study, these findings encourage the continued application of lung-sparing procedures when feasible.     

Modern thirty-day operative mortality for surgical resections in lung cancer

Modern postoperative mortality rates for resectional operations for lung cancer are not readily available. In recent publications estimating the risk factors for surgical resection, mortality rates of 10% to 15% for pneumonectomy and 5% to 7% for lobectomy are frequently quoted. In order to determine modern operative mortality rates (up to 30 days postoperatively), the Lung Cancer Study Group (LCSG) analyzed the surgical mortality rates of the various participating centers during the years 1979 to 1981. A total of 2,200 resections for lung cancer were available for analysis. Of the 2,220 resections performed, 1,058 were lobectomies, 569 were pneumonectomies, and 143 were lesser resections (segmental or wedge). Eighty-one postoperative deaths occurred from among the 2,220 resections (3.7%). The mortality rate for pneumonectomy was 6.2% and for lobectomy, 2.9%. Lesser resections carried a 1.4% mortality rate, not statistically different from lobectomy. In patients under the age of 60 years, the mortality rate was 1.3%, 60 to 69 years, 4.1%, and over 70 years, 7.1%, all significantly different (p less than 0.01). The postoperative mortality rate for patients 70 years or older was 7.1% (pneumonectomy 5.9% and lobectomy 7.3%). It is obvious that greater care was taken in selection among the older pneumonectomy patients. The striking similarity of postoperative mortality rates for resectional operations for lung cancer among the various centers of the LCSG and among the various institutions within these centers suggest that these data are a reasonably accurate analysis of modern surgical mortality rates in the treatment of lung cancer.