Pulmonary Resection For Bronchogenic Carcinoma Research Articles

Invited Commentary

Invited Commentary

Subsequent pulmonary resection for bronchogenic carcinoma after pneumonectomy

Background. Patients who have undergone a pneumonectomy for bronchogenic carcinoma are at risk of cancer in the contralateral lung. Little information exists regarding the outcome of subsequent lung operation for lung cancer after pneumonectomy. Methods. The records of all patients who underwent lung resection after pneumonectomy for lung cancer from January 1980 through July 2001 were reviewed. Results. There were 24 patients (18 men and 6 women). Median age was 64 years (range, 43 to 84 years). Median preoperative forced expiratory volume in 1 second was 1.47 L (range, 0.66 to 2.55 L). Subsequent pulmonary resection was performed 2 to 213 months after pneumonectomy (median, 23 months). Wedge excision was performed in 20 patients, segmentectomy in 3, and lobectomy in 1. Diagnosis was a metachronous lung cancer in 14 patients and metastatic lung cancer in 10. Complications occurred in 11 patients (44.0%), and 2 died (operative mortality, 8.3%). Median hospitalization was 7 days (range, 2 to 72 days). Follow-up was complete in all patients and ranged between 6 and 140 months (median, 37 months). Overall 1-, 3-, and 5-year survivals were 87%, 61%, and 40%, respectively. Five-year survival of patients undergoing resection for a metachronous lung cancer (50%) was better than the survival of patients who underwent resection for metastatic cancer (14%; p = 0.14). Five-year survival after a solitary wedge excision was 46% compared with 25% after a more extensive resection ( p = 0.54). Conclusions. Limited pulmonary resection of the contralateral lung after pneumonectomy is associated with acceptable morbidity and mortality. Long-term survival is possible, especially in patients with a metachronous cancer. Solitary wedge excision is the treatment of choice.

Frequency and mortality of acute lung injury and acute respiratory distress syndrome after pulmonary resection for bronchogenic carcinoma.

We reviewed the frequency and mortality of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) in our population of patients submitted to pulmonary resection for primary bronchogenic carcinoma. From January 1993 to December 1999, a total of 1221 patients received pulmonary resection for primary bronchogenic carcinoma. Of these, 27 met the criteria of post-operative ALI/ARDS. There were 24 men and three women with a mean age of 64 years (range 45--79). Pre-operatively, predicted mean of PaO(2), PaCO(2) and %FEV1 were 72 mmHg (57--86), 37 mmHg (33--42) and 80% (37--114), respectively. Associated cardiac risk factors were present in eight patients. Three patients (11%) had pre-operative radiotherapy. Surgical-pathologic staging included 14 patients at Stage I, 8 patients at Stage II, four patients at Stage IIIa and one patient at Stage IIIb. ALI/ARDS occurred in 2.2% of our operated lung cancer patients. ALI was diagnosed in 10 patients and ARDS in 17 patients. The mean time of presentation following surgery was 4 days (range 1--10) and 6 days (1--13) for ALI and ARDS, respectively. According to the type of operation, the frequency was highest following right pneumonectomy (4.5%), followed by sublobar resection (3.2%), left pneumonectomy (3%), bilobectomy (2.4%), and lobectomy (2%). The frequency following extended operations was 4%. No differences were found between the ALI/ARDS group and the total population of resected lung cancer patients (control group) with respect to sex, mean age, pre-operative blood gases, %FEV1, surgical--pathologic staging and the use of pre-operative radiotherapy. Four patients with ALI (40%) and 10 patients with ARDS (59%) died. Mortality was highest following right pneumonectomy, extended operations and sublobar resections. Hospital mortality of the total population of operated lung cancer patients in the same period was 2.8% (34 patients). ALI/ARDS accounted for 41% of our hospital mortality. (1) ALI/ARDS is a severe complication following resection for primary bronchogenic carcinoma. (2) We did not detect any significant difference between the ALI/ARDS group and the control group regarding age, pre-operative lung function, staging and pre-operative radiotherapy. (3) ALI/ARDS is associated with high mortality, the highest mortality rates having been observed following right pneumonectomy and extended operation; it currently represents our leading cause of death following pulmonary resection for lung carcinoma. (4) ALI/ARDS may also occur after sublobar resections with an associated high mortality rate.

Prediction of post‐operative cardiopulamonary function using perfusion scintigraphy in patients with bronchogenic carcinoma

Both ventilation and perfusion scintigraphy are accurate predictors of post-operative ventilatory function. Previous attempts to predict post-operative exercise capacity after lung resection using radioisotope scintigraphy are few and results are conflicting. We studied 32 patients before and 6 months after pulmonary resection for bronchogenic carcinoma to assess the value of lung perfusion scintigraphy for the prediction of post-operative forced lung volumes and parameters on maximum exercise, including maximum ventilation and maximum oxygen uptake. Nine patients were lost to follow-up, and these patients differed from the reinvestigated patients only in the staging of the pulmonary carcinoma and not in preoperative lung function or exercise capacity. We found a clear relationship between the values predicted from a preoperative perfusion scintigraphy, spirometry and a maximum exercise study and the observed values measured 6 months post-operatively. The method underestimated the post-operative values of both spirometric and exercise measurements, especially in the higher range. Only in a few cases were the post-operative observed values less than the predicted values, and in these cases the difference was without clinical significance. Unexpected post-operative respiratory insufficiency was not observed. In conclusion, in patients in whom a pulmonary resection was performed, not only the post-operative spirometric values, but also the more functional related maximum exercise data can be predicted through the knowledge of a preoperative perfusion scintigraphy.

Cardiac operation with associated pulmonary resection

From February 1988 to May 1992, a total of 11 patients aged 52 to 81 years underwent concomitant cardiac operation and pulmonary resection for bronchogenic carcinoma at our institution. All pulmonary lesions were incidental findings on preoperative chest x-ray films. Diagnosis was obtained in six patients before resection. The operation was performed through a midline sternotomy with all patients requiring cardiopulmonary bypass. Pulmonary procedures included two wedge resections, seven lobectomies, and two double lobectomies. Seven patients underwent lobectomy while supported by bypass, with the lungs collapsed, during rewarming. Total bypass time for these patients averaged 143 minutes. Pathologic examination showed all lesions to be non-small-cell malignant tumors; four adenocarcinomas, four squamous cell carcinomas, two bronchoalveolar carcinomas, and one undifferentiated carcinoma. Nine were stage I and two were stage II. One of the wedge resections showed malignant disease involving the surgical margin that later required completion lobectomy. There were no operative deaths and no major postoperative complications. Postoperative hospital stays ranged from 6 to 17 days (mean 10 days) except for one patient who required a prolonged hospitalization because of a complication after thoracentesis on the side opposite the pulmonary resection. Concomitant cardiac operations with lobectomy can be safely performed during cardiopulmonary bypass without significantly prolonging pump time. Our observations suggest that concomitant cardiac surgery with pulmonary resection is a safe and effective technique with minimal morbidity and short hospital stay.

Tumor emboli from lung neoplasms involving the pulmonary vein

Systemic tumor embolization during pulmonary resection for lung neoplasms is an uncommon but potentially catastrophic complication. In recent months, two patients undergoing pulmonary resection for bronchogenic carcinoma were found at operation to have tumor extending into a pulmonary vein. Both patients had systemic tumor embolization, one with a fatal outcome because of occlusion of the superior mesenteric artery. The possibility of systemic tumor embolization should be considered in patients with large, central tumors and particularly those that abut the pulmonary veins. The implications of such pulmonary vein involvement is reviewed, and an algorithm for postoperative evaluation and management of these patients is presented.

Predictability of FEV1 after pulmonary resection for bronchogenic carcinoma.

The aim of this study was to review the reliability of prediction of postoperative FEV1 in patients with bronchogenic carcinoma using a Tc-99m perfusion scan and simple spirometry. Over a 27-month period, 40 patients without known recurrent disease had their FEV1 measured. One quarter of the postoperative values for FEV1 differed from predicted values by less than 5% (2/11 pneumonectomies, 5/23 lobectomies, 3/6 segmental resections) and half differed by no more than 10% of predicted FEV1 (4/11 pneumonectomies, 12/23 lobectomies, 3/6 segmentectomies). One tenth of the predicted values differed by more than 30% and up to 760 mls (1/11 pneumonectomies, 2/23 lobectomies, 1/6 segmentectomy). Disease recurrence, phrenic nerve paralysis, exacerbation of obstructive pulmonary disease and poor collaboration during spirometry explained the most severe erroneous results. Age, preoperative smoking, tumour stage and histology, absence of symptoms at the time of diagnosis and adjuvant radiotherapy showed no statistically significant effect on predictability. Twenty-one patients had a postoperative Tc-99m pulmonary scan simultaneous to the spirometric control. Overestimation of postoperative FEV1 was associated with heterogeneous distribution of ventilation and perfusion.

Pleural lavage after pulmonary resection for bronchogenic carcinoma

Pleural lavage after pulmonary resection for bronchogenic carcinoma

Pleural lavage after pulmonary resection for bronchogenic carcinoma

A cytologic examination of pleural fluid was performed on a pleural lavage specimen collected at the completion of operation after pulmonary resection in 135 of 599 patients undergoing curative pulmonary resection for a non-small cell carcinoma of the lung between 1977 and 1982. The cytologic results of lavage was positive for malignant cells in 12 of the 135 patients (8.9%). The incidence of positive results was correlated with lymph node status (N2 greater than N1 greater than N0), cell type (adenocarcinoma greater than other non-small cell lung cancers), stage (III greater than II greater than I), and visceral pleural status (invaded greater than not invaded). No positive cytologic results were noted in 39 patients having a diagnostic excisional pulmonary biopsy prior to more definitive resection. The disease has recurred in nine of the 12 patients with positive cytologic results (only two in the ipsilateral pleural space), and eight have died. The prognostic role of pleural lavage cytology needs more study.

Pulmonary Disease: An Annotated Bibliography of Recent Literature

Pulmonary Disease: An Annotated Bibliography of Recent Literature

Bronchogenic Carcinoma and Postoperative Empyema: Is Survival Really Enhanced?

From 1959 to 1974, 542 patients underwent curative resection for bronchogenic carcinoma. Postoperative empyema occurred in 17 of these patients. The overall 5-year survival of these 17 patients was only 18%, compared with 27% in the 525 patients without empyema. We were unable to demonstrate by our study or by a review of the literature that postoperative empyema favorably influences survival in patients who have had pulmonary resection for bronchogenic carcinoma.

Predicting Loss of Pulmonary Function After Pulmonary Resection for Bronchogenic Carcinoma

Studies of regional pulmonary function using radioactive 133xenon gas and spirometric tests (forced vital capacity and forced expiratory volume in the first second) were performed before and after unilateral pulmonary resection for cancer of the lung. Ninety-one patients were evaluated; 47 underwent total pneumonectomy, and 44 underwent lobectomy. The postoperative serial evaluations were classified into short-term and long-term studies (less than or more than three months, respectively). The preoperative and postoperative data were utilized to derive formulas for predicting an estimate of the overall functional loss after pulmonary resection based on the number of segments removed. The correlation between the predicted and measured postoperative values was good for resections involving more than three segments (r = 0.83). Prediction for smaller resections was unreliable. While both regional and overall pulmonary functions were relatively stable after pneumonectomy, there was a disproportionate early loss, followed by significant functional improvement with time following lobectomy. The anticipation of and preparation for this early loss of function may be crucial in the treatment of these patients.

Survival with residual tumor on the bronchial margin after resection for bronchogenic carcinoma

Sixty-four (14.7 percent) of 434 consecutive patients having pulmonary resection for bronchogenic carcinoma were found to have microscopic residual tumor on the cut margins of the resected specimens. These subjects were further subdivided histologically into those with direct extension of the tumor (34 patients), lymphatic permeation (14 patients), clumps of cancer cells in parabronchial tissues (six patients), and the presence of carcinoma in situ change (10 patients). Bronchopleural fistulas developed in eight (12.5 percent) of 64 patients. The operative mortality rate was 15.6 percent, with four of the deaths occurring as the result of bronchopleural fistulas. Thirty-two patients (50 percent) survived 1 year, 21 (32.8 percent) survived 3 years, and 15 (23.4 percent) lived for 5 years or more. The patients with tumor in the submucosal and peribronchial lymphatics had the worst prognosis. 78.6 percent having died within 1 year and the remainder within 3 years. All 5-year survivors were men with squamous cell carcinoma and had relatively small tumors (mean diameter 2.9 cm). No direct relationship between the length of the resected bronchial stump and survival could be established; a short stump did not preclude long survival. The possible factors involved in the relatively high 5 year survival rate in this group of patients and the therapeutic implications of these factors are discussed.

Influence of postoperative empyema on survival after pulmonary resection for bronchogenic carcinoma.

Fifty patients who had developed empyema after pulmonary resection for primary carcinoma of the lung were individually paired with patients who had not suffered this complication. Pairs were matched as far as possible for age, sex, extent of operation, histology of tumour, extent of primary spread, extent of lymphatic spread, and use of postoperative radiotherapy. Analysis of survival times both for the matched pairs and for the two groups of patients showed no significant difference in long-term survival. The results suggest that any immunological suppression of carcinoma cells due to sepsis in the pleural space is ineffective in prolonging survival.

Major Pulmonary Resection for Bronchogenic Carcinoma in the Elderly

The results of major pulmonary resection in 58 patients greater than 70 years of age were reviewed. The histological distribution and extent of nodal metastases in this age group are the same as in younger patients. The absolute five-year survival rate for the 55 patients undergoing curative resection was 30% (17 patients). It was 36% (11 patients) for those patients with squamous cell carcinoma and 22% (5 patients) for those with adenocarcinoma. The operative mortality was only 14% (8 patients). Of the 49 patients treated by lobectomy, 17 lived five years or more free of disease, whereas none of the 6 patients treated by pneumonectomy survived five years. The five-year survival rate of 30% in this series of elderly patients treated by major pulmonary resection makes resections in such patients with bronchogenic carcinoma worthwhile.

EVALUATION OF THE RISK IN PULMONARY RESECTION FOR BRONCHOGENIC CARCINOMA

Abstract Preoperative pulmonary function test results in 258 patients who underwent pulmonary resection for bronchogenic carcinoma were studied in relation to postoperative mortality from cardiopulmonary complications. Poor outcome of surgery was related to the maximal breathing capacity value below 59 per cent of the predicted normal, age over sixty-nine years, and abnormal electrocardiographic findings. Combinations of these factors were associated with a very high mortality (56 per cent). This group of patients needs further evaluation on an individual basis to identify the risk of pulmonary resection. A formula to predict the risk of surgery based on the maximal breathing capacity value is suggested. Values for one second forced expiratory volume and vital capacity were of no use in predicting the outcome of surgery.

Evaluation of the risk in pulmonary resection for bronchogenic carcinoma

Preoperative pulmonary function test results in 258 patients who underwent pulmonary resection for bronchogenic carcinoma were studied in relation to postoperative mortality from cardiopulmonary complications. Poor outcome of surgery was related to the maximal breathing capacity value below 59 per cent of the predicted normal, age over sixty-nine years, and abnormal electrocardiographic findings. Combinations of these factors were associated with a very high mortality (56 per cent). This group of patients needs further evaluation on an individual basis to identify the risk of pulmonary resection. A formula to predict the risk of surgery based on the maximal breathing capacity value is suggested. Values for one second forced expiratory volume and vital capacity were of no use in predicting the outcome of surgery.

Pulmonary Resection for Bronchogenic Carcinoma in Geriatric Patients

Pulmonary Resection for Bronchogenic Carcinoma in Geriatric Patients

Early Detection of Bronchogenic Carcinoma

1) In spite of the fact that the mortality of pulmonary resection for bronchogenic carcinoma is now less than 10 per cent, the salvage of patients having this disease is still disappointingly low. Earlier diagnosis is our only means of improving this salvage. 2) In our experience there is a five months' delay between the onset of symptoms and the time the patient presents himself to the physician and a further delay of six months between the visit to the physician and a correct diagnosis. 3) The delay in correct diagnosis is usually due to the making of an incorrect diagnosis. Virus pneumonia and unresolved pneumonia are two diagnoses that are frequently made in patients having this disease. 4) The early bronchogenic carcinoma represents only a change in the bronchial mucosa which obstructs the bronchus. Signs or symptoms of bronchial obstruction should be regarded with suspicion. A localized wheeze and the finding of a region of localized emphysema on the x-ray film are the earliest symptom and sign of bronchogenic carcinoma. Cough is the most common symptom complained of by the patient. In evaluating this symptom the change in the cough history from a hacking cough to paroxysmal type of coughing is the most important factor. 5) X-ray Inspection of the chest is the most valuable diagnostic method in the detection of this disease. Mass radiography Is bringing to light many early lesions in the asymptomatic stage. Mass radiography, however, unless repeated often cannot be the answer to early diagnosis. 6) Bronchoscopy is an excellent diagnostic procedure but when negative does not rule out bronchogenic carcinoma. The examination for neoplastic cells in material coughed up or obtained at bronchoscopy has made it possible to make many more early diagnoses. 7) Exploratory thoracotomy may often be necessary in order to diagnose early bronchogenic carcinoma. Exploratory thoracotomy is safe and should be recommended when there is sufficient evidence to suspect early neoplasm. 8) In our patients it was found that approximately 40 per cent were inoperable at the time they first visited the physician. This disappointing fact is one reason why the salvage rate in this disease is still low. 9) Continued vigilance on the part of the general practitioner and insistence upon accurate diagnoses of lesions appearing within the lung will bring many more patients having bronchogenic carcinoma to the thoracic surgeon at a stage where the lesion can be completely removed.