Lung resection for patients with lung cancer and chronic obstructive pulmonary disease

The number of lung resection for patients with lung cancer has been increasing lineally for last two decades in Japan. It reached more than 30,000 in 2009. Subsequently those combined with chronic obstructive pulmonary disease (COPD) also have increased. As pulmonary vascular bed has already been lost to some extent due to chronic alveolar destruction, a careful preoperative physiologic assessment according to a guideline by American College of Chest Physicians (ACCP) or European Respiratory Society( ERS)/European Society of Thoracic Surgeons( ESTS) is important to select patients to be underwent lung resection within acceptable risk. The process to evaluate the risk of lung resection for a lung cancer patient has three steps structured by forced expiratory volume in 1 sec( FEV1), diffusion capacitiy for carbon monoxide (DLco), and exercise capacity. We suggested that it would be more practical to add global initiative for obstructive lung disease( GOLD) staging of each patient and distribution of emphysematous lung obtained by functional imaging modarities to the pathway of flow chart of the guideline. Some patients with very low FEV1 demonstrate increase in FEV1 after lung resection by so called lung volume reduction effect. To utilize lots of findings and experiences obtained from lung volume reduction surgery( LVRS) contributes to select patients with lung cancer and COPD and to perform lung resection and perioperative care properly.     

Impact of previous cardiovascular surgery on postoperative morbidity and mortality after major pulmonary resection for non-small cell lung cancer

Purpose

The aim of this study was to evaluate the impact of previous cardiovascular surgery on the postoperative morbidity and mortality following major pulmonary resection for non-small cell lung cancer (NSCLC).

Methods

Medical records of 227 patients, who underwent major pulmonary resection for NSCLC from 2003 to 2012 at our department, were reviewed retrospectively. Thirty-one patients with a mean age of 65.8 years had previous cardiovascular surgery (group A) including coronary artery revascularization in 11 patients, peripheral arterial revascularization in 6 patients, carotis endarterectomy in 9 patients, and combined coronary artery revascularization and carotis endarterectomy in 5 patients, whereas 167 patients (mean age?=?62.0 years) had no cardiovascular comorbidity (group B). Twenty-nine patients with nonsurgically treated cardiovascular comorbidity were excluded from this study.

Results

There were no significant differences in overall postoperative morbidity (22.6 % in group A vs. 19.2 % in group B) and mortality (no mortality in group A vs. 2.4 % in group B) between both groups.

Conclusions

Major pulmonary resections for NSCLC can be performed safely in patients with previous cardiovascular surgical history who are fulfilling the common cardiopulmonary criteria of operability. Operative risk in this subpopulation is comparable to that in patients without cardiovascular comorbidity.     

Long-term results after pulmonary resection in elderly patients with non-small cell lung cancer

BACKGROUND: The number of elder by patients with lung cancer is expected to increase. But, there was no report that 10 years completely passed in surgically treated elderly patients (E-pts). This study assesses late results of surgery. METHODS: From 1981 to 1987, 160 patients with non-small cell lung cancer underwent lobectomy or pneumonectomy with mediastinal lymph node dissection. Of these, 37 (23%) were 70 years of age or older. The outcome of this group was compared with that of 123 non-elderly patients (NE-pts). RESULTS: There were no significant differences in the background between E-pts and NE-pts. Five- and 10-year survivals in the E-pts were 35.1%, and 24.3%, respectively. In outcome more than 5 years from operation, E-pts had a significantly poorer prognosis than NE-pts (p=0.04) by any causes of death, but a similar prognosis by primary death. E-pts died of nontumor-related death significantly more than NE-pts (p=0.6). CONCLUSIONS: This study showed that E-pts could consummate their lives completely. Additionally, when long-term prognosis of the postoperative E-pts was discussed, we should contemplate that E-pts had more deaths from nontumor-related causes.     

Minimal alteration of pulmonary function after lobectomy in lung cancer patients with chronic obstructive pulmonary disease

BACKGROUND: The aim of this study was to evaluate the influence of chronic obstructive pulmonary diseases (COPD) on postoperative pulmonary function and to elucidate the factors for decreasing the reduction of pulmonary function after lobectomy. METHODS: We conducted a retrospective chart review of 521 patients who had undergone lobectomy for lung cancer at Chiba University Hospital between 1990 and 2000. Forty-eight patients were categorized as COPD, defined as percentage of predicted forced expiratory volume at 1 second (FEV1) less than or equal to 70% and percentage of FEV1 to forced vital capacity less than or equal to 70%. The remaining 473 patients were categorized as non-COPD. RESULTS: Although all preoperative pulmonary function test data and arterial oxygen tension were significantly lower in the COPD group, postoperative arterial oxygen tension and FEV1 were equivalent between the two groups, and the ratio of actual postoperative to predicted postoperative FEV1 was significantly better in the COPD group (p < 0.001). With multivariable analysis, COPD and pulmonary resection of the lower portion of the lung (lower or middle-lower lobectomies) were identified as independent factors for the minimal deterioration of FEV1. Actual postoperative FEV1 was 15% lower and higher than predicted, respectively, in the non-COPD patients with upper portion lobectomy and the COPD patients with lower portion lobectomy. Finally, we created a new equation for predicting postoperative FEV1, and it produced a higher coefficient of determination (R(2)) than the conventional one. CONCLUSIONS: The postoperative ventilatory function in patients with COPD who had lower or middle-lower lobectomies was better preserved than predicted.     

Preoperative pulmonary rehabilitation in patients undergoing lung resection for non-small cell lung cancer.

BACKGROUND: The impact of short-term preoperative pulmonary rehabilitation on exercise capacity of patients with chronic obstructive pulmonary disease undergoing lobectomy for non-small cell lung cancer is evaluated. METHODS: A prospective observational study was designed. Inclusion criteria consisted of an indication to lung resection because of a clinical stage I or II non-small cell lung cancer and a chronic obstructive disease on preoperative pulmonary function test. In such conditions, maximal oxygen consumption by a cardio-pulmonary exercise test was evaluated; when this resulted as being < or =15 ml/kg/min a pulmonary rehabilitation programme lasting 4 weeks was considered. Twelve patients fulfilled inclusion criteria, completed the preoperative rehabilitation programme and underwent a new functional evaluation prior to surgery. The postoperative record of these patients was collected. RESULTS: On completion of pulmonary rehabilitation, the resting pulmonary function test and diffuse lung capacity of patients was unchanged, whereas the exercise performance was found to have significantly improved; the mean increase in maximal oxygen consumption proved to be at 2.8 ml/kg/min (p<0.01). Eleven patients underwent lobectomy; no postoperative mortality was noted and mean hospital stay was 17 days. Postoperative pulmonary complication was recorded in 8 patients. CONCLUSIONS: Short-term preoperative pulmonary rehabilitation could improve the exercise capacity of patients with chronic obstructive pulmonary disease who are candidates for lung resection for non-small cell lung cancer.     

Perioperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease

Objective: The purpose of this study was to investigate the impact of pulmonary rehabilitation on surgical morbidity and lung function in lung cancer patients with chronic obstructive pulmonary disease (COPD). Methods: Prospectively, 22 lung cancer patients with COPD who underwent lobectomy between 2000 and 2003 were enrolled for this study as a rehabilitation group (Rehab. Group). The criteria of COPD were preoperative forced expiratory volume in 1 second (FEVl)/forced vital capacity (FVC) ≦70% and more than 50% of low attenuation area in a computed tomography. Preoperatively patients performed aggressive pulmonary exercise for two weeks and received chest physiotherapy postoperatively. As a historical control, 60 patients with lung cancer who fulfilled the same criteria but did not receive rehabilitation between 1995 and 1999 (control group) were entered in this study. Results: Patient backgrounds were all equivalent between the two groups. However, FEV1 and FEV1/FVC were significantly lower in the Rehab. Group (p<0.05). Prolonged oxygen supplement and tracheostomy tended to be more frequent in the control group. The ratio of actual postoperative to predicted postoperative FEV1 was significantly better in the Rehab. Group (p=0.047). Furthermore, postoperative hospital stay was significantly longer in the control group (p=0.0003). Conclusion: Despite lower FEV1 and FEV1/FVC in the Rehab. Group, postoperative pulmonary complications and long hospital stay could be effectively prevented and FEV1 was well preserved by rehabilitation and physiotherapy.     

Lactate dehydrodgenase levels predict pulmonary morbidity after lung resection for non-small cell lung cancer.

OBJECTIVE: The prevention of pulmonary complication after pulmonary resection for non-small cell lung cancer may minimize postoperative mortality rates and hospitalization period. The purpose of this study was to identify preoperative factors associated with the development of pulmonary complications after lung resections to help predict which patients are at increased risk for morbidity. METHODS: From January 2000 to June 2003, 108 consecutive pulmonary resections were performed for non-small cell lung cancer in our institution. The following information was recorded: demographic, clinical, functional, and surgical variables. We evaluated all complications, which arose after pulmonary resection during hospitalization. The risk of complication was evaluated using univariate and multiple logistic regression analysis to estimate odds ratio. RESULTS: Sixty-six lobectomies, 31 pneumonectomies, 11 bilobectomies and four wedge resections were done. Forty-nine complications were realized in all patients. A logistic regression analysis on relevant variables showed that only the increased serum lactate dehydrogenase (LDH) levels (>320 U/l) was a significant predictor of a pulmonary complication (P=0.03). Age, side of resection, low FEV(1), stage of the disease, low partial arterial oxygen pressure, low partial arterial carbon dioxide pressure, cigarette smoking and concomitant disease were not significant predictors of morbidity. CONCLUSION: Patients who have higher serum LDH levels are at increased risk for developing postoperative morbidity. Postoperative physical therapy and medical care might be intensified in those patients at high risk.     

Survival after resection of metachronous non-small cell lung cancer in 127 patients

BACKGROUND: In a number of patients with treated primary non-small cell lung cancer (NSCLC) a second primary tumor will be diagnosed. Our experience with surgery in these patients was analyzed and possible prognostic parameters were defined. METHODS: Patients with metachronous NSCLC (n = 127) who underwent resection from 1970 through 1997 were analyzed. All tumors were classified postsurgically. Median interval between the tumors was 3.7 years. Actuarial survival time was estimated and risk factors influencing survival were evaluated. RESULTS: Overall 5-year survival after the first resection was 70% and after the second resection was 26%. Patients with stage IA of the second primary tumor did have a significantly better survival (p < 0.005) as compared with patients with higher staged second primaries. Stage of second primary tumor and age were significant predictors of survival, whereas stage of first tumor, interval between resections, histology, and type of resection were not. CONCLUSIONS: Survival of patients with metachronous NSCLC and resection of both tumors is high, but poorer than after resection of the first tumor. Irrespective of the interval, patients with stage IA second primary tumor may benefit more from pulmonary resection.     

Risk analysis of pulmonary resection for elderly patients with lung cancer

Purpose

The indications for pulmonary resection in elderly patients with lung cancer concomitant with another disease are unclear. We conducted this retrospective study to establish the risk factors of complications and survival to improve patient selection.

Methods

The subjects were 295 patients aged ≥75 years, who underwent pulmonary resection for lung cancer. We assessed comorbidity according to the Charlson comorbidity index (CCI) and examined risk factors for morbidity and the prognostic factors.

Results

Postoperative complications developed in 55 patients (morbidity 18.6 %). The median survival time was 59.3 months and the 5-year survival rate was 69.7 %. Multivariate logistic regression analyses selected smoking and thoracotomy as risk factors for complications, and a history of cerebrovascular disease, cancer stage, and thoracotomy as risk factors for a prolonged hospital stay (PHS). Video-assisted thoracic surgery (VATS) decreased the risk of morbidity and PHS, and influenced survival. Multivariate analysis with the Cox proportional hazard model identified CCI ≥ 2, morbidity, and PHS as unfavorable survival factors, in addition to age ≥80 and cancers that were non-adenocarcinoma or advanced.

Conclusions

Although CCI ≥ 2 was associated with poorer survival, it was not necessarily a risk factor of postoperative complications or PHS. Performing VATS when possible could reduce the incidence of postoperative complications and PHS in elderly patients.     

Treatment and survival after lung resection for non-small cell lung cancer in patients with microscopic residual disease at the bronchial stump.

OBJECTIVE: The aim of this study is a retrospective evaluation of survival in patients who had undergone lung resection for non-small cell lung cancer and in whose microscopic residual disease at the bronchial resection margin was found, according to the type of infiltration, histology, lymph node involvement and postoperative treatment. METHODS: A total of 1384 patients underwent lung resection for non-small cell lung cancer at the Thoracic Surgery Unit of the University of Siena from 1983 through 1998. All patients underwent complete mediastinal lymphadenectomy and this guaranteed an accurate stadiation. Staging was done according to the TNM and UICC classifications. Residual microscopic disease at the bronchial resection margin was divided in mucosal microscopic residual disease and extramucosal microscopic residual disease. Patients dying within 30 days from operation were excluded from survival analyses. Survival was analysed by the product limit method of Kaplan and Meier and curves were compared using the log-rank test. RESULTS: Microscopic residual disease was found postoperatively at the bronchial margin in 3.39% (47/1384), of all patients undergoing lung resection for non-small cell lung cancer. Thirty patients (2.16%) had extramucosal microscopic residual disease and 17 (1.22%) had mucosal microscopic residual disease. Seventeen patients received adjuvant radiotherapy after operation, two patients underwent completion pneumonectomy; no chemotherapy was given. Median survival for the whole group was 22 months. The probability of survival was not significantly (P > 0.05) correlated with the type of infiltration, nor with lymph node disease, neither with histology, although patients with squamous cell carcinoma had a median survival of 30 versus 12 months of patients with adenocarcinoma. The probability of survival could not be correlated with the administration of adjuvant radiotherapy. CONCLUSIONS: A frozen-section analysis of the bronchial resection margin and peribronchial tissue should be made in all patients with endobronchial tumour. We suggest that patients with microscopic residual tumour and stage I or II disease should undergo re-operation, if possible. In patients with documented N2 disease we don't recommend re-operation; extending the magnitude of the resection is unlikely to alter their outcome. Choice treatment for these patients is radiotherapy.     

Risk assessment of perioperative mortality after pulmonary resection in patients with primary lung cancer: the 30- or 90-day mortality

Objectives

Although 30-day mortality rate is adapted to evaluate perioperative mortality after surgery, whether 90-day mortality rate adequately evaluates perioperative mortality remains unknown. Therefore, we analyzed 30- and 90-day mortality rates after pulmonary resection in patients with primary lung cancer.

Methods

A total of 2207 pulmonary resections for primary lung cancer performed between 1996 and 2010 at the Aichi Cancer Center Hospital were analyzed and divided into two groups of almost equal number: the early period group (1070 patients, 1996–2004) and the late period group (1137 patients, 2005–2010). Sixty-six and 34 patients died within a year during the early and late periods, respectively. The causes of death (recurrence, bleeding, sudden death, respiratory failure, and adverse event of chemotherapy), and 30- and 90-day mortality rates were investigated.

Results

The 30-/90-day mortality rates in the early and late period groups were 0.56/0.75 and 0.35/0.79 %, respectively. The postoperative survival days of 75 patients who died from recurrence within 1 year after pulmonary resection and 7 patients from bleeding or sudden death were more than 91 days and <30 days, respectively. The median postoperative survival of patients who died from respiratory failure was 67 days (range 20–142 days) in the early period and 100 days (range 47–149 days) in the late period. In the late period, it was difficult to assess perioperative mortality of pulmonary complications with 30-day mortality.

Conclusions

A risk assessment of perioperative mortality after pulmonary resection should be performed using the 30- and 90-day mortality.     

Risk factors for morbidity after pulmonary resection for lung cancer in younger and elderly patients

The aim of this study was to evaluate the perioperative morbidity, mortality, and risk factors for morbidity after lung cancer resection in younger and elderly patients. This study retrospectively reviewed 1073 patients with non-small cell lung cancers (NSCLC) who underwent pulmonary resection. The risk factors for morbidity were analyzed independently in groups of 664 younger (<70 years) patients and 409 elderly (≥ 70 years) patients. Co-morbidities, such as hypertension, ischemic heart disease, and renal insufficiency were more frequently observed in the elderly group in comparison to the younger group. However, there were no statistical differences in the rates of overall morbidity and 30-day mortality between the younger and elderly groups (36% vs. 42% and 0.3% vs. 0.5%, respectively). Multivariate analyses revealed the risk factors for morbidity to be % forced expiratory volume in 1 s (FEV(1)), the extent of pulmonary resection and tumor histology in the younger group, and smoking, hypertension, renal insufficiency and % diffusing capacity of the lung to carbon monoxide (DLCO) in the elderly group, respectively. In conclusion, the rate of morbidity and mortality in elderly patients were similar to those observed in younger patients. However, perioperative management should be cautiously performed while taking into account the risk factors for morbidity especially in elderly patients because they frequently have various co-morbidities.