Surgical Treatment for Non-Small Cell Lung Cancer in Patients on Hemodialysis due to Chronic Kidney Disease: Clinical Outcome and Intermediate-Term Results

Preoperative renal dysfunction and long-term survival after surgery for non-small cell lung cancer

OBJECTIVE

To investigate the association of preoperative renal dysfunction and long-term outcomes following lung cancer surgery.

METHODS

Using the Japanese Lung Cancer Registry data, we retrospectively examined 16,377 patients who underwent surgery for non-small cell lung cancer during 2010. Patients' renal function status was categorized as follows: serum creatinine <1.5 mg/dL (control, n = 16,169), serum creatinine ≥1.5 mg/dL with no dialysis (nondialysis-dependent chronic kidney disease, n = 113), and dialysis-dependent end-stage renal disease (n = 95). The association of patients' characteristics with overall survival was evaluated using multivariate Cox proportional hazard model.

RESULTS

The 5-year overall survival rates in patients with dialysis-dependent end-stage renal disease and with nondialysis-dependent chronic kidney disease were significantly worse than that in the control group (52.9% and 57.5% vs 78.0%; P < .001 for both comparisons), but were comparable to the reported 5-year overall survival rates in the natural history of end-stage renal disease (∼60%) and moderate to severe chronic kidney disease (∼50%). Cancer causes not related to lung cancer accounted for 62.2% of deaths in dialysis-dependent end-stage renal disease, which was more frequent than that in the control group (P = .002). Dialysis-dependent end-stage renal disease and nondialysis-dependent chronic kidney disease were independent risk factors for overall survival after lung cancer surgery (hazard ratio, 2.05 [P < .001] and hazard ratio, 2.04 [P = .001], respectively).

CONCLUSIONS

Preoperative renal dysfunction may be adversely associated with overall survival after lung cancer surgery. Our findings could aid patients to set proper expectation of the risks and benefits about surgery for lung cancer.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care

INTRODUCTION

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care.

METHODS

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task Force criteria.

RESULTS

Recommendations for preoperative care focus on risk assessment, patient preparation (prehabilitation), and the choice of procedure (open thoracotomy vs. video-assisted thoracic surgery).

CONCLUSIONS

These recommendations should help pulmonologists to improve preoperative management in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Postoperative complications and perioperative management in patients on hemodialysis undergoing lung resection

OBJECTIVES

The rate of lung resection in patients on hemodialysis (HD) is increasing with the increasing number of HD. However, studies assessing lung resection in HD are limited. The study aimed to investigate the perioperative management and postoperative complications of lung resection in HD patients.

METHODS

Between 2007 and 2019, of the 4989 patients underwent lung resection, 43 patients had been receiving HD. We compared the characteristics of a Clavien-Dindo classification grade ≥ 2 group against grade ≤ 1 group. Predictive factors of complications were analyzed by logistic regression analysis.

RESULTS

Thirty-three patients were men (median age: 69 years). Thirty-eight patients had lung cancer. The reason for HD was diabetic nephropathy in 19 patients, nephrosclerosis in 10, and miscellaneous in 14. The median duration of HD before surgery was 64.6 months. The type of lung resection was lobectomy in 24, segmentectomy in 10, and partial resection in 9 patients. Bronchial calcification was detected in 16 (37%). Reinforcement at the stump was performed in 9 lobectomies, of which 6 involved bronchial calcification. Postoperative complications were detected in 21 (49%), including grade ≥ 2 complications in 14 (33%). Multivariate analysis revealed that pack-year smoking ≥ 10 (p = 0.01) and operation time ≥ 140 min (p = 0.02) were predictors of grade ≥ 2 morbidity.

CONCLUSIONS

Heavy smoking and longer operative time may result in postoperative complication requiring therapeutic intervention. The frequency of bronchial calcification is relatively high in HD patients, and reinforcement of the calcified bronchial stump should be considered during lobectomy.

When ESKD complicates cancer screening and cancer treatment

End-stage kidney disease (ESKD) affects the recommended screening, incidence, treatment, and mortality of cancer. Cancer occurring in a patient with ESKD can influence candidacy for kidney transplantation as well as dialysis decision-making and cancer treatment. Certain cancers are more common among ESKD patients, notably, viral-mediated cancers that are associated with human papilloma or hepatitis viruses, and urothelial cancers associated with analgesic and Balkan nephropathies. Solid tumors are not believed to occur more frequently in ESKD patients. The presence of ESKD may confer a higher risk of post-surgical complications as well as mortality. The cost-effectiveness of cancer screening depends upon individual cancer risk and estimated overall survival. The high mortality associated with ESKD argues against routine cancer screening in dialysis patients. Cancer treatment in ESKD may be complicated by the need to avoid, adjust doses of and/or coordinate the timing of administration of imaging contrast, chemotherapy, and immunotherapy with dialysis treatments. There is a general dearth of information on the treatment of cancer in ESKD patients. These issues will be discussed, and some general guidelines presented based upon the current literature.

Recommendations for perioperative management of lung cancer patients with comorbidities

Objectives

To improve surgical outcomes, clinicians must provide optimal perioperative care for comorbidities identified as significant factors in risk models for patients undergoing lung cancer surgery.

Methods

We reviewed trends in perioperative care for idiopathic pulmonary fibrosis, cardiovascular diseases, and end-stage renal diseases in patients undergoing lung cancer surgery, as large clinical databases indicate that these comorbidities are significant risk factors for lung cancer surgery. Articles identified by keyword searches were included in the analysis.

Results

Significant predictive factors for acute exacerbation of idiopathic pulmonary fibrosis were identified. However, no effective perioperative care was identified for prevention of acute exacerbation of interstitial pneumonia. The timing of coronary revascularization and antithrombotic management for cardiovascular diseases are subjects of ongoing research, and acid–base balance is essential in the management of hemodialysis patients with end-stage renal diseases.

Conclusions

To improve surgical outcomes for lung cancer patients, future studies should continue to study optimal perioperative management of comorbidities.

Outcomes, safety, and feasibility of video-assisted thoracic surgery in lung cancer patients on hemodialysis: a case series

OBJECTIVE

The rate of surgical resection of lung cancer in patients on hemodialysis is expected to increase due to the development of hemodialysis, improved diagnosis of lung cancer, and increases in the number and age of patients. However, studies assessing outcomes of lung resection in these patients are limited. In this retrospective case series, we investigated the safety and efficacy of video-assisted thoracic surgery (VATS) for lobectomy or segmentectomy for lung cancer in patients on hemodialysis.

METHODS

Between January 2010 and January 2017, lobectomy or segmentectomy using VATS was performed for seven lung cancer cases in six patients receiving hemodialysis at our institution. There were two female and five male patients, with a median age of 61 years (range 53-76 years). Six patients underwent lobectomy, and segmentectomy and wedge resection were performed in each one case, respectively; systematic mediastinal lymph node dissection (ND2a-2) was performed in six patients.

RESULTS

There were no perioperative deaths in this case series. Median recurrence-free and overall survival rates were 20 months (range 3-82 months) and 31 months (range 3-82 months), respectively.

CONCLUSIONS

Video-assisted thoracic surgery (VATS) is a safe and effective procedure for resection of lung cancer in hemodialysis patients and should be considered after accurate determination of surgical indications and careful perioperative management.