Resection for bronchial carcinoma in the elderly

The results of surgery for carcinoma of the bronchus among an elderly population are reviewed in relation to the total number of cases seen. Although there is a 20% operative hospital mortality, nevertheless a survival rate of 39% for four years makes surgery in the elderly worthwhile. The span of life in untreated cases is even less than in the younger age groups.     

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.     

Bilobectomy for bronchogenic carcinoma

During a 12-year period, bilobectomy was performed on 166 patients for the treatment of primary lung carcinoma: 108 patients (65%) underwent right upper and middle lobectomy, while 58 patients (35%) underwent right middle and lower lobectomy. Indications for bilobectomy were tumor extending across a fissure (45%), absent fissure (21%), endobronchial tumor (14%), extrinsic tumor or nodal invasion of bronchus intermedius (10%), and vascular invasion (5%). Thirty-one patients (19%) suffered 41 perioperative complications, and 7 patients (4.2%) died. Upper and middle lobectomies were not associated with a significantly different morbidity (p greater than 0.10) or mortality (p greater than 0.10) when compared with middle and lower lobectomy. The postoperative chest roentgenograms of all patients demonstrated ipsilateral volume loss, and 31 patients were found to have asymptomatic hydropneumothoraces, which cleared during the follow-up period. Late complications occurred in 4 patients (2%) and included two empyemas, one bronchopleural fistula, and one superficial wound infection. These results indicate that bilobectomy is associated with morbidity and mortality that lie between those currently reported for lobectomy and pneumonectomy.     

Resection for bronchogenic carcinoma involving the carina: long-term results and effect of nodal status on outcome

OBJECTIVE: Bronchogenic carcinoma in close proximity to or involving the carina remains a challenging problem for thoracic surgeons. The operative procedures to allow complete resection are technically demanding and can be associated with significant morbidity and mortality. Little is known about long-term survival data to guide therapy in these patients. METHODS: We conducted a single-institution retrospective review. RESULTS: We have performed 60 carinal resections for bronchogenic carcinoma: 18 isolated carinal resections for tumor confined to the carinal or proximal main stem bronchus; 35 carinal pneumonectomies; 5 carinal plus lobar resections, and 2 carinal resections for stump recurrence after prior pneumonectomy. Thirteen patients (22%) had a history of lung or airway surgery. The overall operative mortality was 15%, improved from the first half of the series (20%) to the second half (10%), and varied according to the type of resection performed. Adult respiratory distress syndrome was responsible for 5 early deaths, and all late deaths were related to anastomotic complications. In 34 patients, all lymph nodes were negative for metastatic disease; 15 patients had positive N1 nodes, and 11 patients had positive N2/N3 nodes. Complete follow-up was accomplished in 90%, with a mean follow-up of 59 months. The overall 5-year survival including operative mortality was 42%, with 19 absolute 5-year survivors. Survival was highest after isolated carinal resection (51%). Lymph node involvement had a strong influence on survival: patients without nodal involvement had a 5-year survival of 51%, compared with 32% for patients with N1 disease and 12% for those with N2/N3 disease. CONCLUSIONS: This constitutes one of the largest single-institution reports on carinal resection for bronchogenic carcinoma involving the carina. Morbidity and mortality rates are acceptable. The overall survival including operative mortality is 42%. Positive N2/N3 lymph nodes may be a contraindication to surgery because of poor prognosis.     

Carinal resection for bronchogenic carcinoma

The purpose of this study was to evaluate the results of carinal resection for bronchogenic carcinoma in our institute. From 1981 to 1999, 24 carinal resection were performed for squamous cell carcinoma (n = 19), adenoid cystic carcinoma (n = 2), small cell carcinoma (n = 1), adenocarcinoma (n = 1), and mucoepidermoid carcinoma (n = 1). Nineteen underwent sleeve pneumonectomy, 2 had carinal resection without lung resection, 2 had carinal resection with right middle and lower lobectomy, and 1 had wedge pneumonectomy. In the patients with sleeve or wedge pneumonectomy, there were 5 operative death and 3 patients had survived for more than 3 years. Two patients with low-grade malignant tumors underwent carinal resection without lung resection and survived more than 10 years. We believe that limited carinal resection for low-grade malignant tumors are safe and valuable procedure. Careful selection of patients with sleeve or wedge pneumonectomy is mandatory.     

Post-irradiation surgery for bronchogenic carcinoma

In an attempt to improve both the resectability and survival rates for bronchogenic carcinoma, pre-operative supervoltage radiotherapy was introduced in 1961 and continued for a period of three years. Patients with either a histological or cytological diagnosis were given a tumour dose of 4,500 r over six weeks and then a two-month period elapsed before surgery. A follow-up of cases treated during the period revealed a five-year survival rate of 15·7%. This rate is low when compared with the results achieved at this hospital with surgery alone. This finding is attributed to the harmful effects of radiotherapy which have led to a high bronchopleural fistula rate of 15·5%. A single case of myocardial radionecrosis also occurred. No improvement is noted in the resectability rate. An overall assessment is that radiotherapy has provided no benefits but has in fact greatly increased both the morbidity and mortality rates.     

Carinal resection for bronchogenic carcinoma

Techniques are available for carinal resection and reconstruction for bronchogenic carcinoma involving the carina. Successful outcome depends on careful patient selection, thorough preoperative evaluation, careful anesthetic management, strict attention to surgical technique, and compulsive postoperative care. Since 1973 we have performed 37 carinal resections for bronchogenic carcinoma: 21 right carinal pneumonectomies, 7 carinal resections, 7 carina plus lobe resections, and 2 carina plus pneumonectomy stump resections. Five patients had diseased N2 nodes and 13 patients had diseased N1 nodes. Complications included pulmonary (8), vocal cord paresis (3), atrial fibrillation (9), anastomotic stenosis (4), and anastomotic separation (3). There were 3 early postoperative deaths (8%). All were related to adult respiratory distress syndrome and were unresponsive to aggressive treatment. There were 4 late postoperative deaths between 2 and 4 months (10.9%). All late postoperative deaths were related to anastomotic complications (stenosis [1] and separation [3]). There are 5 absolute 5-year survivors and an actuarial 5-year survival rate of 19%.     

Reoperation for recurrent bronchogenic carcinoma

From a total of 869 patients primarily operated on for bronchogenic carcinoma, nine underwent a second operation for recurrence of the tumour. The median interval between the operations was 16 months. In four patients the second operation consisted of resection of ipsilateral residual lung after primary segmental resection or lobectomy. One patient underwent contralateral pneumonectomy after primary segmental resection. In the four remaining cases a contralateral lobectomy or segmental resection was performed after primary lobectomy. Four of the nine patients are still alive but, after a short observation time, only two are tumour-free. On the basis of these findings we cannot recommend reoperation for bronchogenic carcinoma, except in very rare, individually selected cases.     

Parenchymal sparing operations for bronchogenic carcinoma

By the end of the 1950s, the principles of tracheobronchial and pulmonary artery (PA) reconstruction had been established, and their successful clinical application had taken place. It was not until very recently, however, that these techniques aroused widespread interest among thoracic surgeons as a means to achieve complete cancer resection while preserving functioning lung parenchyma. At the present time, sleeve resection of the bronchus and/or PA has a definite role in the surgical management of lung cancer. Growing interest in this field is evidenced by an increasing number of technical variations intended to adapt the basic technique to the different anatomical settings. Also pitfalls, complications, and their prevention and treatment are being extensively described. Last but not least, functional and oncological long-term results, comparing favorably with those of more extended resections, are being reported by many groups. This demonstrates that sleeve lobectomy is no longer reserved only for particularly skillful surgeons. Sleeve lobectomy has achieved its rightful position among the techniques commonly used in thoracic surgery after 40 years of improving understanding and alternating enthusiasm and legitimate doubts.     

Segmental resection for bronchogenic carcinoma.

Segmental resection was performed on 168 patients with peripheral, Stage I bronchogenic carcinoma from 1957 to July 1, 1978. Seventy-four patients (44%) had adenocarcinoma, 58 (34%) had an epidermoid type, 28 (17%) had an unadifferentiated tumor, and 8 (5%) had a bronchoalveolar variety. Ninety-five resections were done on the left lung, the most frequent procedure being removal of the superior division of the left upper lobe (38 patients). On the right side, 73 resections were done. The anterior segment was removed most frequently (19 patients). There were 3 surgical deaths, for a mortality of less than 2%. Complications requiring prolonged hospitalization were associated with air leak in 10 (6%) of the 168 patients. Survival by actuarial curve is 53% at 5 years, 33% at 10 years, and 25% at 15 years. Forty-five patients (27%) died of metastatic carcinoma. Patients with epidermoid lesions have the most favorable prognosis.     

Resection for lung cancer in the elderly patient

Age is sometimes used as an excuse not to resect lung cancer. Nugent et al [10] noted that, although only 6% of patients younger than 45 years had stage I or II disease, 33% underwent surgical resection. In contrast, of the 33% of elderly patients who had stage I or II disease, only 6% underwent surgical resection. The elderly patients who are carefully selected for lung resection are undoubtedly stronger physiologically than others their same age. Patients with adequate predicted postoperative lung function, no contraindications from other medical problems, good performance status, and social support should be offered standard resection for early-stage NSCLC. Lung cancer resection in elderly patients is justified and has decreasing morbidity and mortality rates. Careful patient selection and operative planning are necessary, however. It is wise to have a diagnosis and staging done before the patient arrives in the operating suite. The surgeon should avoid extended resections when possible. In addition, elderly patients should be ambulated as soon as possible and adequate pain control should be ensured. Finally, the stage of the cancer and occurrence of cardiopulmonary complications are the main determinants of outcome.     

Sleeve pneumonectomy for bronchogenic carcinoma.

Carcinomas of the right upper lobe that locally infiltrate the trachea represent a major challenge with regard to removal and reconstruction. Sixteen patients who had right pneumonectomy with carina resection between 1969 and 1977 were reviewed, and some implications of the surgical and anesthetic techniques were analyzed. The short-term results give merit to this extended procedure, and the fact that there is one long-term survivor suggests that some patients can be cured of their disease.     

Endoscopic laser treatment for bronchogenic carcinoma

The use of laser therapy for endobronchial lesions has met with general enthusiasm. From published series it is difficult to determine specific indications for its use, based upon patients' complaints, locations of tumor, and any concomitant therapies. Most reports do not provide sufficient information to permit adequate comparisons regarding improvement in symptoms and long-term efficacy. Exophytic lesions of the trachea and mainstem bronchi are most amenable to therapy by laser, and improvement in symptoms correlates best with improved patency of large airways. In most patients the major portion of the endobronchial debulking procedure can be performed quickly and safely by physically coring out the exophytic tumor mass with the rigid end of the bronchoscope. A large biopsy forceps can help accomplish this with very little bleeding. The laser can then remove any remaining tumor and produce hemostasis by coagulation of the tumor bed. The major purpose of laser therapy is to lessen or completely relieve symptoms of airway obstruction. Laser therapy to obstructed lobar or segmental bronchi rarely reduces symptoms unless they are associated with post-obstructive pneumonia. When the obstruction is longstanding, laser ablation may fail to establish airway patency. Hemoptysis from exophytic lesions can usually be well controlled. Treatment of lesions that produce extrinsic compression of the trachea or bronchi is of little value. At present, laser therapy is one of several treatments available for neoplastic endotracheal or endobronchial obstruction. Other local therapies include external-beam irradiation, cryotherapy, electrocoagulative therapy, and intraluminal brachytherapy with insertion of afterloading catheters. Most of these modalities are available in large oncologic centers, and it will take the better part of the next decade to identify specific indications for each of these therapies individually and in combination. Currently, Nd:YAG therapy has an established role in the palliative treatment of obstructive endobronchial disease. Response rates to therapy with relief of obstruction are in the range of 80 to 85 per cent. Nd:YAG therapy is easy, quick, and, with proper caution, safe. In the majority of cases it must be repeated on one or several occasions. Photodynamic therapy is now being critically evaluated for the treatment of similar lesions.