Operative risk of pneumonectomy: Influence of preoperative induction therapy
Henning A. Gaissert, Dong Yoon Keum, Cameron D. Wright, Marek Ancukiewicz, Dean M. Donahue, John C. Wain, Michael Lanuti, Noah C. Choi, Douglas J. Mathisen; MGH, Boston, MA
Comment on this Abstract
Objective: Prior studies reporting increased perioperative mortality of pneumonectomy for lung cancer after induction therapy may influence patient selection and limit the candidacy for pneumonectomy. A single institution experience was reviewed to evaluate our results.
Methods: A retrospective study was performed to determine the impact of induction therapy on operative risk.
Results: Between 1994 and 2005, 232 patients underwent pneumonectomy for lung cancer, including completion (35; 15.1%), carinal (17; 7.3%) and with chest wall (23; 9.9%) resections. One hundred fifty-one patients (65%) underwent pneumonectomy only. Seventy-three patients received induction therapy (combined XRT/chemo 59, XRT only 6; chemotherapy only 8; 31.5%) or remote mediastinal radiation (8 patients, 3.5%). Indications for induction therapy were stage IIIA disease in 48, IIIB in 15, IIB in 5, and VI in 4 patients. Patients receiving preoperative therapy were younger (mean age 56.8 vs. 62.6 years; p=0.0003), had less heart disease (9.9 vs. 29.1%; p=0.0008), higher preoperative FEV1 (2.38 vs. 2.10L; p=0.0019), lower preoperative hematocrit (35.2 vs. 37.9%; p<0.0001), and a higher proportion of right pneumonectomy (59.3 vs. 42.4%; p=0.0189). Hospital mortality was 7.4 % (6/81) after preoperative therapy and 10.6% (16/151) after resection only (p=0.49). Hospital mortality was greater after right pneumonectomy (right 13.4 vs. left 5.8%; p=0.0713). Five preoperative predictors of mortality identified during multivariable analysis (Table 1) did not include induction therapy. Differences in individual or combined cardiopulmonary morbidities between those who did or did not receive induction therapy were not significant (combined morbidity: induction 42.5%, resection only 42.0%; p=1.0).
Conclusion: The risk of pneumonectomy is not increased by preoperative radiation or chemotherapy. Patient selection, in particular the exclusion of patients with heart disease, may account for this finding. The operative mortality of right pneumonectomy, though higher than after left-sided procedures, should not preclude its use in carefully selected patients.
Table 1
| Odds ratio | 95% CI | p-value |
| FVC% Δ by 10% | 0.69 | 0.52 - 0.93 | 0.0142 |
| CAD or CHF | 5.37 | 1.64 - 17.55 | 0.0055 |
| Steroid usage | 12.43 | 2.54 - 60.91 | 0.0019 |
| Carinal procedure | 3.72 | 0.80 - 17.16 | 0.0926 |
| Completion procedure | 3.41 | 1.05 - 11.02 | 0.0407 |
| Right-sided procedure | 3.11 | 1.08 - 8.94 | 0.0355 |
| Induction therapy | 0.91 | 0.29 - 2.84 | 0.8705 |
CI: Confidence intervalFVC: Forced vital capacityCAD: Coronary artery diseaseCHF: Congestive heart failure
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