Risk Factors for Early Mortality and Major Complications Following Pneumonectomy for Non-small Cell Carcinoma of the Lung

doi:10.1378/chest.121.6.1890

Chest

Volume 121, Issue 6, June 2002, Pages 1890-1897

https://doi.org/10.1378/chest.121.6.1890 Get rights and content

Study objectives

To assess the mortality rate and the incidence of cardiopulmonary complications after pneumonectomy for non-small cell lung carcinoma (NSCLC) and to identify possible associated risk factors.

Design

Observational study of patients who underwent pneumonectomy. Potential risk factors were analyzed from a local database including all thoracic surgical cases.

Setting

A university hospital and a chest medical center.

Patients and methods

From January 1, 1990, to April 30, 2000, 193 consecutive pneumonectomies were performed for NSCLC in two affiliated institutions. The following information was recorded: demographic, clinical, functional, and surgical variables; as well as intraoperative and postoperative events. The risk of mortality and cardiopulmonary complications was evaluated using multiple logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs).

Results

After undergoing pneumonectomy, all patients were successfully extubated in the operating room and then transferred to a postanesthesia care unit (126 patients) or ICU (67 patients). The 30-day mortality rate was 9.3%, and cardiovascular and/or pulmonary complications occurred in 47% of cases. Coronary artery disease (CAD) was a predictor of 30-day mortality (OR, 2.9; 95% CI, 1.1 to 8.9). Cardiac morbidity (mainly arrhythmias) was significantly related to advanced age (OR, 3.7; 95% CI, 1.6 to 8.6) and pathologic stages III/IV (OR, 1.4; 95% CI, 1.1 to 4.7), whereas continuous epidural analgesia was associated with a reduced incidence of respiratory complications (OR, 0.2; 95% CI, 0.1 to 0.6).

Conclusions

Pneumonectomy for lung cancer is a high-risk procedure, the risk for which is significantly related to the presence of CAD and advanced pathologic stages. Importantly, the provision of epidural analgesia contributes to lower the risk of respiratory complications.

Section snippets

Patient Management

From January 1, 1990, to April 30, 2000, 815 consecutive patients underwent thoracic surgery for NSCLC in the following two affiliated institutions: an academic medical center (Hôpital Universitaire de Genève [HUG]; Geneva, Switzerland); and a regional hospital (Center Valaisan de Pneumologie [CVP]; Valais, Switzerland) that covered an area with approximately 450,000 inhabitants. Among the 815 surgical cases, there were 193 pneumonectomies (24%). All patients were operated on by one of three

General Characteristics

The 193 patients who underwent pneumonectomy had a mean age of 63 ± 8 years and included a majority of smokers (80%) and men (75%). Arterial hypertension (30%), emphysema (29%), mild-to-moderate renal insufficiency (19.2%), peripheral vascular disease (10.4%), and diabetes mellitus (8.8%) were the most frequent associated medical diseases. The diagnosis of CAD was documented in 24 patients (12.4%) based on clinical history and ECG findings (angina, 3 patients; myocardial infarction, 10

Discussion

Previous investigations^15,^16,¹⁷ have shown that readily accessible clinical and functional markers are useful to predict complications after thoracic surgery. In our cohort of 193 patients who underwent pneumonectomy for NSCLC, we identified CAD as the main risk factor of 30-day operative mortality, whereas aging (ie, ≥ 70 years) and advanced cancer stages (ie, stages III and IV) were markers of nonfatal cardiac complications such as arrhythmias. Importantly, continuous epidural analgesia

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2022, Clinical and Translational Radiation Oncology
Citation Excerpt :
Furthermore, three studies included elderly patients [15,26,42]. Twelve studies (42.9%) included patients who underwent surgical resection as the sole treatment method [22,26–30,33,35–37,39,40] and eight studies (28.6%) assessed cardiac events after combined therapy of surgery with chemotherapy and/or radiotherapy [23–25,31,32,34,38,41]. Five studies (17.9%) considered radiotherapy (3D-conformal radiotherapy, intensity-modulated radiotherapy, or radioactive implant) with or without chemotherapy as the eligibility criteria of their study samples [15,17–20].
To maximize the likelihood of positive outcome in non-small-cell lung cancer (NSCLC) survivors, potential benefits of treatment modalities have to be weighed against the possibilities of damage to normal tissues, such as the heart. High-quality data-driven evidence regarding appropriate risk stratification strategies is still scarce. The aim of this review is to summarize and appraise available prediction models for treatment-induced cardiac events in patients with NSCLC.
A systematic search of MEDLINE was performed using a Boolean combination of appropriate truncation and indexing terms related to “NSCLC”, “prediction models”, “cardiac toxicity”, and “treatment modalities”. The following exclusion criteria were applied: sample-size of less than 100, no significant predictors in multivariate analysis, lack of model specifications, and case-mix studies. The generic inverse variance method was used to pool the summary effect estimate for each predictor. The quality of the papers was assessed using the Prediction model Risk Of Bias Assessment Tool.
Of the 3,056 papers retrieved, 28 prediction models were identified, including seven for (chemo-)radiotherapy, one for immunotherapy, and 20 for surgical resection. Forty-one distinct predictors were entered in the prediction models. The pooled effect estimate of the mean heart dose (HR = 1.06, 95%CI:1.04–1.08) and history of cardiovascular diseases (HR = 3.1, 95%CI:1.8–5.36) were shown to significantly increase the risk of developing late cardiac toxicity after (chemo-)radiotherapy. Summary estimates of age (OR = 1.17, 95%CI:1.06–1.29), male gender (OR = 1.61, 95%CI:1.4–1.85), and advanced stage (OR = 1.34, 95%CI:1.06–1.69) were significantly associated with higher risk of acute cardiac events after surgery. Risk of bias varied across studies, but analysis was the most concerning domain where none of the studies were judged to be low risk.
This review highlights the need for a robust prediction model which can inform patients and clinicians about expected treatment-induced heart damage. Identified clues suggest incorporation of detailed cardiac metrics (substructures’ volumes and doses).
Pneumonectomy in Stage IIIA-N2 NSCLC: Should It Be Considered After Neoadjuvant Chemotherapy?
2019, Clinical Lung Cancer
Owing to the expected poor long-term outcomes and high postoperative morbidity and mortality, patients with stage IIIA-N2 tumors candidate to pneumonectomy (PN) are usually excluded from surgery. This study aims to analyze the outcome of patients who underwent PN to prove its safety and feasibility.
We retrospectively analyzed data from 233 patients who underwent PN for N2 non–small-cell lung cancer (NSCLC) between 1998 and 2015. Eighty-five patients were occult N2 disease (group 1), whereas 148 patients underwent induction therapy (IT) for stage IIIA-N2 (group 2).
Overall morbidity, postoperative mortality, and 90-day mortality rates were 46.8%, 2.6%, and 8.6%, respectively. The 2 groups (group 1 vs. 2) had similar postoperative and 90-day mortality rates: 2.4% versus 2.7% (P = 1.00), and 9.4% versus 8.1% (P = .81), respectively. The incidence of major morbidity was higher and statistically significant in group 2 compared with group 1: 23% versus 12.9% (P = .1). Postoperative bronchopleural fistula occurred in 4.7% (4/85) of patients with occult N2 (group 1) and in 10.1% (15/148) of patients undergoing IT (group 2) (P = .10). Median overall survival (OS) was 2.2 years, with a 3 and 5-year OS of 43.4% and 31.6%, respectively. Disease-free survival (DFS) was 1.5 years, with 3 and 5-year DFS of 41.6% and 32%, respectively; no difference in OS and DFS between the 2 groups was found.
Considering the acceptable morbidity and mortality rate and the long-term survival, PN should not be excluded for selected patients with stage IIIA-N2 NSCLC as a matter of principle.
Nononcologic Mortality after Pneumonectomy Compared to Lobectomy
2022, Seminars in Thoracic and Cardiovascular Surgery
Pneumonectomy is associated with high mortality. Knowledge of the cause and timing of death is critically important to reduce mortality. This study aimed to compare long-term nononcologic mortality between pneumonectomy and lobectomy patients and investigate factors associated with nononcologic mortality. Medical records of 337 patients who underwent pneumonectomy and 7545 patients who underwent lobectomy from 2009 to 2018 were reviewed. Postoperative morbidity, mortality, and cause of death were investigated. Competing risk analysis was performed to compare nononcologic mortality between pneumonectomy and lobectomy patients. Independent prognostic factors of nononcologic death were analyzed. The 90 day, 1 year, and 5 year mortality rates after pneumonectomy were 7.1%, 20.8%, and 49.3%, respectively. The respective nononcologic mortality rates after pneumonectomy were 6.5%, 11.6%, and 14.5%. The most common nononcologic cause of death was pneumonia. The 5 year cumulative incidence of nononcologic mortality was higher after pneumonectomy than after lobectomy (14.5% vs. 2.1%; p < 0.001). Risk of nononcologic death was higher after pneumonectomy (hazard ratio 1.54; p = 0.038). Older age (hazard ratio 1.09; p < 0.001) was an independent prognostic factor associated with nononcologic death after pneumonectomy. Higher predicted postoperative diffusion capacity for carbon monoxide (PPO DLCO) approached significance (hazard ratio 0.97; p = 0.054) as a protective factor. Long-term nononcologic mortality was higher after pneumonectomy than lobectomy and the main cause of nononcologic death was pneumonia. Clinicians should prevent and aggressively treat pneumonia after surgery, particularly in older patients and those with low PPO DLCO.
A Randomized Study Comparing the Incidence of Postoperative Pain After Phrenic Nerve Infiltration Vs Nonphrenic Nerve Infiltration During Thoracotomy
2019, Seminars in Thoracic and Cardiovascular Surgery
Thoracotomy is a common surgical procedure performed worldwide for lung disease. Despite major advances in analgesia, patients still experience severe shoulder, central back and surgical incision site pain in the postoperative period. This study aimed to assess whether intraoperative phrenic nerve infiltration reduces the incidence of postoperative pain and improves peak flow volume measurements during incentive spirometry. 90 patients undergoing open lobectomy were randomly assigned to have phrenic nerve infiltration (n = 46) or not (n = 44). The phrenic nerve infiltration group received 10 mL of 0.25% bupivacaine into the periphrenic fat pad. Preoperative assessments of spirometry and pain scores were recorded (at rest and with movement). Postoperative assessments included peak flow and pain measurements at intervals up to 72 hours. Less shoulder pain was experienced with phrenic nerve infiltration up to 6 hours postsurgery at rest (P = 0.005) and up to 12 hours with movement (P < 0.001). Reduced back pain was reported in the phrenic nerve infiltration group up to 6 hours after surgery both at rest (P = 0.001) and with movement (P = 0.00). Phrenic nerve infiltration reduced pain at the incision site for up to 3 hours both at rest (P < 0.001) and with movement (P = 0.001). Spirometry readings dropped in both groups with consistently lower readings at baseline and follow-up in the PNI group (P = 0.007). Lower analgesic usage of patient controlled analgesia morphine (P < 0.0001), epipleural bupivacaine (P = 0.001), and oramorph/zomorph (P = 0.0002) were recorded. Our findings indicate that the use of phrenic nerve infiltration significantly reduced patient pain scores during the early postoperative period, particularly during movement. We believe that each technique has advantages and disadvantages; however, further studies with large sample size are warranted.
The Impact of Postoperative Pulmonary Complications on Perioperative Outcomes in Patients Undergoing Pneumonectomy: A Multicenter Retrospective Cohort Study of the German Thorax Registry
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View all citing articles on Scopus

: This work was supported by the Andreas Naef Foundation (Lausanne, Switzerland) and the Lancardis Foundation (Sion, Switzerland).

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Chest

Clinical InvestigationsSurgeryRisk Factors for Early Mortality and Major Complications Following Pneumonectomy for Non-small Cell Carcinoma of the Lung

Study objectives

Design

Setting

Patients and methods

Results

Conclusions

Section snippets

Patient Management

General Characteristics

Discussion

Chest

Chest

Thorac Cardiovasc Surg

Ann Thorac Surg

J Clin Epidemiol

Chest

Ann Thorac Surg

Chest

Chest

Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

Thorac Cardiovasc Surg

Cancer in the European Union: IARC Cancer-Base

Cancer du poumon

Four decades of surgery for bronchogenic carcinoma in one centre

Eur Respir J

Clinical Investigations
Surgery
Risk Factors for Early Mortality and Major Complications Following Pneumonectomy for Non-small Cell Carcinoma of the Lung