Management of Complications After Pneumonectomy

The Role of Adjuvant Chemotherapy in pN1 (IIB/IIIA) NSCLC Patients Who Undergo Pneumonectomy: Is It Still Justified in the Modern Era?

INTRODUCTION

We aimed to assess our 25-year experience in order to evaluate the role of adjuvant chemotherapy in patients who undergo pneumonectomy for pN1 NSCLC.

MATERIALS AND METHODS

We retrospectively reviewed the outcomes and medical records of patients undergoing pneumonectomy for NSCLC with pathological diagnosis of pN1, excluding all patients who underwent neoadjuvant treatment. We compared patients treated with adjuvant chemotherapy with patients who did not undergo neoadjuvant treatment during a follow-up soon after surgery. Gray's test was used to assess differences in the cumulative incidence of relapse or CSS between the different groups. Kaplan-Meier methods were used for drawing overall survival (OS) plots. In order to assess differences in survival between the groups, the log-rank test was used. The cumulative incidence of relapse, CSS, and OS were calculated at 1, 2, 3, 4, and 5 years of follow-up.

RESULTS

The 30-day and 90-day mortality rates of our cohort were 6% and 11,6%. Excluding the first three months after surgery (deaths linked to postoperative comorbidity), after 5 years we found no significant differences between the two cohorts (adjuvant CT and no adjuvant CT) in terms of the overall survival (OS) (p: 0.31), cancer-specific survival (CSS) (p: 0.59), disease-free survival (DFS) (p: 0.94), and relapse rate (p: 0.76).

CONCLUSIONS

Patients with pN1 NSCLC that was completely resected through pneumonectomy and radical lymphadenectomy may represent a particular cohort, which could be strictly followed up without adjuvant chemotherapy.

Pneumonectomy for Unilateral Proximal Interruption of Pulmonary Artery: A Case Series from the Literature

BACKGROUND

Unilateral proximal interruption of the pulmonary artery (UPIPA) is a rare congenital disease, and its optimal management remains undefined in the existing literature. The occasional necessity for pneumonectomy is still supported by limited evidence.

METHODS

A systematic review of the literature was conducted using the PubMed search engine, focusing on UPIPA cases that received pneumonectomy. Thirty-one pertinent articles were selected and included in the analysis. A case reported from our institution was included in the analysis.

RESULTS

We found 25 adults and seven children affected by UPIPA who received an indication for pneumonectomy, plus an additional case that was reported by our institution. Among adult patients, the predominant indication was hemoptysis (57%), followed by suspected or confirmed lung cancer (23%). Approximately 46% of surgical procedures were classified as urgent or emergent. Postoperative complications were observed in 36% of cases, with no recorded mortality. In pediatric cases, pneumonectomy was primarily a life-saving intervention, performed urgently or emergently in 75% of instances. A possible late complication in pediatric patients involves a mediastinal shift leading to respiratory distress, which may be mitigated using an inflatable prosthesis.

CONCLUSIONS

Pneumonectomy achieves complete resolution of UPIPA symptoms. In the adult population, its primary indication is hemoptysis, with procedures conducted in both elective and urgent/emergent settings. Despite a mortality rate of zero, a notable proportion of patients may experience postoperative complications. In pediatric cases, the clinical presentation varies more extensively, and pneumonectomy is typically reserved for life-threatening situations, emphasizing the need for careful patient selection.

Retrospective study of outcomes after extended resection for tracheobronchial adenoid cystic carcinoma

OBJECTIVE

Tracheobronchial adenoid cystic carcinoma is a rare, slow-growing malignancy with a considerable propensity for local extension that may require complex airway resection to achieve tumor-free margins. The objective of this study was to assess whether our experience supports complex airway resection for tracheobronchial adenoid cystic carcinoma.

METHODS

Consecutive patients who underwent curative resection for tracheobronchial adenoid cystic carcinoma at our institution between 1970 and 2019 were included retrospectively and classified as having had complex or standard resection. Complex surgery included total tracheal replacement, associated esophageal resection, pneumonectomy, total laryngectomy with tracheal resection, and carinal resection. Standard surgery included tracheal resection, bronchoplastic resection, lobectomy, and bilobectomy. We obtained data from medical records, referring physicians, patients, relatives, and public death records.

RESULTS

Of 59 included patients, 38 had complex and 21 had standard surgery. All 4 (6.8%) patients who died postoperatively had undergone complex surgery. Postoperative morbidity was 32.2% overall and was significantly higher after complex surgery (P = .043). Overall 5- and 10-year survival rates were 81.5% and 60.2%, with no significant differences between groups (P = .31). By univariate analysis, T4 tumor and microscopically detectable tumor in the operative specimen margins and gross tumor in the operative specimen margins were associated with poorer survival (P < .05). In the subgroup with microscopically detectable tumor resection, survival was significantly better with adjuvant radiotherapy (P < .05).

CONCLUSIONS

Complex resection for extended tracheobronchial adenoid cystic carcinoma may achieve local control and satisfying long-term survival. However, this demanding procedure is associated with high postoperative morbidity and mortality rates. Because adjuvant radiotherapy improved outcomes after resection resulting in microscopically detectable tumor in the operative specimen margins, expected outcomes after resection with no detectable tumor in the margins must be compared to those after resection resulting in microscopically detectable tumor in the margins plus radiotherapy, according to the operative risk.

ARDS after Pneumonectomy: How to Prevent It? Development of a Nomogram to Predict the Risk of ARDS after Pneumonectomy for Lung Cancer

(1) Background: The cause of ARDS after pneumonectomy is still unclear, and the study of risk factors is a subject of debate. (2) Methods: We reviewed a large panel of pre-, peri- and postoperative data of 211 patients who underwent pneumonectomy during the period 2014−2021. Univariable and multivariable logistic regression was used to quantify the association between preoperative parameters and the risk of developing ARDS, in addition to odds ratios and their respective 95% confidence intervals. A backward stepwise selection approach was used to limit the number of variables in the final multivariable model to significant independent predictors of ARDS. A nomogram was constructed based on the results of the final multivariable model, making it possible to estimate the probability of developing ARDS. Statistical significance was defined by a two-tailed p-value < 0.05. (3) Results: Out of 211 patients (13.3%), 28 developed ARDS. In the univariate analysis, increasing age, Charlson Comorbidity Index and ASA scores, DLCO < 75% predicted, preoperative C-reactive protein (CRP), lung perfusion and duration of surgery were associated with ARDS; a significant increase in ARDS was also observed with decreasing VO2max level. Multivariable analysis confirmed the role of ASA score, DLCO < 75% predicted, preoperative C-reactive protein and lung perfusion. Using the nomogram, we classified patients into four classes with rates of ARDS ranking from 2.0% to 34.0%. (4) Conclusions: Classification in four classes of growing risk allows a correct preoperative stratification of these patients in order to quantify the postoperative risk of ARDS and facilitate their global management.

Role of Pneumonectomy in T1–4N2M0 Non-Small Cell Lung Cancer: A Propensity Score Matching Analysis

Background

N2 stage disease constitutes approximately 20%–30% of all non-small cell lung cancer (NSCLC). Concurrently, surgery remains the first-choice treatment for patients with N2 NSCLC if feasible. However, the role of pneumonectomy in N2 NSCLC has rarely been investigated and remains controversial.

Methods

We enrolled 26,798 patients with T1–4N2M0 NSCLC (stage IIIA/IIIB) from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015. We compared the overall survival (OS) and cancer-specific survival (CSS) between patients who received pneumonectomy and those who did not receive surgery. The Kaplan–Meier method, Cox regression analyses, and propensity score matching (PSM) were applied to demonstrate the effect of pneumonectomy.

Results

Patients receiving pneumonectomy had a significantly better OS and CSS than those without pneumonectomy both before [adjusted-HR (95% CI): 0.461 (0.425–0.501) for OS, 0.444 (0.406–0.485) for CSS] and after PSM [adjusted-HR (95% CI): 0.499 (0.445–0.560) for OS, 0.457 (0.405–0.517) for CSS] with all p-values <0.001. Subgroup analysis demonstrated concordant results stratified by demographic or clinicopathological variables. In sensitivity analysis, no significant difference was observed between patients receiving single pneumonectomy and chemoradiotherapy without surgery in OS and CSS both before [unadjusted-HR (95% CI): 1.016 (0.878–1.176) for OS, 0.934 (0.794–1.099) for CSS, p = 0.832] and after PSM [unadjusted-HR (95% CI): 0.988 (0.799–1.222) for OS, 0.938 (0.744–1.182) for CSS] with all p-values >0.4.

Conclusion

For patients with T1–4N2M0 NSCLC (stage IIIA/IIIB), pneumonectomy is an independent protective factor of OS and should be considered when applicable.

Pneumonectomy and broncho-pleural fistula: predicting factors and stratification of the risk

The goal of the study is to evaluate the different risk factors and stratify the patients, before the surgery, into distinct risk classes. We retrospectively reviewed pre, peri, and postoperative outcomes of 366 consecutive patients who underwent pneumonectomy for lung cancer between the last 10 years (2009-2019). We classified the patients into four classes, depending on preoperative assessments. Differences between groups were assessed with the log-rank test. Multivariable Cox proportional hazards regression analysis was used to assess the independent prognostic significance of the variables associated with the development of BPF at univariate analysis. Finally, we performed non-linear [artificial neural network (ANN)] multiple regression analyses. All tests were two-sided, and p values < 0.05 were considered significant. Fifty-one patients (13.9%) out of 366 developed BPF. Male sex (p = 0.048), right side (p = 0.015), postoperative pulmonary complications (p = 0.0139) and adjuvant treatments (p = 0.0169) were the independent predicting factors of fistulas in multivariate analysis. The right side (p = 0.043) and adjuvant treatments (p = 0.032) were the independent predicting factors of BPF after the ANN analysis. Based on multivariate and artificial neural network analysis and our experience, we observed a trend of growing risk of BPF in the first 4 weeks (early fistula), considering the four classes. Preoperative differentiation of the patients into four risk classes could allow a correct stratification of the growing risk of developing early BPF. This information could be significant to share with patients and the other physicians during the decision-making process, to minimise the risk of BPF.

A case of recurrent pneumothoraces in a newborn

Pneumothoraces are not an uncommon finding in the newborn period. Recurrent pneumothoraces can be associated with complications of prematurity or use of ventilators but can be seen in rapidly progressive cystic lung disease. We report a case of recurrent pneumothoraces in an infant with the rapidly progressive cystic disease in the setting of an absent right pulmonary artery. The patient ultimately underwent pneumonectomy for definitive management of the recurrent unilateral pneumothoraces.

UniPortal thoracoscopic pneumonectomy does not compromise perioperative and long-term survival in patients with NSCLC: A retrospective, multicenter, and propensity score matching study

OBJECTIVES

To compare the perioperative and oncologic outcomes following pneumonectomy performed by uniportal video-assisted thoracoscopic surgery (U-VATS) and thoracotomy in patients with centrally located non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Patients with NSCLC who underwent pneumonectomy at the Shanghai Pulmonary Hospital (SPH) and Sun Yat-sen University Cancer Center (SYUCC) with the U-VATS approach or open approach between 2011 and 2016 were selected. Propensity score matching (1:3) was performed to balance the baseline covariates. Overall survival (OS) rates and recurrence-free survival (RFS) rates were estimated and compared using the Kaplan-Meier method, respectively.

RESULTS

The enrollees in the study were 579 patients in the SPH cohort, with 501 (86.5%) in the open group and 48 (13.5%) in the U-VATS group, and 271 patients in the SYUCC cohort, with 245 (90.4%) in the open group and 26 (9.6%) in the U-VATS group. After propensity score matching, morbidity rates and 30-day mortality rates were found to be similar between the U-VATS group and open group in both the SPH and SYUCC cohorts. The long-term OS rate of patients who underwent U-VATS pneumonectomy did not significantly differ compared with the patients who underwent open pneumonectomy in both cohorts (SPH, p = .900; SYUCC, p = .240). Cox regression analysis revealed that the surgical option was not a risk factor for the OS rate (SPH: hazard ratio [HR], 0.925; 95% confidence interval [CI], 0.555 to 1.542; SYUCC: HR, 1.524; 95% CI, 0.752 to 3.087).

CONCLUSION

U-VATS can be used to safely perform pneumonectomy in patients with centrally located NSCLC without compromising the perioperative and oncologic outcomes compared with an open approach.

Nononcologic Mortality after Pneumonectomy Compared to Lobectomy

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.

The postoperative chest in lung cancer

Most of the complications following lung cancer surgery occur in the early postoperative period and can result in significant morbidity and mortality. Delayed complications can also occur. Diagnosing these complications can be challenging because clinical manifestations are non-specific. Imaging plays an important role in detecting these complications in a timely manner and facilitates prompt interventions. Hence, it is important to have knowledge of the expected anatomical alterations following lung cancer surgeries, and the spectrum of post-surgical complications and their respective imaging findings to avoid misinterpretations or delay in diagnosis.

Extended Sleeve Lobectomy is an Alternative for Centrally Located Lung Cancer With Superior Short- and Long-term Outcomes

INTRODUCTION

Extended sleeve lobectomy (ESL) is a feasible alternative to pneumonectomy; however, the survival benefit is unclear, and preoperative selection of potential candidates for ESL remains a problem.

MATIERALS AND METHODS

ESL was performed on selected candidates with double sleeve lobectomy for more than 1 lobe (eg, left upper lobe and S6 segment resection). Three-dimensional (3-D) reconstruction was routinely validated. Patients were candidates for ESL if the predicted distal stump length was > 6 mm and the pulmonary vein of the remaining segments was not invaded.

RESULTS

Of the 1809 patients with centrally located lung cancer for surgical resection, 86 patients with tumors invading more than 1 lobe were enrolled in the study. After evaluation by 3-D reconstruction, 22 (95.7%) of 23 selected candidates underwent ESL, and 63 patients were deemed unsuitable for ESL and underwent pneumonectomy (43 cases) or thoracic exploration (20 cases). Surgical outcomes between the ESL and pneumonectomy groups were similar in terms of complications, blood loss and surgical duration, but the 6-minute walking distance was significantly improved in the ESL group (371 ± 111 m vs. 191 ± 55 m, respectively; P < .001). The mean forced expiratory volume in 1 second was 1.6 ± 0.3 L at the 1-year follow up examination in the ESL group. In the survival analysis, no difference was observed between the ESL and pneumonectomy groups in terms of 3-year overall survival (85% vs. 89%, respectively; P = .626) and 3-year disease-free survival (75% vs. 76%, respectively; P = .625).

CONCLUSIONS

ESL is a feasible and superior surgical procedure in terms of its short-term and long-term outcomes, and we suggest 3-D reconstruction to identify candidates for ESL.

Extrapleural pneumonectomies for pleural mesothelioma

Introduction: Malignant pleural mesothelioma (MPM) is a fatal malignancy for which there is no definitive cure. The most effective multimodality treatment in prolonging survival is still matter of debate. Surgery remains one of the cornerstones in the multimodality therapy for MPM. Extra-pleural pneumonectomy and pleurectomy/decortication are the two main curative-intent procedures; however, the superiority of one technique over the other is still debated. This review aims to assess short- and long-term results of extrapleural pneumonectomy for MPM.Areas covered: This article focuses on the role of extrapleural pneumonectomy in MPM. A systematic review was performed by using electronic databases to identify studies that included patients treated by this procedure for MPM. Endpoints included overall survival, disease-free survival, recurrence rate, perioperative mortality, and morbidity.Expert commentary: This paper offers an overview of the results that are currently obtained in patients undergoing extrapleural pneumonectomy for MPM. The benefit of surgical treatments in MPM is still debated and its primary goal should be the achievement of a macroscopic complete resection. Several alternative multimodality protocols exist, with specific advantages and drawbacks; therefore, individualization of care for each patient is fundamental. The complexity of the surgical treatment mandates that patients be referred to specialized centers.

Pneumonectomy for Non-Small Cell Lung Cancer

Lung cancer is the leading cause of cancer deaths and its incidence continues to increase. Emerging therapies as part of a multimodal approach are making more patients eligible for surgical resection. As more surgeons are treating locally advanced non-small cell lung cancer they find themselves recommending pneumonectomy as the surgical component of the multidisciplinary plan. Performing a pneumonectomy is technically demanding and is associated with many potential perioperative comorbidities. With the proper preparation, experience, and attention to perioperative care, pneumonectomy can be carried out safely with excellent outcomes and a good quality of life.

Outcome After Pneumonectomy in 17 Dogs and 10 Cats: A Veterinary Society of Surgical Oncology Case Series

OBJECTIVE

To report the signalment, presenting clinical signs, surgical complications, histologic diagnosis, postoperative complications, and outcome of dogs and cats undergoing pneumonectomy.

STUDY DESIGN

Retrospective case series; multicenter study.

ANIMALS

Client-owned dogs (n=17) and cats (n=10).

METHODS

Signalment, clinical signs, side affected, surgical data, preoperative diagnostic tests (including complete blood count, serum biochemistry, cytologic diagnosis, chest radiographs, and computed tomography), histologic diagnosis, surgical complications, adjunctive therapy, and date and cause of death were collected from records of dogs and cats that underwent pneumonectomy. Survival estimates and complication were assessed.

RESULTS

Seventeen animals had a left-sided pneumonectomy performed (12 dogs, 5 cats) and 10 animals had a right-sided pneumonectomy (5 dogs, 5 cats). Fourteen animals were diagnosed with neoplasia (52%). The overall incidence of complications for dogs and cats were 76 and 80%, respectively, with major complications in 41 and 50%, respectively. Respiratory complications (persistent pleural effusion, oxygen dependence, persistent increased respiratory rate, or coughing) were the most frequent complications. No animals died or were euthanatized intraoperative or within the first 24 hours postoperative. One dog (6%) and 2 cats (20%) died, or were euthanatized in the first 2 weeks postoperative.

CONCLUSION

Based on this case series, right and left pneumonectomy can be performed with low perioperative mortality in dogs and cats, with some animals experiencing prolonged survival.