Previous Lung Resection Research Articles

Intraoperative oxygen challenge for toleration of single lung ventilation in a patient with severe obstructive airway disease: A case report

Perioperative risk assessment is complex in patients with chronic obstructive pulmonary disease who have undergone previous lung resection surgery. A 70-year-old female with severe chronic obstructive pulmonary disease and previous right middle and lower lobectomy, presented for left lower lobe superior segmentectomy. Respiratory function tests revealed a forced expiratory volume in 1 second of 0.72L, a forced vital capacity of 1.93L, and a carbon monoxide transfer factor of 10.0 ml/min/mmHg. A cardiopulmonary exercise test demonstrated little ventilatory reserve with profound arterial desaturation on peak exercise, however, a normal peak oxygen consumption (16.7 ml/min/kg) and a nadir minute ventilation/carbon dioxide slope of 24 implied a limited risk of perioperative cardiovascular morbidity. Given these conflicting results we performed an intraoperative oxygen challenge test under general anaesthesia with sequential ventilation of different lobes of the lung. We demonstrate the use of the oxygen challenge test as an effective intervention to further assess safety and tolerance of anaesthesia of patients with limited respiratory reserve being assessed for further complex redo lung resection surgery. Further, this test was a risk stratification tool that allowed informed decisions to be made by the patient about therapeutic options for treating their lung cancer. The prognostic value of traditional physiological parameters in patients with chronic obstructive pulmonary disease who have undergone previous lung resection surgery is uncertain. The intraoperative oxygen challenge test is another risk stratification tool to assist clinicians in assessment of safety and tolerance of anaesthesia for patients being considered for lung resection.

Experiences with venovenous extracorporeal membrane oxygenation (ECMO) support for thoracic surgery in Hungary. Retrospective clinical study

Introduction: Most modern thoracic operations are performed with single-lung ventilation balancing between convenient surgical approach and adequate gas exchange. The technical limitations include difficult airways or insufficient parenchyma for the intraoperative single-lung ventilation. Earlier, cardiopulmonary bypass was the only solution, however, today the extracorporeal membrane oxygenation is in the forefront. Aim: We retrospectively analysed our elective operations by use of venovenous ECMO to assess the indication, safety, perioperative morbidity and mortality. Patients and method: 12 patients were operated using venovenous (VV-) ECMO between 28 April 2014 and 30 April 2018 in the National Institute of Oncology. The main clinicopathological characteristics, data regarding the operation, the use of ECMO and survival were collected. Results: The mean age was 45 years, 2 patients had benign and 10 had malignant diseases. Extreme tracheal stricture was the indication for ECMO in 3 cases, while 4 patients had previous lung resection and lacked enough parenchyma for single-lung ventilation. 5 patients had both airway and parenchymal insufficiency. The average time of apnoea was 142 minutes without interruption in any of the cases. We did not experience any ECMO-related complication. We had no intraoperative death and 30-day mortality was 8.33%. Conclusion: In case of technical inoperability, when there is no airway or insufficient parenchyma for gas exchange, but pulmonary vascular bed is enough and there is no need for great-vessel resection, VV-ECMO can safely replace the complete gas exchange without further risk of bleeding. The use of VV-ECMO did not increase the perioperative morbidity and mortality. Previously inoperable patients can be operated with VV-ECMO. Orv Hetil. 2019; 160(42): 1655-1662.

MTE15.01 Identifying High Risk Patients: What Makes a Patient Too High Risk for Surgery and Who Decides?

MTE15.01 Identifying High Risk Patients: What Makes a Patient Too High Risk for Surgery and Who Decides?

What are the Prevalence of Abdominal Aortic Aneurysm in Patients with Chronic Obstructive Pulmonary Diseases and the Characteristics of These Patients?

To determine the prevalence of abdominal aortic aneurysm (AAA) in patients with chronic obstructive pulmonary disease (COPD) and to assess the characteristics of these patients. Stable COPD patients (age, >40 years) were included in the study between January 2014 and June 2014. Patients with acute exacerbations and a previous lung resection were excluded. Data regarding demographic characteristics were recorded. The modified Medical Research Council (mMRC) dyspnea scale was used to assess the severity of breathlessness. The COPD Assessment Test (CAT) was performed. Abdominal aortic diameter was measured using abdominal ultrasonography (AUS), and AAA was diagnosed as an aortic diameter of ≥30 mm at the renal artery level. In total, 82 patients were examined. AAA was detected in five (6.1%) patients. Diabetes mellitus, hypertension, and coronary artery disease were present in four patients with AAA. The average mMRC score was 3.2±0.4, and the mean CAT score was 18.4±6.0. Aneurysmal diameter was >50 mm in four patients and 37 mm in one patient. Statistically significant differences were found between patient with AAA and those without AAA with respect to the mean abdominal aortic diameters at the renal artery and iliac artery levels (p=0.012 and 0.002, respectively). Our findings suggest that AAA is associated with COPD, with a prevalence rate of 6.1%. AAA is usually asymptomatic until a clinical status of rupture, which is associated with a higher mortality risk. Early diagnosis of AAA is lifesaving. In COPD patients, AAA might be easily determined using AUS, which is a noninvasive and relatively cheap procedure.

P1.05-075 The Correlation between the Prognoses of Patients with Non-Small Cell Lung Cancer and Preoperative Platelet- Lymphocyte Ratio

The platelet- lymphocyte ratio (PLR) is a prognostic factor that correlates immunity or inflammation with tumor invasion. We retrospectively investigated the correlation between prognosis and preoperative PLR in patients with non-small cell lung cancer who underwent anatomical lung resection in our hospital. We conducted a retrospective study of 116 patients with primary lung cancer who underwent anatomical lung resection in our hospital from January 2009 to May 2014. We excluded patients who underwent previous lung resection or had intraoperative malignant pleural effusion or positive surgical margins. We analyzed 105 patients (65 with adenocarcinoma, 25 with squamous cell carcinoma, 9 with large cell carcinoma, and 2 with adenosquamous carcinoma). We constructed a ROC curve with PLR values calculated preoperative blood analyses and determined that the threshold was 160. We divided the patients into high and low PLR groups. We analyzed these two groups with respect to background, pathological findings, and cancer-specific survival. Additionally, we investigated factors that correlated with cancer-specific survival with. The median patient age was 71 years (range, 50-88 years). There were 75 male patients and 25 female patients. The median follow-up duration was 43 months (range, 0-85 months). Regarding surgical techniques, 101 patients underwent lobectomy, 3 underwent segmentectomy, and 1 patient underwent sleeve lobectomy. A total of 47, 34, 8, 9, 6, and 1 patients were diagnosed with pathological stage IA, IB, IIA, IIB, IIIA, and IIIB cancer. The overall survival rate was 71.3%. When examining background characteristics, tumor size was larger and T factor was more elevated in the high PLR groups, and pathological stage was more advanced in the high PLR group. N factor was not significantly different between the two groups. Cancer-specific survival was significantly poorer in the high PLR group than in the low group (p=0.0007). Considering tumor types, patients with adenocarcinoma in the high PLR group had poorer prognosis compared to the patients with adenocarcinoma in the low PLR group (p=0.0002), but for squamous cell carcinoma and in the other tumor types, there was no significant difference (p=0.20 and p=0.86, respectively). Multivariate analysis revealed that PLR was an independent prognosis factor for the cancer-specific survival. In the patients who underwent anatomical resection with lung cancer, PLR was correlated with prognosis.

Long-term results of percutaneous radiofrequency ablation of pulmonary metastases: a single institution experience.

Surgical resection of pulmonary metastases is considered as a therapeutic procedure in selected cases. However, many patients are unable to tolerate surgical intervention due to comorbidities and/or poor pulmonary reserve, also related to repeated parenchymal resections. Considering this scenario, we decided to investigate the role of radiofrequency ablation (RFA). The outcomes of all patients that underwent RFA for lung metastases, during the period 2003-2013, were analysed. The primary end-points were overall survival (OS) and local progression-free survival (LPFS). Secondary end-point was the analysis of possible risk factors affecting OS and LPFS. Ninety-nine RFAs were performed on 61 patients (38 men, 23 women, median age of 74 years). Fourteen patients were treated for two or more lesions, for a total of 86 lesions. Twelve lesions were treated up to three times. The median lesion diameter was 2 cm. The majority of patients were affected by lung metastases from colorectal cancer (47.5%). All procedures were successfully completed. One death occurred, whereas the morbidity rate was 11% (8% pneumothorax requiring chest drainage). At a median follow-up of 28 months, the 1-, 3-, 5-year OS (LPFS) rates were 94.8% (86.3%), 49.0% (70.3%) and 44.5% (68.3%), respectively. No significant correlation was found, using univariate and multivariate analysis, between OS and age, gender, histology of primary cancer (colon versus others), type of approach (computed tomography versus ultrasonography guidance), number of treated lesions (1 vs >1), disease-free interval (from primary tumour to first lung metastases) (1-35 vs >35 months), previous lung resections (yes versus no), whereas a tendency towards better OS was observed, by applying univariate analysis, for a lesion of <3 cm (P = 0.051) and for the presence of local disease 1 month after treatment (P = 0.056), however, without a statistically significant difference. With regard to LPFS, lesion dimensions (P = 0.005) and the presence of local disease 1 month after treatment (P < 0.001) were found to be significant risk factors, in both univariate and multivariate analyses. RFA appears as a feasible and safe procedure, with an acceptable morbidity, offering the possibility to safely repeat the treatment on the same lesion. RFA can be considered a valid option for the local control of lung metastases, in patients not eligible for surgery, especially those with lesions smaller than 3 cm.

Abstract 4334: Elevated lactic acid is a negative prognostic factor in metastatic lung cancer

Abstract Introduction: Hyperlactatemia with or without type B lactic acidosis is a rare complication of malignancy, previously observed most often in hematological malignancies. Underlying pathophysiology involves reduced lactic acid metabolism from metastatic liver dysfunction as well as overproduction of lactic acid from aberrant glycolytic metabolism of tumors. Clinical data to evaluate the potential value of arterial or venous lactic acid (LA) level assessment as a predictor of overall survival (OS) or/and response to treatment are lacking. The aim of this study was to assess the prognostic value of LA in patients with metastatic lung cancer. Methods: Patients diagnosed with stage IV non-small cell lung cancer (NSCLC) or extensive stage small cell lung cancer (SCLC) from 2012 to present, were included in this single center, retrospective study. Patients with sepsis or acute exacerbation of heart failure were excluded from the study. Arterial and venous LA level, bicarbonate, anion gap, urine ketones, serum LDH were recorded for each patient and their associations with demographic and clinical data and OS were analyzed with the Chi-square test, Kaplan-Meier's actuarial method (log-tank test) and Cox proportional hazard model. Results: 85 patients (43 males, mean age 73.1, range 45-96 years) were studied. The maximal levels of arterial or venous LA were significantly associated with presence of ≥2 metastatic sites (p = 0.001), ICU admission or transfer (p = 0.016), intubation (p = 0.029), elevated serum anion gap (p&amp;lt;0.001) and LDH levels (p&amp;lt;0.001). No significant associations emerged between LA level and gender, age, smoking status, histology, tumor size or grade, previous lung resection, location of metastases, COPD, previous metformin use, ketonuria, and previous or ongoing palliative chemotherapy. Hyperlactatemia (p&amp;lt;0.001), histologic subtype (p = 0.019), ICU admission or transfer (p = 0.014), intubation (p = 0.026), number of metastatic sites (p = 0.01), AG (p&amp;lt;0.01) and LDH (p&amp;lt;0.001) were univariately associated with OS. LDH was the only independent prognostic factor [OR = 0.162 (95% CI: 0038-0.687), p = 0.014]. Conclusion: Our results suggest that elevated LA is a predictor of poor OS in metastatic lung cancer patients, irrespective of chemotherapy. Here lie implications for targeting tumor-derived LA production via manipulation of glycolytic enzymes or lactate transporters, with use of LA as a surrogate marker of response. Citation Format: Panagiotis J. Vlachostergios, Nirav Parikh, Katerina Oikonomou, Eugene Gibilaro, George Apergis. Elevated lactic acid is a negative prognostic factor in metastatic lung cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4334. doi:10.1158/1538-7445.AM2015-4334

P39. Management of respiratory symptoms in patients with advanced lung cancer

Lung cancer is the most common cancer worldwide in terms of both incidence and mortality. Prognosis is generally poor. Of all patients with lung cancer, approximately 15% survive for 5 years after diagnosis while 80% die within 1 year. Respiratory symptoms observed in patients with lung cancer (dyspnea, cough, haemoptysis) are determined by cancer’s histologic type, biological properties, and anatomic location. They may be caused either by the primary tumour itself or by locoregional metastases within the thorax. Respiratory symptoms can result from immediate mechanical effects of cancer spread, such as localized obstruction of large airways, postobstructive pneumonia, formation of fistulae between airways and other intrathoracic structures, pleural effusion, and paresis of diaphragm or vocal cords due to encroachment upon respective nerves. In such patients, noninvasive therapies may be insufficient to palliate respiratory symptoms. Invasive techniques are available to benefit this group of patients. Respiratory symptoms can be caused by chemotherapy, or complications of radiotherapy (airway stenosis and necrosis, fistula formation, haemoptysis). Moreover, comorbid conditions such as chronic obstructive lung disease (COPD), heart failure, pulmonary embolism, previous lung resection or malnutrition likewise contribute to respiratory symptoms. Dyspnea is the most frequently reported symptom in lung cancer patients: over of 65% patients have this symptom at some time during the course of their illness. In management of cancer-related dyspnea, opioids will remain the mainstay of therapy for the foreseeable future. Further studies will also be needed to identify the target populations who would benefit from oxygen, benzodiazepines, and the wide spectrum nonpharmacological interventions to relieve dyspnea. The design of these studies should respect the difference between cancer-related dyspnea and dyspnea from other causes. Suppression of cancer-related cough should also be addressed in future randomized studies. Current recommendations for palliative care in patients with advanced lung cancer, organized according to salient respiratory symptoms: Dyspnea: opioids; supplemental oxygen; other pharmacological interverventions; nonpharmacological interventions; dyspnea due to comorbidities and its treatment. Cough: opioids, non-opioid cough supressants, chemotherapy. Haemoptysis: pharmacologic treatment, bronchoscopic management, palliative thoracic radiotherapy. Malignant pleural effusion: thoracocentesis, chest tube dranaige, pleurodesis, and pleuroperitoneal shunting.

The role of percutaneous image-guided ablation for lung tumors.

Surgical resection is the standard treatment for early-stage primary lung cancer and selected cases with pulmonary metastases. However, lung resection may not be possible in patients with compromised pulmonary function, concurrent medical conditions, or previous lung resections. Image-guided ablation has emerged as a less invasive treatment option for unresectable lung tumors that allows for preservation of pulmonary function and promising efficacy. Hereby we describe the indications for and outcomes of image-guided ablation performed for the management of pulmonary malignancies.

The early and long-term outcomes of completion pneumonectomy: report of 56 cases

The aim of this study was to analyse the early and long-term results of completion pneumonectomy (CP). A retrospective review of consecutive patients who underwent CP in the Shanghai Chest Hospital. Fifty-six CP were performed between January 2003 and July 2013. There were 45 conventional CP (CCP) and 11 rescue CP (RCP) cases. CCP was defined as resection of the remaining lung because of the occurrence of new lesions in patients with previous lung resection. RCP was defined as resection of the remaining lung because of severe complication after primary lung surgery. The mortality and morbidity rates of CCP were 4.4 and 33.3%, respectively. For CCP, the morbidity was significantly higher in benign cases than in malignant cases (80.0 vs 27.5%, P = 0.04). The mortality and morbidity rates of RCP were 27.3 and 90.9%, respectively. For RCP, advanced age (P = 0.046) and preoperative mechanical ventilation (P = 0.03) were related to higher postoperative mortality. The overall 5-year survival rate was 80% for benign cases, whereas for lung malignancy cases, it was 30%. Survival varied (median 60.0 vs 35.0 vs 10.0 months, I vs II vs III, P < 0.01) for different TNM stages and was better for a time interval (between primary surgery and occurrence of lesion) of >2 years (median 60.0 vs 18.0 months, P < 0.01). CP was an operation with high risk, especially for RCP. Advanced age and mechanical ventilation before the operation were related to higher mortality in RCP. CCP of benign cases was related to higher postoperative risk, but with good survival. For lung malignancy, survival was better for a time interval (between primary surgery and occurrence of lesion) of >2 years.

Back To Blockers?

Back To Blockers?

Lung Transplantation for Cystic Fibrosis: Outcome of 101 Single-Center Consecutive Patients

Bilateral sequential lung transplantation (BSLT) is nowadays considered a valid therapeutic option for patients with end stage cystic fibrosis. We report our experience with 104 BSLTs in 101 patients. The overall survivals at 1, 3, 5, 10 years were 79%, 65%, 58%, and 42%, respectively. Perioperative mortality was 14.8% (n = 15). The leading causes of perioperative mortality were primary graft dysfunction and sepsis. Three patients were retransplanted owing to obliterative bronchiolitis. In 70 cases (69%), patients displayed ≥1 additional risk factors: previous lung resections, colonization by Burkholderia cepacia, diabetes, pneumothorax, or noninvasive ventilatory support. The mean preoperative 1-second forced expiratory volume of 0.69 ± 0.2 L (22%) increased to 85% at 1 year after the operation. The mean time on the waiting list was 12 ± 5 months. The 5 patients treated with extracorporeal membrane oxygenation before urgent transplantation were operated after 3, 5, 6, 30, and 3 days respectively. During the procedure, cardiopulmonary bypass was required in 33 patients (32%). Lung transplantation represents a unique opportunity to ameliorate the quality and improve the survival of patients affected by cystic fibrosis. Timing of referral and patient selection remain crucial for success.

Bilateral Lung Transplantation in Asymmetric Thorax: Case Reports

Suppurative lung diseases, such as cystic fibrosis and bronchiectasis, when diffuse and associated with important functional loss, can be treated with bilateral lung transplantation with good results. These diseases are frequently associated with previous lung resections presenting an asymmetric thorax, thus making lung extraction difficult and generating disproportion between the graft and the pleural cavity. To treat this condition, pneumonectomy and single lung transplantation is a feasible option; however, there are associated comorbidities and an invariable need for extracorporeal circulation. Described herein are 2 patients with an asymmetric thorax, treated with bilateral transplantation and lung volume reduction with lobectomy.

Detection of primary and recurrent lung cancer by means of F-18 fluorodeoxyglucose positron emission tomography (FDG PET)

Positron emission tomography (PET), with the glucose analog F-18 fluoro-deoxyglucose (FDG), takes advantage of the enhanced glucose uptake observed in neoplastic cells. We examined whether the detection of preferential FDG uptake with PET permits differentiation between benign and malignant focal pulmonary lesions in patients with suspected primary or recurrent lung cancer. Between November 1991 and September 1993, 100 patients with indeterminate focal pulmonary abnormalities including 16 patients who had previous lung resections for cancer were prospectively studied. Tissue diagnosis was obtained by transbronchial or percutaneous biopsy (n = 49) and open biopsy or resection (n = 35). Three patients underwent extended observation (> 2 years) alone. Excluded were 13 patients lacking firm pathologic diagnoses and less than 2-year follow-up. FDG activity in the lesion was expressed as a calculated standardized uptake ratio. Mean standardized uptake ratio (+/- standard deviation) was 6.6 (+/- 3.1) in 59 patients with cancer versus 2.0 (+/- 1.6) in 28 with benign disease (p = 0.0001; unpaired t test, two-sided). With a standardized uptake ratio > or = 2.5 used for detecting malignancy, sensitivity, specificity, and accuracy were 97% (57/59), 82% (23/28), and 92% (80/87), respectively. Notably, in patients evaluated for pulmonary abnormalities after lung resection for cancer, all chest recurrences were correctly identified. The exceptional sensitivity of FDG PET demonstrates that malignant pulmonary lesions preferentially accumulate FDG, which results in a standardized uptake ratio > or = 2.5. PET may be useful for distinguishing recurrent tumor from postoperative, or postradiation, changes. If performed in all patients before open biopsy, PET increases the diagnostic yield by reducing the number of patients who have benign lesions at operation. Moreover, by lowering expenditures for hospitalization and other diagnostic procedures, FDG PET may significantly reduce health care costs.

Lung volumes after an increase in lung distension in pneumonectomized ferrets.

To investigate the role of lung distension in compensatory lung growth, the right lung of each of 21 adult male ferrets was replaced with a silicone rubber balloon filled with mineral oil. Three to thirteen weeks after surgery, the oil was removed through a subcutaneous port. Lung volumes were measured serially until 3-6 wk after balloon deflation. With pneumonectomy the total lung capacity (TLC) decreased to less than 50% of the preoperative value and remained essentially unchanged while the balloon was inflated. At balloon deflation, TLC and vital capacity did not change immediately, whereas functional residual capacity increased by 44%, indicating a change of 2-3 cmH2O in end-expiratory transpulmonary pressure. TLC increased by 10% within 3 days and continued to increase over the subsequent 3-5 wk by a total of 25% over TLC at balloon deflation. There was little difference in this response between animals whose balloons were deflated 3 wk after surgery and those in which deflation was delayed up to 13 wk. After pneumonectomy in the adult ferret, the remaining lung increases in volume in response to an increase in lung distension even weeks or months after surgery. The extent to which this volume increase involves lung tissue growth or depends on previous lung resection is at present unknown. This model may be useful for studies of the mechanisms by which lung distension influences lung volume and compensatory lung growth.