Propensity-matched Analysis Demonstrates Long-term Risk of Respiratory and Cardiac Mortality After Pneumonectomy Compared With Lobectomy for Lung Cancer

Determining the optimal time to report mortality after lobectomy for lung cancer: An analysis of the time-varying risk of death

Objective

Surgical mortality has traditionally been assessed at arbitrary intervals out to 1 year, without an agreed optimum time point. The aim of our study was to investigate the time-varying risk of death after lobectomy to determine the optimum period to evaluate surgical mortality rate after lobectomy for lung cancer.

Methods

We performed a retrospective study of patients undergoing lobectomy for lung cancer at our institution from 2015 to 2022. Parametric survival models were assessed and compared with a nonparametric kernel estimate. The hazard function was plotted over time according to the best-fit statistical distribution. The time points at which instantaneous hazard rate peaked and stabilized in the 1-year period after surgery were then determined.

Results

During the study period, 2284 patients underwent lobectomy for lung cancer. Cumulative mortality at 30, 90, and 180 days was 1.3%, 2.9%, and 4.9%, respectively. Log-logistic distribution showed the best fit compared with other statistical distribution, indicated by the lowest Akaike information criteria value. The instantaneous hazard rate was greatest during the immediate postoperative period (0.129; 95% confidence interval, 0.087-0.183) and diminishes rapidly within the first 30 days after surgery. Instantaneous hazard rate continued to decrease past 90 days and stabilized only at approximately 180 days.

Conclusions

In-hospital mortality is the optimal follow-up period that captures the early-phase hazard during the immediate postoperative period after lobectomy. Thirty-day mortality is not synonymous to "early mortality," as instantaneous hazard rate remains elevated well past the 90-day time point and only stabilizes at approximately 180 days after lobectomy.

Persistent N2 After Induction Is Not a Contraindication to Surgery for Lung Cancer

BACKGROUND

Surgical management for potentially resectable stage IIIA-N2 non-small cell lung cancer (NSCLC) is controversial. For some, persistent N2 disease after induction therapy is a contraindication to resection. We examined outcomes of a well-selected surgical cohort of postinduction IIIA-N2 NSCLC patients with persistent N2 disease.

METHODS

We retrospectively reviewed all resected clinical IIIA-N2 NSCLC patients from 2001 to 2018. Thorough preoperative staging, including invasive mediastinal staging, was performed. Those with nonbulky N2 disease, appropriate restaging, and potential for a margin-negative resection were included. After resection, patients were classified as having persistent N2 disease or mediastinal downstaging (N2 to >N0/N1). Persistent N2 patients were further classified as uncertain resection (R[un]) or complete resection (R0) according to the International Association for the Study of Lung Cancer definition. Kaplan-Meier survival analysis was used.

RESULTS

Fifty-four patients met inclusion criteria. After induction, 31 patients (57%) demonstrated persistent N2 disease, and 23 patients (43%) had mediastinal downstaging. Preinduction invasive mediastinal staging was performed in 98.1%. Most had clinical single-station N2 disease (75.9%). Margin-negative resections were performed in 100%. Eight patients were reclassified as R(un) due to positive highest sampled mediastinal station. The median overall survival for persistent N2 was 26 months for R(un) and 69 months for R0. Overall survival for the downstaged group was 67 months (P = .31).

CONCLUSIONS

Overall survival for patients with non-R(un) or persistent N2 (true R0) was similar to those with mediastinal downstaging. Well-selected patients with persistent N2 disease experience reasonable survival after resection and should have surgery considered as part of their multimodality treatment. This study underscores the importance of classifying the extent of mediastinal involvement for persistent N2 patients, supporting the proposed International Association for the Study of Lung Cancer R(un) classification.

Sarcopenia on preoperative chest computed tomography predicts cancer-specific and all-cause mortality following pneumonectomy for lung cancer: A multicenter analysis

Background

Mortality risk prediction in patients undergoing pneumonectomy for non‐small cell lung cancer (NSCLC) remains imperfect. Here, we aimed to assess whether sarcopenia on routine chest computed tomography (CT) independently predicts worse cancer‐specific (CSS) and overall survival (OS) following pneumonectomy for NSCLC.

Methods

We included consecutive adults undergoing standard or carinal pneumonectomy for NSCLC at Massachusetts General Hospital and Heidelberg University from 2010 to 2018. We measured muscle cross‐sectional area (CSA) on CT at thoracic vertebral levels T8, T10, and T12 within 90 days prior to surgery. Sarcopenia was defined as T10 muscle CSA less than two standard deviations below the mean in healthy controls. We adjusted time‐to‐event analyses for age, body mass index, Charlson Comorbidity Index, forced expiratory volume in 1 second in % predicted, induction therapy, sex, smoking status, tumor stage, side of pneumonectomy, and institution.

Results

Three hundred and sixty‐seven patients (67.4% male, median age 62 years, 16.9% early‐stage) underwent predominantly standard pneumonectomy (89.6%) for stage IIIA NSCLC (45.5%) and squamous cell histology (58%). Sarcopenia was present in 104 of 367 patients (28.3%). Ninety‐day all‐cause mortality was 7.1% (26/367). After a median follow‐up of 20.5 months (IQR, 9.2–46.9), 183 of 367 patients (49.9%) had died. One hundred and thirty‐three (72.7%) of these deaths were due to lung cancer. Sarcopenia was associated with shorter CSS (HR 1.7, p = 0.008) and OS (HR 1.7, p = 0.003).

Conclusions

This transatlantic multicenter study confirms that sarcopenia on preoperative chest CT is an independent risk factor for CSS and OS following pneumonectomy for NSCLC.

Physiological Biomarkers Assessed by Low-Tech Exercise Tests Predict Complications and Overall Survival in Patients Undergoing Pneumonectomy Due to Lung Cancer

Due to its debilitating character pneumonectomy this is last-resort procedure. Preoperative results of the 6-min walking test (6MWT) help to identify high risk of postoperative complications and increased mortality in patients undergoing lobectomy for lung cancer. The aim of the study was to validate the value of 500 m in 6MWT as an indicator, which differentiates risk of complications in patients undergoing pneumonectomy. 125 patients who underwent pneumonectomy at Thoracic Surgery Department between 2009 and 2018. On the day preceding the surgery, patients underwent 6MWT. The patients were in median age of 63 years. The cut-off value of 500 m identified patients with increased 90-day mortality [17.9% vs. 3.5%, odds ratio (OR) 6.271, 95% confidence interval (CI) 1.528-25.739], first-year mortality (30.7% vs. 11.6%, OR 3.378, 95%CI 1.310-8.709), and overall survival (p = 0.02). Patients who covered a distance ≤ 500 m had an increased risk of atrial fibrillation (35.9% vs. 16.3%, OR 2.880, 95%CI 1.207-6.870) and cardiac complications (38.4% vs. 19.8%, OR 2.537, 95%CI 1.100-5.849). Patients unable to reach 500 m in 6MWT are in a high risk of postoperative death after pneumonectomy, what may be a result of increased frequency of postoperative cardiac complications. Poor result of 6MWT is a predictor of worse overall survival.