The advantage of sleeve lobectomy as an alternative to pneumonectomy for preserving lung function is obvious and among other arguments allows operating on patients with lung cancer who would not ...tolerate pneumonectomy. The purpose of this retrospective, nonrandomized study is to compare the early (30-day mortality) and late (5-year survival) outcomes of both procedures.
The charts of 310 patients who underwent either pneumonectomy or sleeve lobectomy for lung cancer stages I to IIIA from 1987 to 1997 were reviewed. One hundred ninety-four patients underwent pneumonectomy, and 116 patients underwent sleeve lobectomy. Specific operative complications, i.e., anastomotic leakage versus stump dehiscence, perioperative complications, 30-day or in-hospital mortality, and 5-year survival were registered for comparison of the immediate risk of the respective procedures.
In the bronchial sleeve lobectomy group, the incidence of anastomotic leakage was 6.9% (8 of 116 patients) and the operative mortality was 4.3%. The incidence of bronchial stump fistulas after pneumonectomy was 3.6% (7 of 194 patients), and early mortality was 4.6%. All but 6 patients (98%) had a complete resection. Overall 5-year survival after sleeve lobectomy was 39% and after pneumonectomy, 27%. The distribution of 5-year survival stage by stage in either group is presented. Sleeve lobectomy, age younger than 65 years, pN0, and stage I are positive prognostic factors for long-term survival. In the multivariate analysis, pneumonectomy is a negative prognostic factor.
The indication for pneumonectomy versus sleeve lobectomy depends on the localization of the primary tumor on the one hand, and on cardiorespiratory function, which might be more often distinctly impaired in the sleeve group, on the other hand. This could explain why the mortality in the sleeve lobectomy group was identical with that in the pneumonectomy group. However, both techniques are appropriate treatment modalities of advanced lung cancer or patients with critical functional reserve. Therefore, whenever possible, sleeve lobectomy should be performed.
The European Society of Thoracic Surgeons (ESTS) organized a workshop dealing with lymph node staging in non-small cell lung cancer. The objective of this workshop was to develop guidelines for ...definitions and the surgical procedures of intraoperative lymph node staging, and the pathologic evaluation of resected lymph nodes in patients with non-small cell lung cancer (NSCLC). Relevant peer-reviewed publications on the subjects, the experience of the participants, and the opinion of the ESTS members contributing on line, were used to reach a consensus. Systematic nodal dissection is recommended in all cases to ensure complete resection. Lobe-specific systematic nodal dissection is acceptable for peripheral squamous T1 tumors, if hilar and interlobar nodes are negative on frozen section studies; it implies removal of, at least, three hilar and interlobar nodes and three mediastinal nodes from three stations in which the subcarinal is always included. Selected lymph node biopsies and sampling are justified to prove nodal involvement when resection is not possible. Pathologic evaluation includes all lymph nodes resected separately and those remaining in the lung specimen. Sections are done at the site of gross abnormalities. If macroscopic inspection does not detect any abnormal site, 2-mm slices of the nodes in the longitudinal plane are recommended. Routine search for micrometastases or isolated tumor cells in hematoxylin-eosin negative nodes would be desirable. Randomized controlled trials to evaluate adjuvant therapies for patients with these conditions are recommended. The adherence to these guidelines will standardize the intraoperative lymph node staging and pathologic evaluation, and improve pathologic staging, which will help decide on the best adjuvant therapy.
Objective: Segmentectomy has recently been suggested as alternative to lobectomy for curative treatment of early-stage non-small cell lung cancer (NSCLC). This study was performed to investigate if ...localisation of the resected segment or width of resection margins influence local recurrence following complete segmentectomy of stage IA NSCLC. Methods: Between 1987 and 2002, 49 segmentectomies and 150 lobectomies were performed in patients with pT1pN0cM0-NSCLC in our institution. Indications for segmentectomy were a limited pulmonary function or severe comorbidity. The median follow-up duration was 54 months. Local recurrence was distinguished from secondary primary lung cancer and was defined as tumour within the same lung or in the ipsilateral mediastinum. Segment localisation, width of resection margins, tumour size, tumour type, grading and age were analysed concerning their influence on local recurrence. Results: Local recurrence occurred in 16% of patients with segmentectomy and was significantly more frequent than in patients with lobectomy (5%; p = 0.005; log-rank test). Segmentectomy in the S1–3 region tended more frequently to local recurrence than segmentectomy in the remaining segments (p = 0.08; log-rank test): There was no recurrence following segmentectomy in the S7–10 region (n = 6) or of S4–5 (n = 5). Recurrence occurred in 7 (23%) out of 30 patients with segmentectomy in the S1–3 region and in 1 (12%) out of 8 patients with S6-segmentectomy. Also, resection margins ≤ 1 cm tended to be associated with local recurrence (p = 0.06; log-rank test). Conclusions: The frequency of local recurrence following segmentectomy might be influenced by segment localisation and width of resection margins. Segmentectomy within the S1–3 region should be avoided whenever possible.
Postoperative mortality rates have been published in relation to operative procedure or preexisting pulmonary and extrapulmonary diseases. We analyzed our patients for the effect of the postoperative ...tumor stage on perioperative mortality.
Retrospective study of all thoracotomies for resections ( n=1281) in primary lung cancer from January 1987 to December 1997. Uni- and multivariate analysis was performed for operative procedure, mortality (30 and 90 days), tumor stage, sex, age, tumor localization, and completeness of resection. Radical resection was achieved in 91.9% of the patients.
Overall postoperative deaths occurred in 4% and 7.3% of patients after 30 and 90 days respectively. Depending on the operative procedure the mortality after segmental resection ( n=116) was 0.9% and 1.7%, lobectomy ( n=621) 3.0% and 5.7%, sleeve lobectomy ( n=152) 5.3% and 7.9%, and pneumonectomy ( n=314) 6.7% and 12.5%, respectively. Within 30 and 90 days postoperatively deaths occurred, respectively, in 0.8% and 1.0% of stage I patients ( n=493), 5.4% and 5.4% of stage II ( n=147), 4.9% and 8.8% of stage IIIa ( n=388), 7.2% and 16.6% of stage IIIb ( n=148), 8.9% and 20.5% and of stage IV ( n=114). Multivariate analysis showed postoperative tumor stage to be the factor most closely related to within the first 90 days.
Tumor stage but not type of resection is the strongest predictor of postoperative mortality in these subpopulations.
The current study was conducted to evaluate the maximum tolerable dose of weekly gemcitabine administered simultaneously with radiation and cisplatin in patients with locally advanced nonsmall cell ...lung cancer (NSCLC).
Patients with stage IIIA/B NSCLC received concurrently 63 grays radiation and 20 mg/m² cisplatin Day 1 to 3 in Weeks 1 and 5, plus weekly gemcitabine at escalating doses (150-700 mg/m²) on Fridays after radiation to avoid radiosensitization. The authors assessed dose-limiting toxicities according to Common Toxicity Criteria. The primary endpoint was maximum tolerated dose (MTD) of gemcitabine. Tumor resectability, survival, and disease-free survival (DFS) were also determined.
Forty-two patients were accrued, of whom 95% received radiation and 66% cisplatin as above. Weekly doses of gemcitabine were escalated to 700 mg/m². Grade 3 dysphagia and 1 case of fatal, probably treatment-related pulmonary deterioration established the MTD of gemcitabine at 550 mg/m² weekly. Twenty-five patients underwent surgery, and histopathological complete regression was documented in 26% of these patients. Overall, median actuarial survival and DFS were 23.8 and 12.4 months, respectively.
Gemcitabine at doses up to 550 mg/m² weekly can be given simultaneously with radiation and cisplatin to patients with locally advanced NSCLC. Radical resection thereafter is feasible. The impact of this aggressive therapy should be evaluated further.
To describe the role of sputum and brush cytology in the diagnosis of lung carcinoma and to elucidate the influence of tumor location, histologic tumor type and stage on the sensitivity of both ...methods.
Retrospective and performed on 415 lung cancer patients. Two hundred of them were investigated only by sputum collection, 119 only by brushing and 96 by both methods.
The overall sensitivity of the sputum technique was 0.403 and that of the brush method 0.500, while a combination of both showed a sensitivity of 0.640. The diagnostic yield depended on tumor location, histologic tumor type and stage. Sputum specimens were most valuable in the detection of early and peripheral carcinomas, whereas brushing was superior in finding more advanced and centrally located malignancies. Regarding tumor type, squamous cell carcinomas were diagnosed to the greatest extent by both methods.
A complementary role of both cytologic techniques can be postulated by our data as well as by a literature review.
To assess the postoperative course of pleural leukocyte counts and cytokine concentrations in patients with malignant and nonmalignant lung disease who underwent thoracic surgery.
A total of 21 ...patients undergoing thoracic surgery were included in the study. Twelve patients had a malignant disease, and 9 had a nonmalignant disease. Six patients underwent video-assisted thoracoscopy and 15 underwent thoracotomy. Pleural drainage fluid from the chest tubes was collected postoperatively at 0h, 3h, 6h, 12h, 24h, 48h, 72h, and 96 h. The same schedule, as well as one additional preoperative sample, was applied for blood collections.
A trend toward lower concentrations of tumor necrosis factor-α (TNF-α), granulocyte-macrophage colony-stimulating factor, and interleukin-10 was observed in patients with malignant disease compared to those without malignancy. These differences achieved significance for TNF-α in the drainage fluid of those patients with nonmalignant disease who had undergone formal thoracotomy. Patients with malignant disease showed significantly lower macrophage fractions in drainage fluid and lymphocyte fractions in serum. All patients with complications had malignant disease and showed the lowest cytokine concentrations, as well as the lowest fractions of both macrophages in drainage fluid and lymphocytes in serum.
The data suggest that malignancy may lead to impairment of the wound-healing process via modification of the inflammatory cell infiltrate and locally released cytokines.
Indications and results of completion pneumonectomy Jungraithmayr, Wolfgang; Hasse, Joachim; Olschewski, Manfred ...
European journal of cardio-thoracic surgery,
07/2004, Letnik:
26, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Objectives: Completion pneumonectomy (CP) is widely known to be associated with a high morbidity and mortality. However, in certain instances, CP offers the only chance for a cure. The results of the ...following three groups were investigated: progressive or recurrent benign disease, recurrence of a malignant tumour and complication after lung resection. Methods: Between January 1986 and April 2003, 525 patients underwent pneumonectomy, 86 of these being completion pneumonectomies (16.4%). Six patients suffered from a progression or recurrence of a benign disease, 41 patients had a recurrence of a malignant tumour (local recurrence, secondary carcinoma and recurrent metastases) and 39 patients had a complication after lung resection. Among patients with a complication, the indication for CP was either an emergency or urgent condition. Right CP was carried out in 48 cases and left CP in 38. Results: The overall 30-day mortality was 20.2, 0% in the group with benign disease, 10% in the group with a recurrent malignant tumour and 33.3% in the group with a complication after lung resection. The 30-day mortality of CP was significantly higher (P=0.014) on the right side (29.8%) than on the left side (7.7%). Differentiation between emergency and urgent indications resulted in 30-day mortalities as follows: 54 and 23%, respectively. This difference is significant (P=0.002). The 30-day mortality for patients with anastomotic or stump insufficiency was 41% (P=0.002). Five-year survival of all patients was 28% and in the group of patients with a complication after lung resection 32%. Conclusions: Lethality of CP remains high, especially after CP for a complication performed in an emergency condition. Possible risk factors are right side of operation, CP performed in an emergency condition and CP for anastomotic or stump insufficiency, either or not involving sepsis. However, considering the long-term survival, CP is certainly justified.
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