Invited commentary

Abstract

Two large North American series have assessed death associated with lung cancer. In 1983, the Lung Cancer Study Group (LCSG) published results of surgical resection for lung cancer [1Ginsberg R.J. Hill L.D. Eagan R.T. et al.Modern thirty-day operative mortality for surgical resections in lung cancer.J Thorac Cardiovasc Surg. 1983; 86: 654-658PubMed Google Scholar]. These results are easy to remember, and I quote them closely to patients: 1.5% for wedge or segmental resection, 3% for lobectomy, and 6% for pneumonectomy—a doubling of risk per magnitude of the procedure. Despite concern quoting figures published 20 years ago, these figures are similar to my own personal results. Another, more recent large series published in 1995 included data from part of the prospective, multi-institutional National Veterans Affairs Surgical Quality Improvement Program [2Harpole Jr, D.H. DeCamp Jr, M.M. Daley J. et al.Prognostic models of thirty-day mortality and morbidity after major pulmonary resection.J Thorac Cardiovasc Surg. 1999; 117: 969-979Abstract Full Text Full Text PDF PubMed Scopus (242) Google Scholar]. In this series, a total of 3,516 patients (mean age, 64.9 years) underwent either lobectomy (n = 2,949) or pneumonectomy (n = 567). Thirty-day mortality was 4.0% for lobectomy (119 of 2,949) and 11.5% for pneumonectomy (65 of 567). In Japan. a large series of 7,099 patients from the Japanese Association for Chest Surgery, which presumably included some of the current patients, had an overall 30-day operative mortality rate of 1.3%. By operative procedure, the mortality rates were 3.2% for pneumonectomy, 1.2% for lobectomy, and 0.8% for a lesser operation [3Wada H. Nakamura T. Nakamoto K. Maeda M. Watanabe Y. Thirty-day operative mortality for thoracotomy in lung cancer.J Thorac Cardiovasc Surg. 1998; 115: 70-73Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar]. The current paper, also a large series, has results that will be envied by all thoracic surgeons. In addition to usual 30-day mortality, they additionally analyzed patients who lingered in hospital and died beyond the 30-day cut-off—in-hospital mortality. Thirty-day and in-hospital mortality rates for segmentectomy or wedge, lobectomy, and pneumonectomy were, respectively, 0.3% and 0.9%; 0.3% and 1.3%; and 3.1% and 5.9%. These mortality statistics are currently the lowest published. The authors split the 3,270 patients into two time groups of almost equal number and analyzed those results. The more recent group had 30-day and in-hospital mortality rates of 0.5% and 0.8%, respectively. Comparison of the two time periods indicates an almost threefold decrease in the percentage of pneumonectomies and an almost threefold increase in the percentage of wedges and segmental resections. To explain the change in practice, the authors have commented on increased detection of early stage lung cancer by the use of computed tomography scanners. Another possible reason is that the authors [4Asamura H. Suzuki K. Watanabe S. Matsuno Y. Maeshima A. Tsuchiya R. A clinicopathological study of resected subcentimeter lung cancers a favorable prognosis for ground glass opacity lesions.Ann Thorac Surg. 2003; 76: 1016-1022Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar] and Japanese surgeons do limited resections for bronchioalveolar lung carcinoma presenting as ground-glass opacification on computed tomography scanning. It is a well-known fact that mortality rate is related to the extent of resection. If lesser resections are being performed, the mortality rate will decrease. Despite this assumption, 30-day mortality rates for lobectomy (0.3%) and pneumonectomy (3.1%) are still low compared with other series. What is Japan doing differently from the rest of the world? Apart from the fact that lesser resections are more frequently performed, the answers to that question are unfortunately missing. Regression analysis looking at risk factors is absent, as are basic demographic data such as age, sex, smoking history, pulmonary function tests, type of lung cancer, and so forth. Selection criteria are also missing. Are patients with comorbidities being excluded? Does the practice of doing lesser resections for lung cancer result in improved long-term survival? The LCSG data suggested that lobectomy was the preferred operation for lung cancer. An assumption that low-risk patients and lesser procedures are responsible for the remarkable results cannot be made without further data, which are eagerly awaited. If the spectrum of patients managed in Japan is similar to what we currently see, then we have much to learn.