Surgical outcomes and complications of pneumonectomy after induction therapy for non-small cell lung cancer

Underutilization of Systemic Therapy in Patients With NSCLC Undergoing Pneumonectomy: A Missed Opportunity for Survival

Introduction

Recent trials have reported promising results with the addition of immunotherapy to chemotherapy for patients with locally advanced NSCLC, but in practice, the proportion of patients who receive systemic therapy (ST) has historically been low. Underutilization of ST may be particularly apparent in patients undergoing pneumonectomy, in whom the physiologic insult and surgical complications may preclude adjuvant therapy (ADJ). We, therefore, evaluated the use of ST for patients with NSCLC undergoing pneumonectomy.

Methods

We queried the National Cancer Database, including all patients with NSCLC who underwent pneumonectomy between 2006 and 2018. Logistic regression was used to identify associations with ST and neo-ADJ (NEO). Overall survival was compared after propensity score matching (1:1) patients undergoing ST to those undergoing surgery alone using Kaplan-Meier and Cox regression methods.

Results

A total of 2619 patients were identified. Among these, 12% received NEO, 43% received ADJ, and 45% surgery alone. Age younger than 65 years (adjusted odds ratio [aOR] = 1.53, 95% confidence interval; [CI]: 1.10-2.11), Asian ethnicity (aOR = 2.68, 95% CI: 1.37-5.23), treatment at a high-volume center (aOR = 1.39, 95% CI: 1.06-1.81), and private insurance (aOR = 1.42, 95% CI: 1.05-1.94) were associated with NEO, whereas age younger than 65 years (aOR = 1.95, 95% CI: 1.61-2.38), comorbidity index less than or equal to 1 (aOR = 1.66, 95% CI: 1.29-2.16), and private insurance (aOR = 1.47, 95% CI: 1.20-1.80) were associated with any ST. In the matched cohort, ST was associated with better survival than surgery (adjusted hazard ratio = 0.67, 95% CI: 0.58-0.78).

Conclusions

A high proportion of patients who undergo pneumonectomy do not receive ST. Patient and socioeconomic factors are associated with the receipt of ST. Given its survival benefit, emphasis should be placed on multimodal treatment strategies, perhaps with greater consideration given to neoadjuvant approaches.

["Tissue Handling" in Thoracic Surgery - Results of a Delphi Expert Consensus Conference of the German Society for Thoracic Surgery]

BACKGROUND

The aim of this working group of the German Society for Thoracic Surgery (DGT) was to develop an expert consensus based on the Delphi method to define "tissue handling" and depict intraoperative handling of specific anatomical structures during thoracic surgery.

METHODS

Invited experts (thoracic surgery specialists; n = 93) completed two consecutive rounds of electronic Delphi questions on four main topics: transection of lung parenchyma, dissection/separation of pulmonary vessels, angioplasty/vascular anastomoses, and bronchus settling closure/plasty/anastomosis. Consensus was set at ≥ 75% agreement. At the subsequent expert conference, the results of the Delphi surveys were discussed and TED voting was used to try to reach consensus.

RESULTS

In each case, 66 (71%) answers were given in the first round of questions and 33 (35%) in the second round. Disputed questions were evaluated again by a final vote at the expert conference (54 participants; average participation 55%). The term "tissue handling" includes all procedures for dissection, transection, sealing, and reconstruction of various autologous tissues in the context of thoracic surgery (100% consensus). Similarly, the term "angioplasty expansion" was defined with a 97% consensus. Consensus was reached mainly for the technique of transecting the lung parenchyma using stapling suture devices, the recommendation of covering anastomoses as well as bronchial stump after pretreatment (> 75%).

CONCLUSIONS

This expert consensus describes for the first time the concept of tissue handling in thoracic surgery. Furthermore, this Delphi process led to a comprehensive current inventory of different intraoperative procedures in German thoracic surgery with derived consensual recommendations for tissue handling of lung parenchyma, vessels and bronchial structures.

Fissureless trans-pericardial left upper lobectomy of the lung: a technique to avoid pneumonectomy

Fissureless lobectomy of the lung is an operative technique in which hilar vessels and bronchus are divided before the interlobar fissure is separated. When hilar vessels and bronchus cannot be exposed because of tumor progression, this procedure cannot be used. As an alternative, we propose here trans-pericardial fissureless left upper lobectomy, in which the left upper bronchus is exposed by dividing the posterior wall of the pericardium after the left upper pulmonary vein is divided in the pericardial cavity. This technique enables us to perform fissureless left upper lobectomy even when hilar vessels cannot be accessed outside the pericardium.

[Pneumonectomy for Non-small Cell Lung Cancer: Predictors of Operative Mortality and Survival]

外科手术是目前根治非小细胞肺癌（non-small cell lung cancer, NSCLC）的最有效方式。全肺切除作为一种术式被应用于临床中。对于中央型肺癌，袖式肺叶切除术因其术后肺功能丧失少、术后并发症及死亡率低逐渐取代全肺切除术成为主流。然而为保证肿瘤学效果，当其他术式无法完全切除时，全肺切除术式仍是必要的。全肺切除术后主要发生心肺并发症，充分了解全肺切除术后相关并发症能帮助临床医师及时做出诊断，并进一步采取相关措施降低术后并发症对患者的不良影响。充分了解预后相关危险因素可帮助临床医师提前采取措施尽可能规避风险，从而改善患者预后。