[Lung cancer surgery and cirrhosis]

Survival of Patients with Lung Cancer in the Setting of Liver Cirrhosis: A Multicenter Propensity Score Matching Study

Purpose

The survival outcome of lung cancer patients with coexisting liver cirrhosis has thus far received limited attention in the literature. In this study, we evaluated whether liver cirrhosis is an independent risk factor for the survival of patients with lung cancer.

Materials and Methods

We conducted a retrospective, multicenter, propensity-matched study of lung cancer patients with and without liver cirrhosis. To determine differences in survival, we sought to identify risk factors associated with poor outcomes using Kaplan–Meier survival analysis and Cox proportional hazards regression.

Results

There were no statistically significant differences in the baseline clinical characteristics of patients between the cirrhosis and non-cirrhosis groups. The median overall survival of patients with and without cirrhosis was 13.07 months (95% confidence interval [CI]: 10.56–16.84) and 13.67 months (95% CI: 10.42–16.91), respectively (p=0.76). Cox proportional hazards regression analysis revealed that liver cirrhosis was not an independent risk factor for poor outcome (hazard ratio [HR]: 1.057, 95% CI: 0.805–1.388, p=0.690). In patients with cirrhosis, lower serum albumin levels, higher Charlson Comorbidity Index score, advanced-stage lung cancer, and treatment modality were factors associated with poor outcome. Increase in serum albumin by 1 g was associated with a 30% reduction in the risk of mortality (HR: 0.700, 95% CI: 0.494–0.993, p=0.045). While every point increase in the Charlson Comorbidity Index score by 1 point was linked to a 9% higher risk of mortality (HR: 1.090, 95% CI: 1.023–1.161, p=0.007).

Conclusion

The survival rates of lung cancer patients with and without cirrhosis did not differ significantly. Higher serum albumin levels and lower Charlson Comorbidity Index scores were associated with improved survival.

Does liver cirrhosis have any impact on patients with lung cancer after surgical resection?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: does cirrhosis have any impact on patients with lung cancer after surgical resection? Altogether, 134 papers were found using the reported search, of which 6 cohort studies represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Five of the cohort studies found that liver cirrhosis was correlated to higher postoperative mortality after lung cancer surgery, 4 also showed a correlation with higher postoperative morbidity and 2 of them found that patients with Child grade B or above experienced a higher risk of morbidity and mortality than those with Child grade A. Four of the cohort studies found that cirrhotic patients had poorer long-term survival, with 2 studies showing patients with Child grade B or above having a worse overall survival than those with Child grade A. Therefore, we conclude that liver cirrhosis (especially Child grade B or above) imposed a significant unfavourable impact on both short-term and long-term outcomes for patients intended for lung cancer surgery.

Perioperative Care of Patients With Liver Cirrhosis: A Review

The incidence of cirrhosis is rising, and identification of these patients prior to undergoing any surgical procedure is crucial. The preoperative risk stratification using validated scores, such as Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease, perioperative optimization of hemodynamics and metabolic derangements, and postoperative monitoring to minimize the risk of hepatic decompensation and complications are essential components of medical management. The advanced stage of cirrhosis, emergency surgery, open surgeries, old age, and coexistence of medical comorbidities are main factors influencing the clinical outcome of these patients. Perioperative management of patients with cirrhosis warrants special attention to nutritional status, fluid and electrolyte balance, control of ascites, excluding preexisting infections, correction of coagulopathy and thrombocytopenia, and avoidance of nephrotoxic and hepatotoxic medications. Transjugular intrahepatic portosystemic shunt may improve the CTP class, and semielective surgeries may be feasible. Emergency surgery, whenever possible, should be avoided.