Postoperative complications in relation with induction therapy for lung cancer

Effect of lung isolation with different airway devices on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery: a propensity score-matched study

BACKGROUND

Postoperative pneumonia is one of the common complications after video-assisted thoracoscopic surgery. There is no related study on the effect of lung isolation with different airway devices on postoperative pneumonia. Therefore, in this study, the propensity score matching method was used to retrospectively explore the effects of different lung isolation methods on postoperative pneumonia in patients undergoing video-assisted thoracoscopic surgery.

METHODS

This is A single-center, retrospective, propensity score-matched study. The information of patients who underwent VATS in Weifang People 's Hospital from January 2020 to January 2021 was retrospectively included. The patients were divided into three groups according to the airway device used in thoracoscopic surgery: laryngeal mask combined with bronchial blocker group (LM + BB group), tracheal tube combined with bronchial blocker group (TT + BB group) and double-lumen endobronchial tube group (DLT group). The main outcome was the incidence of pneumonia within 7 days after surgery; the secondary outcome were hospitalization time and hospitalization expenses. Patients in the three groups were matched using propensity score matching (PSM) analysis.

RESULTS

After propensity score matching analysis, there was no significant difference in the incidence of postoperative pneumonia and hospitalization time among the three groups (P > 0.05), but there was significant difference in hospitalization expenses among the three groups (P < 0.05).

CONCLUSIONS

There was no significant difference in the effect of different intubation lung isolation methods on postoperative pneumonia in patients undergoing thoracoscopic surgery.

Comparison of pulmonary function changes between patients receiving neoadjuvant chemotherapy and chemoradiotherapy prior to minimally invasive esophagectomy: a randomized and controlled trial

PURPOSE

Adequate pulmonary function is important for patients undergoing surgical resection of esophageal cancer, especially those that received neoadjuvant therapy. However, it is unknown if pre-operative radiation affects pulmonary function differently compared to chemotherapy. The purpose of this study was to compare changes in pulmonary function between patients undergoing minimally invasive esophagectomy (MIE) who received neoadjuvant chemotherapy or chemoradiotherapy.

METHODS

Between March 2017 and March 2018, esophageal cancer patients requiring neoadjuvant therapy were prospectively enrolled and randomly assigned to receive chemotherapy (CT) or chemoradiotherapy (CRT) before MIE. All patients received pulmonary function testing before and after the neoadjuvant therapy. Changes in pulmonary function, operative data, and pulmonary complications were compared between the 2 groups.

RESULTS

A total of 71 patients were randomized and underwent MIE after receiving CT (n = 34) or CRT (n = 37). Baseline clinical characteristics were comparable between the 2 groups. The CRT group experienced a greater decrease of forced expiratory volume at 1 s (FEV₁) (2.66 to 2.18 L, p = 0.023) and diffusion capacity of the lung for carbon monoxide divided by the mean alveolar volume (DLCO/Va) (17.3%, p < 0.001) than the CT group (FEV₁ 2.53 to 2.41 L; DLCO/Va 4.8%). The incidence of pulmonary complications was higher in the CRT group (13.51 vs. 8.82%), but the difference was not significant (p = 0.532).

CONCLUSIONS

Preoperative CRT affects pulmonary function more than CT alone, but does not increase the risk of pulmonary complications in patients undergoing MIE.

[Postoperative complications after major lung resection]

INTRODUCTION

The advent of the minimally invasive techniques has allowed an expansion of the indications for thoracic surgery, particularly in older patients and those with more comorbidities. However, the rate of postoperative complications has remained stable.

STATE OF THE ART

Postoperative complications are defined as any variation from the normal course. They occur in 30% but majority of them are minor. The 30-day mortality rate for lung resection varies range between 2 % and 3% in the literature. Complications can be classified as: (1) early (occurring in the first 24hours) including both "generic" surgical complications (especially postoperative bleeding) and complications more specific to lung surgery (Acute respiratory syndrome, atelectasis); (2) in-hospital complications and those occurring during the first 3 months; these are dominated by infectious events in particular pneumonia but also bronchial (bronchopleural fistula), pleural (pneumothorax, hydrothorax) or cardiac complications; (3) late complications are dominated by chronic pain, affecting 60% of patients having a thoracotomy at three months. Lobectomy is the most common lung resection. Pneumonectomy is a distinct procedure requiring a specific peri- and postoperative management. Right pneumonectomy is associated with a higher risk with a treatment related-mortality ranging between 7 and 10%.

CONCLUSION

Major lung resection has benefited from minimally invasive approaches and fast track to surgery. However, it is important to note the occurrence of new and specific complications related to those news surgical access.

Preoperative functional workup for patients with advanced lung cancer

Locally advanced lung cancer remains a surgical indication in selected patients. This condition often demands larger resections. As a consequence preoperative functional workup is of paramount importance to stratify the risk and choose the most appropriate treatment. We reviewed the current evidence on functional evaluation with a special focus on specific aspects related to locally advanced lung cancer stages (i.e., risk after neoadjuvant treatment, pneumonectomy). Evidence is discussed to provide information that could assist clinicians in their preoperative workup of these challenging patients.

Bronchial colonization and complications after lung cancer surgery

PURPOSE

Infectious complications occur following pulmonary resections preceded or not by induction chemoradiotherapy. We aimed to investigate whether bacterial colonization of the bronchial tree at the time of surgery was associated with postoperative complications.

PATIENTS AND METHODS

A retrospective analysis of all patients who underwent open anatomical pulmonary resections for malignancies at a single center was performed. Demographical data of the included patients, intraoperative data, and data on the postoperative course of patients were collected. Outcome of patients with a positive intraoperative bronchial culture was compared to patients with a negative bronchial culture. Relations between the presence of potential bacterial pathogens in the bronchial tree and other possible risk factors for the development of postoperative infectious and non-infectious complications, were analyzed using uni- and multivariate analysis.

RESULTS

Between January 2010 and January 2012, a total of 121 consecutive patients underwent open anatomical pulmonary resections for malignancy, of whom 45 were preceded by induction chemoradiotherapy and 5 by induction chemotherapy. Intraoperative bronchial cultures were taken from 58 patients (48 %). Patients with a positive bronchial culture developed significantly more infectious (88 % vs. 20 %, p < 0.001) and non-infectious complications (63 % vs. 12 %, p = 0.001). Positive intraoperative bronchial cultures showed the strongest association with the development of infectious and non-infectious postoperative complications (OR 24.8 and 12.2, respectively). After multivariate analysis, only BMI less than 20 kg/m(2) and the presence of a positive intraoperative bronchial culture were found to be independent risk factors for the development of infectious complications. Chemoradiotherapy was not associated with postoperative complications in the present study.

CONCLUSIONS

Bacterial colonization of the bronchial tree assessed intraoperatively, appears to be associated with higher rates of infectious and non-infectious complications after pulmonary resection. Whether early starting of appropriate antibiotics based on intraoperative-taken culture findings will reduce the infectious complication rate in a subcategory of patients needs to be investigated.

Role of induction therapy: surgical resection of non-small cell lung cancer after induction therapy

Patients with Stage III non-small cell lung cancer are best managed by multimodality therapy. Patients with N2 disease can be treated with induction therapy (usually chemotherapy) followed by surgical resection. Patients whose medical comorbidities preclude surgery should be treated with definitive chemoradiotherapy. T3 or T4 tumors involving the superior sulcus or spine are best managed with induction chemoradiotherapy and surgical resection.

Impact of laterality on early and late survival after pneumonectomy

BACKGROUND

This study evaluated the effect of laterality on survival in patients who underwent pneumonectomy for lung cancer.

METHODS

We reviewed the Surveillance, Epidemiology, and End Results (SEER) database for patients who underwent pneumonectomy for lung cancer from 1988 through 2006. Predictors of survival were determined by univariate and multivariable analysis.

RESULTS

A total of 9746 patients had pneumonectomies. Left pneumonectomies (56%) were more common than right; 67% of patients were men with mean age of 63 years (range, 12 to 92 years). Tumor pathology was squamous cell in 49% and adenocarcinoma in 34%. Stage distribution was stage I, 28%; stage II, 28%; stage IIIA, 19%; stage IIIB, 18%; and stage IV, 6%. Overall survival was 67% and 40%, respectively, at 1 and 3 years; with 63% and 39% for right vs 70% and 41% for left (p<0.001). Mortality at 1 and 3 months was 8% and 16% for right pneumonectomies and 4% and 9% for left (p<0.001). Multivariate predictors of worse survival were right pneumonectomy, age, stage, male sex, tumor size, grade, prior malignancy, not married, number of positive lymph nodes, and fewer lymph nodes evaluated (all p<0.05). The adjusted hazard ratio for right pneumonectomy was 1.12 (95% confidence interval, 1.07 to 1.18; p<0.00001). For 3-month survival, right pneumonectomy had an adjusted odds ratio of 2.01 (95% confidence interval, 1.77 to 2.29; p<0.001). Neoadjuvant radiotherapy did not affect 3-month survival (adjusted odds ratio, 0.88; 95% confidence interval, 0.1 to 7.03, p=0.9).

CONCLUSIONS

A right pneumonectomy is associated with approximately twice the perioperative mortality as a left pneumonectomy. However, neoadjuvant radiotherapy does not appear to add incremental risk, and long-term survival is not affected by laterality.

Pneumonectomy is a valuable treatment option after neoadjuvant therapy for stage III non-small-cell lung cancer

OBJECTIVE

The mortality of pneumonectomy after chemotherapy or chemoradiotherapy for locally advanced non-small-cell lung cancer is reported to be as high as 26%. We retrospectively reviewed the medical records of patients undergoing these procedures in 2 specialized thoracic centers to determine the outcome.

METHODS

Retrospective analyses were performed of all patients who underwent pneumonectomy after neoadjuvant chemotherapy or chemoradiotherapy for locally advanced non-small-cell lung cancer from 1998 to 2007. Presurgical treatment consisted of 3-4 platin-based doublets alone in 20% of patients or combined with radiotherapy (45Gy) to the tumor and mediastinum in 80% of patients.

RESULTS

Of 827 patients who underwent neoadjuvant therapy, 176 pneumonectomies were performed, including 138 (78%) extended resections. Post-induction pathologic stages were 0 in 36 patients (21%), I in 33 patients (19%), II in 38 patients (21%), III in 57 patients (32%), and IV in 12 patients (7%). Three patients died of pulmonary embolism, 2 patients of respiratory failure, and 1 patient of cardiac failure, resulting in a 90 postoperative day mortality rate of 3%; 23 major complications occurred in 22 patients (13%). For the overall population, 3-year survival was 43% and 5-year survival was 38%.

CONCLUSION

Pneumonectomy after neoadjuvant therapy for non-small-cell lung cancer can be performed with a perioperative mortality rate of 3%. Thus, the need of a pneumonectomy for complete resection alone should not be a reason to exclude patients from a potentially curative procedure if done in an experienced center. The 5-year survival of 38%, which can be achieved, justifies extended surgery within a multimodality concept for selected patients with locally advanced non-small-cell lung cancer.

How to evaluate the risk/benefit of trimodality therapy in locally advanced non-small-cell lung cancer

The trimodality approach represented by concurrent chemoradiotherapy followed by surgical resection is a highly effective, but potentially toxic therapy for locally advanced non-small-cell lung cancer (NSCLC). In this review, we discuss the current status of this therapy in patients with mediastinal node-positive (N2) stage III NSCLC or superior sulcus tumor, and present an overview of the principles for optimisation of the risk/benefit. Numerous clinical questions remain, and enrolment of patients into well-designed clinical trials should be encouraged.

Operative complications and early mortality after induction therapy for lung cancer

OBJECTIVE

Induction therapy for advanced lung cancer allows improvement of completeness of resection and survival. However, predictive risk factors for postoperative complications and early mortality remain controversial. We report our 14-year experience with this combined approach.

METHODS

One hundred and thirty-nine patients (100 males and 39 females) underwent induction therapy and surgery for stage IIIA and B lung cancer. The mean age was 58.4+/-7.7 years. We retrospectively collected demographic data, preoperative functional parameters, type of operation, associated disorders, staging, induction regimen (chemotherapy alone or associated with radiotherapy). Univariate and multivariate analyses were performed to identify predictors of postoperative complications and early mortality.

RESULTS

One hundred and nine patients received chemotherapy (mainly based on cisplatin and gemcitabine) and 30 received chemoradiotherapy (median dose 50Gy). Complications developed in 49 patients (35%). The most frequent was persistent air leakage (23-30% of the lobectomies), followed by cardiac complications, respiratory failure, and infections. Five patients (3.5%) died in the postoperative period and four of them had received pneumonectomy (mortality for pneumonectomy: 12.5%). The statistical analysis demonstrated that only pneumonectomy was associated with an increased mortality risk with no differences between intra- and extrapericardial dissection or right and left pneumonectomy.

CONCLUSIONS

Induction therapy seems to be associated with an increased incidence of air leakage; the risk of other complications is acceptable. Pneumonectomy is associated with an increased risk of mortality and should be performed in selected patients.

Essai randomisé de phase III de chimiothérapie adjuvante par CDDP/docetaxel versus CDDP/gemcitabine dans les cancers bronchiques non à petites cellules réséqués avec la qualité de vie comme objectif principal

BACKGROUND

Adjuvant chemotherapy improves survival of completely resected non-small cell lung cancer (NSCLC). However the regimen of choice is not yet defined.

METHODS

The primary objective of this comparative, open, randomised multicentre trial is to compare two chemotherapy regimens (cisplatin/docetaxel versus cisplatin/gemcitabine) in the management of resected NSCLC with quality of life (QoL) evaluated at the end of treatment as the primary objective. The secondary objectives are to study the impact of these two chemotherapy regimens on overall and relapse free survival, hematological and non-hematological toxicities, and costs. The primary judgement criterion will be the assessment of end of treatment QoL by the standardised questionnaire, EORTC QLQ-C30. Secondary judgement criteria will be Qol measured by EORTC QLQ-LC13 and SF36, overall and relapse free survival, tolerance and costs. The number of subjects needed is 75 in each group, 150 in total, to detect a difference of 10 points on the EORTC QLC-C30 scores with a standard error of 20 points (alpha 0.05; power 80%).

EXPECTED RESULTS

This trial will provide clinicians with data on the impact of two currently unexplored adjuvant chemotherapy regimens on quality of life, tolerance and costs in NSCLC.

[Postoperative risk after induction treatment on surgery in non-small cell lung cancer]

Induction treatments in non-small cell lung cancer are usually discussed. Long-term survival after surgery and resecability are enhanced in locally advanced cancers. Morbidity and mortality observed after surgery limit the use of these treatments, despite they depend on many other factors: comorbidities in patient, smoking status, cancer staging, and type of surgery. Right pneumectomy enhances this risk more than left pneumectomy or other limited resections allowed by neoadjuvant treatments, especially in case of downstaging.

Postoperative Bleeding: Coagulopathy, Bleeding, Hemothorax

Several issues are involved in determining a patient's risk for postoperative hemorrhage and in managing this potential postoperative complication. The impact of minimally invasive procedures on the incidence of this complication is addressed in this article.

Gemcitabine-Cisplatin Chemotherapy Before Lung Resection: A Case-Matched Analysis of Early Outcome

BACKGROUND

The objective of the present study was to assess whether neoadjuvant chemotherapy with gemcitabine and cisplatin was associated with an increased incidence of morbidity and mortality after major lung resection for lung cancer.

METHODS

We analyzed 570 patients who underwent lobectomy or pneumonectomy for nonsmall-cell lung cancer at our institution from January 2000 through June 2005. Of these, 70 patients underwent three cycles of gemcitabine-cisplatin chemotherapy before operation for locally advanced disease. Propensity scores were constructed to match those patients undergoing neoadjuvant chemotherapy and lung resection with those undergoing surgery alone. The propensity score analysis yielded two groups of 70 well-matched pairs that were compared in terms of baseline characteristics and early outcome (morbidity, mortality, length of postoperative stay, intensive care unit admission).

RESULTS

The two case-matched groups had similar morbidity (p = 0.8), mortality (p = 0.4), perioperative blood transfusions (p = 0.8) and intensive care unit admission rates (p = 0.8). Likewise, the length of postoperative stay did not differ between the groups (p = 0.9).

CONCLUSIONS

Gemcitabin-cisplatin neoadjuvant chemotherapy appears to be safe before major lung resection. This finding warrants its use for efficacy studies of locally advanced and even early-stage lung cancer.

Postoperative Pneumonia after Major Lung Resection

BACKGROUND

Postoperative pneumonia (POP) is a life-threatening complication of lung resection. The incidence, causative bacteria, predisposing factors, and outcome are poorly understood.

DESIGN

Prospective observational study.

METHODS

A prospective study of all patients undergoing major lung resections for noninfectious disease was performed over a 6-mo period. Culture of intraoperative bronchial aspirates was systematically performed. All patients with suspicion of pneumonia underwent bronchoscopic sampling and culture before antibiotherapy.

RESULTS

One hundred and sixty-eight patients were included in the study. Bronchial colonization was identified in 31 of 136 patients (22.8%) on analysis of intraoperative samples. The incidence of POP was 25% (42 of 168). Microbiologically documented and nondocumented pneumonias were recorded in 24 and 18 cases, respectively. Haemophilus species, Streptococcus species, and, to a much lesser extent, Pseudomonas and Serratia species were the most frequently identified pathogens. Among colonized and noncolonized patients, POP occurred in 15 of 31 and 20 of 105 cases, respectively (p = 0.0010; relative risk, 2.54). Death occurred in 8 of 42 patients who developed POP and in 3 of 126 of patients who did not (p = 0.0012). Patients with POP required noninvasive ventilation or reintubation more frequently than patients who did not develop POP (p < 0.0000001 and p = 0.00075, respectively). POP was associated with longer intensive care unit and hospital stay (p < 0.0000001 and p = 0.0000005, respectively). Multivariate analysis showed that chronic obstructive pulmonary disease, extent of resection, presence of intraoperative bronchial colonization, and male sex were independent risk factors for POP.

CONCLUSIONS

Pneumonia acquired in-hospital represents a relatively frequent complication of lung resections, associated with an important percentage of postoperative morbidity and mortality.

Multimodality treatment of unresectable stage III non–small cell lung cancer: Interim analysis of a phase II trial with preoperative gemcitabine and concurrent radiotherapy

OBJECTIVE

We report the preliminary results of a phase II trial undertaken to determine the feasibility and efficacy of gemcitabine and concurrent radiotherapy in patients with inoperable stage III non-small cell lung cancer.

METHODS

Between February 2001 and June 2003, a total of 46 patients (37 male and 9 female, median age 64 years) with clinical stage III non-small cell lung cancer (41 cIIIA and 5 cIIIB) were enrolled in a combined chemoradiation protocol with gemcitabine as the chemotherapeutic agent. Gemcitabine (350 mg/m2) was administered weekly for 5 consecutive weeks as a 30-minute intravenous infusion before radiotherapy (total dose 50.4 Gy, 1.8 Gy/d). Toxicity was routinely assessed. Those patients with disease judged to be resectable at restaging underwent surgery.

RESULTS

Toxicity was moderate, with the exception of 1 grade 3 thrombocytopenia. All but 5 patients were available for restaging. No complete responses were observed. Thirty-four patients (82.9%) had partial responses, 5 (12.2%) had stable disease, and 2 (4.9%) had progressive disease. Twenty-nine of 46 patients (63%, 27 cIIIA and 2 cIIIB) underwent surgery. Radical resection was possible in all cases. Surgery included 17 lobectomies, 4 bilobectomies, and 8 pneumonectomies. There were no deaths. Morbidity was 13.8% (4/29). Pathologic downstaging to stage 0 or I was observed in 18 patients (39%, 18/46). After a median follow-up of 13 months (range 2-28 months), 24 of the patients who had undergone operation (86.2%) were alive, with a median disease-free survival of 16 months. Overall 2-year survival was 66.1%, with a significant difference between resected and unresected disease (82% vs 36%, P = .0002).

CONCLUSION

The results of this induction trial confirm the feasibility and the efficacy of gemcitabine with concurrent radiotherapy.

Reconstitution of Blood Supply of the Denuded Bronchial Stump

BACKGROUND

Our aim was to study the process of microcirculatory reconstitution in the bronchial stump after pneumonectomy.

METHODS

Eighteen juvenile pigs (median weight 40.6 kg) were randomly assigned to three groups. In all animals left pneumonectomy was performed and the stapled bronchial stump (median length 3.8 cm) carefully denuded. Group I animals received coverage of the stump by intercostal flap. In group II, the stump was covered with TachoComb, an impermeable hemostatic fleece; and group III served as a control without any coverage of the stump. Animals were sacrificed at day 14 after surgery. Vascular density was evaluated in serial histologic sections at multiple levels stained with CD-31 antibody. One-way analysis of variance and the Wilcoxon test were used for data analysis.

RESULTS

At autopsy, stumps of group III animals were totally covered by adjacent mediastinal structures. In group I, intercostal flaps were viable and completely healed to the bronchial stumps. There were no signs of infection or stump insufficiency in these groups. In all group II animals, empyema developed, and stumps were found necrotic at macroscopic and histologic evaluation. Statistical analysis revealed significantly lower vascular density of mature vessels in the area of the bronchial stump in group II compared with both other groups.

CONCLUSIONS

Reconstitution of microcirculation of the denuded bronchial stump after pneumonectomy takes place in a centripetal way from adjacent viable tissue. Hence, the purpose of covering the bronchial stump is the improvement of blood supply rather than mechanical reinforcement.

One hundred consecutive pneumonectomies after induction therapy for non-small cell lung cancer: An uncertain balance between risks and benefits

OBJECTIVE

We sought to assess postoperative outcome after pneumonectomy after neoadjuvant therapy in patients with non-small cell lung cancer.

METHODS

This retrospective study included 100 patients treated from January 1989 through December 2003 for a primary lung cancer in whom pneumonectomy had been performed after an induction treatment. Surgical intervention had not been considered initially for the following reasons: N2 disease (stage IIIA, n = 79), doubtful resectability (stage IIIB [T4, N0], n = 19), and M1 disease (stage IV [T2, N0, M1, solitary brain metastasis], n = 2). All patients received a 2-drug platinum-based regimen with a median of 2.5 cycles (range, 2-4 cycles), and 30 had associated radiotherapy (30-45 Gy).

RESULTS

There were 55 right and 45 left resections. Overall 30-day and 90-day mortality rates were 12% and 21%, respectively. At multivariate analysis, one independent prognostic factor entered the model to predict 30-day mortality: postoperative cardiovascular event (relative risk, 45.7; 95% confidence interval, 3.7-226.7; P = .001). Four variables predicted 90-day mortality: age of more than 60 years (relative risk, 5.06; 95% confidence interval, 1.47-17.48; P = .01), male sex (relative risk, 8.25; 95% confidence interval, 1.01-67.34; P = .049), postoperative respiratory event (relative risk, 3.64; 95% confidence interval, 1.14-9.37; P = .007), and postoperative cardiovascular event (relative risk, 7.84; 95% confidence interval, 3.12-19.71; P < .001). Estimated overall survivals in 90-day survivors were 35% (range, 29%-41%) and 25% (range, 19.3%-30.7%) at 3 and 5 years, respectively. At multivariate analysis, one independent prognostic factor entered the model: pathologic stage III-IV residual disease (relative risk, 1.89; 95% confidence interval, 1.09-3.26; P = .022).

CONCLUSIONS

Pneumonectomy after induction therapy is a high-risk procedure, the survival benefit of which appears uncertain.

Value of F-18-fluorodeoxyglucose positron emission tomography after induction therapy of locally advanced bronchogenic carcinoma

OBJECTIVES

Induction therapy is an important treatment option in locally advanced non-small cell lung cancer. F-18-fluorodeoxyglucose positron emission tomography (FDG-PET) has an important role in initial staging. The aim of this study was to assess the value of FDG-PET in restaging after induction therapy and in analyzing tumor viability, nodal status, distant metastases, and prognosis.

METHODS

Forty-seven patients with locally advanced non-small cell lung cancer accepted for resection after induction therapy underwent FDG-PET. Images were interpreted visually for mediastinal nodal status and metastatic spread. The FDG accumulation in the tumor site was measured by using the maximum standardized uptake value.

RESULTS

Unexpected metastases were detected by means of FDG-PET in 9 patients. Surgical intervention was not performed in 8 patients with confirmed metastases. The rate of unexpected findings increased from complete radiologic remission (0%) over partial remission (9%) to no change (67%). The standardized uptake value was higher in tumors with (n = 26) than in those without (n = 11) histologic proof of viability (6.4 +/- 5.3 vs 2.9 +/- 1.6, P = .006). All patients with standardized uptake values of greater than 5.8 had viable tumors. Sensitivity, specificity, and negative predictive value were 81%, 64%, and 58% for tumor viability and 50%, 88%, and 85% for persistent mediastinal disease. Median survival after resection was greater than 56 months for patients with tumor standardized uptake values of less than 4 and 19 months for patients with standardized uptake values of 4 or greater ( P < .001).

CONCLUSION

FDG-PET helps in the selection of patients for resection after induction therapy. It can be used to detect unexpected distant metastases, especially after poor response to induction therapy. Its high negative predictive value in mediastinal restaging allows for omission of repeat mediastinoscopy. Tumor standardized uptake value after induction is a prognostic factor.

Surgery after multimodality treatment for non-small-cell lung cancer

Neoadjuvant treatment for Locally advanced non-small-cell lung cancer (NSCLC) stage IIIA and IIIB promises higher resection rates because of a reduction of the primary tumour and sterilisation of mediastinal nodes ("downstaging"). In this study we analyse the perioperative course and the long-term survival of patients with trimodality treatment. Between 03/1991 and 12/2002, 392 patients with NSCLC underwent resection after induction treatment. Included were 266 males and 126 females, age 55.8 +/- 9 (28-74), of whom 218 were stage-IIIA patients, 174 were stage-IIIB patients. Induction treatment included 3 courses of chemotherapy with cisplatin/etoposide or cisplatin/paclitaxel, followed by one course of chemotherapy with cisplatin/etoposide as well as hyperfractionated accelerated radiotherapy of the primary tumour and the mediastinal nodes with 45 Gy, followed by surgery. Before induction treatment all patients underwent mediastinoscopy. In patients with N3 disease mediastinoscopy was repeated before surgery. Resections included 133 pneumonectomies (34%), 15 bilobectomies (4%), 55 sleeve lobectomies (14%), 168 lobectomies (42.5%), 6 segmentectomies (1,5%), and 15 explorative thoracotomies (4%). In-hospital mortality rates amounted to 4.6% (18 patients) while postoperative morbidity ran up to 46% (180 patients). Morbidity and mortality rates were significantly higher in patients with Karnofsky status lower than 80% and patients older than 65 years. Bronchopleural fistulas occurred in 16 patients (3.2%). The protection of the bronchial stump or anastomosis with viable tissue, like pericardial fat, proves to be a significant factor for the reduction of septic complications. For NSCLC, the 5- and 7-year survival rates were 36% and 31%, respectively, for stage IIIA, and 26% for stage IIIB. This intensive trimodality treatment proves to be feasible. Treatment-related toxicities are overall moderate and acceptable. Accurate cardiopulmonary evaluation before surgery and reinforcement of bronchial stump or anastomosis can contribute to reducing complications. Induction treatment demonstrated a "downstaging effect", so that a clear trend for organ-sparing resection was observed. Long-term survival rates for selected groups look very promising when compared to historical controls.