1
|
Saddoughi SA, Dunne B, Campo-Canaveral de la Cruz JL, Lemaitre P, Diaz Martinez JP, Martinu T, Donahoe L, de Perrot M, Pierre AF, Yasufuku K, Waddell TK, Chaparro C, Cypel M, Keshavjee S, Yeung JC. Extending the age criteria of lung transplant donors to 70+ years old does not significantly affect recipient survival. J Thorac Cardiovasc Surg 2024; 167:861-868. [PMID: 37541572 DOI: 10.1016/j.jtcvs.2023.07.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 07/21/2023] [Accepted: 07/22/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVES To determine the impact of older donor age (70+ years) on long-term survival and freedom from chronic lung allograft dysfunction in lung transplant (LTx) recipients. METHODS A retrospective single-center study was performed on all LTx recipients from 2002 to 2017 and a modern subgroup from 2013 to 2017. Recipients were stratified into 4 groups based on donor lung age (<18, 18-55, 56-69, ≥70 years). Donor and recipient characteristics were compared using χ2 tests for differences in proportions and analysis of variance for differences in means. Univariable and multivariable Cox regression was used to describe differences in long-term survival and freedom from chronic lung allograft dysfunction. RESULTS Between 2002 and 2017, 1600 LTx were performed, 98 of which were performed from donors aged 70 years or older. Recipients of 70+ years donor lungs were significantly older with a mean age of 55.5 ± 12.9 years old (P = .001) and had more Status 3 (urgent) recipients (37.4%, P = .002). After multivariable regression, there were no significant differences in survival or freedom from chronic lung allograft dysfunction between the 4 strata of recipients. CONCLUSIONS Lung transplantation using donors 70 years old or older can be considered when all other parameters suggest excellent donor lung function without compromising short- or long-term outcomes.
Collapse
Affiliation(s)
- Sahar A Saddoughi
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ben Dunne
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Philipe Lemaitre
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Tereza Martinu
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Donahoe
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Marc de Perrot
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrew F Pierre
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Cecilia Chaparro
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, Toronto General Hospital, Toronto, Ontario, Canada.
| |
Collapse
|
2
|
Kidane B, Jacob N, Bruinooge A, Shen YC, Keshavjee S, dePerrot ME, Pierre AF, Yasufuku K, Cypel M, Waddell TK, Darling GE. Postoperative but not intraoperative transfusions are associated with respiratory failure after pneumonectomy. Eur J Cardiothorac Surg 2020; 58:1004-1009. [DOI: 10.1093/ejcts/ezaa107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 02/14/2020] [Accepted: 03/03/2020] [Indexed: 01/17/2023] Open
Abstract
Abstract
OBJECTIVES
Transfusion of blood products has been associated with increased risk of post-pneumonectomy respiratory failure. It is unclear whether intraoperative or postoperative transfusions confer a higher risk of respiratory failure. Our objective was to assess the role of transfusions in developing post-pneumonectomy respiratory failure.
METHODS
We performed a retrospective cohort study using prospectively collected data on consecutive pneumonectomies between 2005 and 2015. Patient records were reviewed for intraoperative/postoperative exposures. Univariable and multivariable analyses were performed.
RESULTS
Of the 251 pneumonectomies performed during the study period, 24 (9.6%) patients suffered respiratory failure. Ninety-day mortality was 5.6% (n = 14) and was more likely in patients with respiratory failure (7/24 vs 7/227, P < 0.001). Intraoperative and postoperative transfusions occurred in 42.2% (n = 106) and 44.6% (n = 112) of patients, respectively and were predominantly red blood cells. On univariable analysis, both intraoperative (P = 0.03) and postoperative transfusion (P = 0.004) were associated with a higher risk of respiratory failure. The multivariable model significantly predicted respiratory failure with an area under curve (AUC) = 0.88 (P = 0.001). On multivariable analysis, the only independent predictors of respiratory failure were postoperative transfusions [adjusted odds ratio (aOR) 6.54, 95% confidence interval (CI) 1.74–24.59; P = 0.005] and lower preoperative forced expiratory volume (adjusted OR 0.96, 95% CI 0.93–0.99; P = 0.03). Estimated blood loss was not significantly different (P = 0.91) between those with (median 800 ml, interquartile range 300–2000 ml) and without respiratory failure (median 800 ml, interquartile range 300–2000 ml).
CONCLUSIONS
Respiratory failure occurred in 9.6% of patients post-pneumonectomy and confers a higher risk of 90-day mortality. Postoperative (but not intraoperative) transfusion was the strongest independent predictor associated with respiratory failure. Intraoperative transfusion may be in reaction to active/unpredictable blood loss and may not be easily modifiable. However, postoperative transfusion may be modifiable and potentially avoidable. Transfusion thresholds should be assessed in light of potential cost-benefit trade-offs.
Collapse
Affiliation(s)
- Biniam Kidane
- Department of Surgery, Section of Thoracic Surgery, University of Manitoba, Winnipeg, MB, Canada
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Nithin Jacob
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Allan Bruinooge
- Department of Surgery, Section of Thoracic Surgery, University of Manitoba, Winnipeg, MB, Canada
| | - Yu Cindy Shen
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Shaf Keshavjee
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Marc E dePerrot
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Andrew F Pierre
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Kazuhiro Yasufuku
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Marcelo Cypel
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Thomas K Waddell
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| | - Gail E Darling
- Department of Surgery, Division of Thoracic Surgery, University of Toronto, Toronto General Hospital, Toronto, ON, Canada
| |
Collapse
|
3
|
Wang Y, Yeung JC, Hanna WC, Allison F, Paul NS, Waddell TK, Cypel M, de Perrot ME, Yasufuku K, Keshavjee S, Pierre AF, Darling GE. Metachronous or synchronous primary lung cancer in the era of computed tomography surveillance. J Thorac Cardiovasc Surg 2019; 157:1196-1202. [DOI: 10.1016/j.jtcvs.2018.09.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 09/10/2018] [Accepted: 09/13/2018] [Indexed: 10/28/2022]
|
4
|
Rodrigues JCL, Pierre AF, Hanneman K, Cabanero M, Kavanagh J, Waddell TK, Chung TB, Pakkal M, Keshavjee S, Cypel M, Yasufuku K, Nguyen ET. CT-guided Microcoil Pulmonary Nodule Localization prior to Video-assisted Thoracoscopic Surgery: Diagnostic Utility and Recurrence-Free Survival. Radiology 2019; 291:214-222. [PMID: 30720402 DOI: 10.1148/radiol.2019181674] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background CT-guided microcoil localization has been shown to reduce the need for thoracotomy or video-assisted thoracoscopic surgery (VATS) anatomic resection. However, only short-term follow-up after CT-guided microcoil localization and lung resection has been previously reported. Purpose To assess the diagnostic utility and recurrence-free survival over a minimum of 2 years following CT-guided microcoil localization and VATS. Materials and Methods Among 1950 VATS procedures performed in a single tertiary institution from October 2008 through April 2016, 124 consecutive patients with CT-guided microcoil localization were retrospectively evaluated. Patient demographics, nodule characteristics, and histopathologic findings were recorded. The primary end point was recurrence-free survival after 2 or more years of CT surveillance. Statistical analysis included Kaplan-Meier survival curves and Cox regression. Results In 124 patients (men, 35%; mean age, 65 years ± 12) with a nodule found at CT, microcoil localization and VATS resection were performed for a total of 126 nodules (mean size, 13 mm ± 6; mean distance to pleura, 20 mm ± 9). On presurgical CT evaluation, 42% (53 of 126) of nodules were solid, 33% (41 of 126) were ground glass, and 24% (30 of 126) were subsolid. VATS excisional biopsy altered cytopathologic diagnosis in 21% (five of 24) of patients with prior diagnostic premicrocoil CT-guided biopsy. At histopathologic examination, 17% (21 of 126) of the nodules were adenocarcinoma in situ, 17% (22 of 126) were minimally invasive adenocarcinoma, 30% (38 of 126) were invasive lung primary tumors, and 22% (28 of 126) were metastases. Among the 72 patients with malignancy at histopathologic examination and at least 2 years of CT surveillance, local recurrence occurred in 7% (five of 72), intrathoracic recurrence in 22% (16 of 72), and extrathoracic recurrence in 18% (13 of 72) after 2 or more years of CT surveillance. There was no recurrence for adenocarcinoma in situ, minimally invasive adenocarcinoma, or invasive lung tumors measuring less than 1 cm. After multivariable adjustment, nodule location at a distance greater than 10 mm from the pleura was an independent predictor of time to recurrence (hazard ratio, 2.9 [95% confidence interval: 1.1, 7.4]; P = .03). Conclusion CT-guided microcoil localization and video-assisted thoracoscopic surgical resection alter clinical management and were associated with excellent recurrence-free survival for superficial premalignant, minimally invasive, and small invasive lung tumors. © RSNA, 2019 Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Jonathan C L Rodrigues
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - Andrew F Pierre
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - Kate Hanneman
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - Michael Cabanero
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - John Kavanagh
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - Thomas K Waddell
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - Tae-Bong Chung
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - Mini Pakkal
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - Shaf Keshavjee
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - Marcelo Cypel
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - Kazuhiro Yasufuku
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| | - Elsie T Nguyen
- From the Divisions of Cardiothoracic Imaging (J.C.L.R., K.H., J.K., T.B.C., M.P., E.T.N.), Thoracic Surgery (A.F.P., T.K.W., S.K., M.C., K.Y.), and Thoracic Pathology (M.C.), Toronto General Hospital, University Health Network, 585 University Ave, Toronto, ON, Canada M5G 2N2; Postgraduate Medical Education, Department of Medical Imaging, University of Toronto, Toronto, Canada (J.C.L.R.); and Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, England, United Kingdom, BA1 3NG (J.C.L.R.)
| |
Collapse
|
5
|
|
6
|
Bendzsak A, Waddell TK, Yasufuku K, Keshavjee S, de Perrot M, Cypel M, Pierre AF, Darling GE. Invasive Mediastinal Staging Guideline Concordance. Ann Thorac Surg 2017; 103:1736-1741. [DOI: 10.1016/j.athoracsur.2016.12.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 11/24/2016] [Accepted: 12/02/2016] [Indexed: 12/12/2022]
|
7
|
Yeung JC, Krueger T, Yasufuku K, de Perrot M, Pierre AF, Waddell TK, Singer LG, Keshavjee S, Cypel M. Outcomes after transplantation of lungs preserved for more than 12 h: a retrospective study. The Lancet Respiratory Medicine 2017; 5:119-124. [DOI: 10.1016/s2213-2600(16)30323-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/29/2016] [Accepted: 09/30/2016] [Indexed: 10/20/2022]
|
8
|
Donahoe LL, Nguyen ET, Chung TB, Kha LC, Cypel M, Darling GE, de Perrot M, Keshavjee S, Pierre AF, Waddell TK, Yasufuku K. CT-guided microcoil VATS resection of lung nodules: a single-centre experience and review of the literature. J Thorac Dis 2016; 8:1986-94. [PMID: 27621851 DOI: 10.21037/jtd.2016.06.74] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Video-assisted thoracoscopic surgery (VATS) is standard of care for small lung resections at many centres. Computed tomography (CT)-guided insertion of microcoils can aid surgeons in performing VATS resections for non-palpable lung nodules deep to the lung surface. METHODS Retrospective analysis of CT-guided microcoil insertions prior to VATS lung resection at a single institution from October 2008 to January 2014. RESULTS A total of 63 patients were included (37% male, mean age 61.6±11.4 years). Forty-two patients (67%) had a history of smoking, with 10 current smokers. Sixty one (97%) patients underwent wedge resection and 3 (5%) patients had segmentectomy. Three (5%) patients required intra-operative staple line re-resection for positive or close margins. Eleven (17%) patients had a completion lobectomy, 5 of which were during the same anaesthetic. The average time between the CT-guided insertion and start of operation was 136.6±89.0 min, and average operative time was 84.0±53.3 min. The intra-operative complication rate was 5% (n=3), including 1 episode of hemoptysis, and 2 conversions to thoracotomy. The post-operative complication rate was 8% (5 patients), and included 2 air leaks, 1 hemothorax (drop in hemoglobin), 1 post chest tube removal pneumothorax, and one venous infarction of the lingula after lingula-sparing lobectomy requiring completion lobectomy. . Average post-operative length of stay was 2.2 days. A diagnosis was made for all patients. CONCLUSIONS CT-guided microcoil insertion followed by VATS lobectomy is safe, with short operative times, short length of stay and 100% diagnosis of small pulmonary nodules. This technique will become more important in the future with increasing numbers of small nodules detected on CT as part of lung cancer screening programs.
Collapse
Affiliation(s)
- Laura L Donahoe
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Elsie T Nguyen
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Tae-Bong Chung
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Lan-Chau Kha
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andrew F Pierre
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
9
|
Tikkanen JM, Cypel M, Machuca TN, Azad S, Binnie M, Chow CW, Chaparro C, Hutcheon M, Yasufuku K, de Perrot M, Pierre AF, Waddell TK, Keshavjee S, Singer LG. Functional outcomes and quality of life after normothermic ex vivo lung perfusion lung transplantation. J Heart Lung Transplant 2015; 34:547-56. [DOI: 10.1016/j.healun.2014.09.044] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 09/29/2014] [Accepted: 09/30/2014] [Indexed: 12/28/2022] Open
|
10
|
Tinckam KJ, Keshavjee S, Chaparro C, Barth D, Azad S, Binnie M, Chow CW, de Perrot M, Pierre AF, Waddell TK, Yasufuku K, Cypel M, Singer LG. Survival in sensitized lung transplant recipients with perioperative desensitization. Am J Transplant 2015; 15:417-26. [PMID: 25612494 DOI: 10.1111/ajt.13076] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 08/19/2014] [Accepted: 09/06/2014] [Indexed: 01/25/2023]
Abstract
Donor-specific HLA antibodies (DSA) have an adverse effect on short-term and long-term lung transplant outcomes. We implemented a perioperative strategy to treat DSA-positive recipients, leading to equivalent rejection and graft survival outcomes. Pretransplant DSA were identified to HLA-A, B, C, DR and DQ antigens. DSA-positive patients were transplanted if panel reactive antibody (PRA) ≥30% or medically urgent and desensitized with perioperative plasma exchange, intravenous immune globulin, antithymocyte globulin (ATG), and mycophenolic acid (MPA). PRA-positive/DSA-negative recipients received MPA. Unsensitized patients received routine cyclosporine, azathioprine and prednisone without ATG. From 2008-2011, 340 lung-only first transplants were performed: 53 DSA-positive, 93 PRA-positive/DSA-negative and 194 unsensitized. Thirty-day survival was 96 %/99%/96% in the three groups, respectively. One-year graft survival was 89%/88%/86% (p = 0.47). DSA-positive and PRA-positive/DSA-negative patients were less likely to experience any ≥ grade 2 acute rejection (9% and 9% vs. 18% unsensitized p = 0.04). Maximum predicted forced expiratory volume (1 s) (81%/74%/76%, p = NS) and predicted forced vital capacity (81%/77%/78%, respectively, p = NS) were equivalent between groups. With the application of this perioperative treatment protocol, lung transplantation can be safely performed in DSA/PRA-positive patients, with similar outcomes to unsensitized recipients.
Collapse
Affiliation(s)
- K J Tinckam
- Laboratory Medicine Program and Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Collaud S, Machuca T, Mercier O, Waddell TK, Yasufuku K, Pierre AF, Darling GE, Cypel M, Rampersaud YR, Lewis SJ, Shepherd FA, Leighl NB, Cho JBC, Bezjak A, Keshavjee S, de Perrot M. Long-term outcome after resection of non-small cell lung cancer invading the thoracic inlet. Ann Thorac Surg 2014; 98:962-7. [PMID: 25069687 DOI: 10.1016/j.athoracsur.2014.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2014] [Revised: 04/23/2014] [Accepted: 05/05/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of this study was to update our previous experience and describe long-term results after resection of non-small-cell lung cancer (NSCLC) invading the thoracic inlet. METHODS Patients from a single center undergoing resection of NSCLC invading the thoracic inlet were reviewed with data retrieved retrospectively from their charts. RESULTS Sixty-five consecutive patients with a median age of 61 (32-76) years underwent resection of NSCLC invading the thoracic inlet from 1991 to 2011. Tumor location was divided into 5 anatomic zones from anterior to posterior. Fifty-two (80%) patients had induction therapy, mostly with 2 cycles of cisplatin-etoposide and 45 Gy of concurrent irradiation. All patients underwent at least first rib resection. Lobectomy was performed in 60 patients (92%). Twenty-four patients (37%) had vertebral resection. Arterial resections were performed in 7 patients (11%). Postoperative morbidity and mortality were 46% and 6%, respectively. Pathologic response to induction was complete (pCR) (n = 19) or nearly complete (pNR) (n = 12) in 31 patients (48%). Adjuvant treatment was administered in 14 (25%) patients. After a median follow-up of 20 (0-193) months, 34 patients are alive without recurrence. The overall 5-year survival reached 69%. Univariate analysis identified site of tumor within the thoracic inlet (p = 0.050), response to induction (p = 0.004), and presence of adjuvant treatment (p = 0.028) as survival predictors. CONCLUSIONS Survival after resection of NSCLC invading the thoracic inlet in highly selected patients reached 69% at 5 years. Tumor location within the thoracic inlet, pathologic response to induction therapy, and adjuvant treatments were significant survival predictors.
Collapse
Affiliation(s)
- Stéphane Collaud
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Tiago Machuca
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Olaf Mercier
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Andrew F Pierre
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Yoga R Rampersaud
- Division of Orthopedic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Stephen J Lewis
- Division of Orthopedic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Frances A Shepherd
- Department of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Natasha B Leighl
- Department of Medical Oncology and Hematology, University Health Network, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - John B C Cho
- Department of Radiation Oncology, University Health Network, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Andrea Bezjak
- Department of Radiation Oncology, University Health Network, Princess Margaret Cancer Centre and the University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
12
|
Eng L, Su J, Qiu X, Palepu PR, Hon H, Fadhel E, Harland L, La Delfa A, Habbous S, Kashigar A, Cuffe S, Shepherd FA, Leighl NB, Pierre AF, Selby P, Goldstein DP, Xu W, Liu G. Second-Hand Smoke As a Predictor of Smoking Cessation Among Lung Cancer Survivors. J Clin Oncol 2014; 32:564-70. [DOI: 10.1200/jco.2013.50.9695] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Second-hand smoke (SHS; ie, exposure to smoking of friends and spouses in the household) reduces the likelihood of smoking cessation in noncancer populations. We assessed whether SHS is associated with cessation rates in lung cancer survivors. Patients and Methods Patients with lung cancer were recruited from Princess Margaret Cancer Centre, Toronto, ON, Canada. Multivariable logistic regression and Cox proportional hazard models evaluated the association of sociodemographics, clinicopathologic variables, and SHS with either smoking cessation or time to quitting. Results In all, 721 patients completed baseline and follow-up questionnaires with a mean follow-up time of 54 months. Of the 242 current smokers at diagnosis, 136 (56%) had quit 1 year after diagnosis. Exposure to smoking at home (adjusted odds ratio [aOR], 6.18; 95% CI, 2.83 to 13.5; P < .001), spousal smoking (aOR, 6.01; 95% CI, 2.63 to 13.8; P < .001), and peer smoking (aOR, 2.49; 95% CI, 1.33 to 4.66; P = .0043) were each associated with decreased rates of cessation. Individuals exposed to smoking in all three settings had the lowest chances of quitting (aOR, 9.57; 95% CI, 2.50 to 36.64; P < .001). Results were similar in time-to-quitting analysis, in which 68% of patients who eventually quit did so within 6 months after cancer diagnosis. Subgroup analysis revealed similar associations across early- and late-stage patients and between sexes. Conclusion SHS is an important factor associated with smoking cessation in lung cancer survivors of all stages and should be a key consideration when developing smoking cessation programs for patients with lung cancer.
Collapse
Affiliation(s)
- Lawson Eng
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Jie Su
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Xin Qiu
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Prakruthi R. Palepu
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Henrique Hon
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Ehab Fadhel
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Luke Harland
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Anthony La Delfa
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Steven Habbous
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Aidin Kashigar
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Sinead Cuffe
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Frances A. Shepherd
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Natasha B. Leighl
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Andrew F. Pierre
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Peter Selby
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - David P. Goldstein
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Wei Xu
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Geoffrey Liu
- Lawson Eng, Jie Su, Xin Qiu, Prakruthi R. Palepu, Henrique Hon, Ehab Fadhel, Luke Harland, Anthony La Delfa, Steven Habbous, Aidin Kashigar, Sinead Cuffe, Frances A. Shepherd, Natasha B. Leighl, Andrew F. Pierre, David P. Goldstein, Wei Xu, and Geoffrey Liu, Princess Margaret Hospital/Ontario Cancer Institute/University Health Network, University of Toronto; Peter Selby, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
13
|
Hanna WC, Paul NS, Darling GE, Moshonov H, Allison F, Waddell TK, Cypel M, de Perrot ME, Yasufuku K, Keshavjee S, Pierre AF. Minimal-dose computed tomography is superior to chest x-ray for the follow-up and treatment of patients with resected lung cancer. J Thorac Cardiovasc Surg 2014; 147:30-3. [DOI: 10.1016/j.jtcvs.2013.08.060] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 08/17/2013] [Accepted: 08/29/2013] [Indexed: 01/14/2023]
|
14
|
de Perrot M, Granton JT, McRae K, Pierre AF, Singer LG, Waddell TK, Keshavjee S. Outcome of patients with pulmonary arterial hypertension referred for lung transplantation: A 14-year single-center experience. J Thorac Cardiovasc Surg 2012; 143:910-8. [DOI: 10.1016/j.jtcvs.2011.08.055] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Revised: 07/21/2011] [Accepted: 08/24/2011] [Indexed: 10/14/2022]
|
15
|
Anraku M, Pierre AF, Nakajima T, de Perrot M, Darling GE, Waddell TK, Keshavjee S, Yasufuku K. Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in the Management of Previously Treated Lung Cancer. Ann Thorac Surg 2011; 92:251-5; discussion 255. [DOI: 10.1016/j.athoracsur.2011.03.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 02/25/2011] [Accepted: 03/07/2011] [Indexed: 11/27/2022]
|
16
|
Cypel M, Yeung JC, Liu M, Anraku M, Chen F, Karolak W, Sato M, Laratta J, Azad S, Madonik M, Chow CW, Chaparro C, Hutcheon M, Singer LG, Slutsky AS, Yasufuku K, de Perrot M, Pierre AF, Waddell TK, Keshavjee S. Normothermic ex vivo lung perfusion in clinical lung transplantation. N Engl J Med 2011; 364:1431-40. [PMID: 21488765 DOI: 10.1056/nejmoa1014597] [Citation(s) in RCA: 737] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND More than 80% of donor lungs are potentially injured and therefore not considered suitable for transplantation. With the use of normothermic ex vivo lung perfusion (EVLP), the retrieved donor lung can be perfused in an ex vivo circuit, providing an opportunity to reassess its function before transplantation. In this study, we examined the feasibility of transplanting high-risk donor lungs that have undergone EVLP. METHODS In this prospective, nonrandomized clinical trial, we subjected lungs considered to be high risk for transplantation to 4 hours of EVLP. High-risk donor lungs were defined by specific criteria, including pulmonary edema and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PO(2):FIO(2)) less than 300 mm Hg. Lungs with acceptable function were subsequently transplanted. Lungs that were transplanted without EVLP during the same period were used as controls. The primary end point was primary graft dysfunction 72 hours after transplantation. Secondary end points were 30-day mortality, bronchial complications, duration of mechanical ventilation, and length of stay in the intensive care unit and hospital. RESULTS During the study period, 136 lungs were transplanted. Lungs from 23 donors met the inclusion criteria for EVLP; in 20 of these lungs, physiological function remained stable during EVLP and the median PO(2):FIO(2) ratio increased from 335 mm Hg in the donor lung to 414 and 443 mm Hg at 1 hour and 4 hours of perfusion, respectively (P<0.001). These 20 lungs were transplanted; the other 116 lungs constituted the control group. The incidence of primary graft dysfunction 72 hours after transplantation was 15% in the EVLP group and 30% in the control group (P=0.11). No significant differences were observed for any secondary end points, and no severe adverse events were directly attributable to EVLP. CONCLUSIONS Transplantation of high-risk donor lungs that were physiologically stable during 4 hours of ex vivo perfusion led to results similar to those obtained with conventionally selected lungs. (Funded by Vitrolife; ClinicalTrials.gov number, NCT01190059.).
Collapse
Affiliation(s)
- Marcelo Cypel
- Toronto Lung Transplant Program, University of Toronto, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Anraku M, Husain S, Mazulli T, Pierre AF. Peri-operative novel 2009 H1N1 influenza virus infection successfully treated with oseltamivir and zanamivir in a lung transplant recipient. J Heart Lung Transplant 2011; 30:354. [DOI: 10.1016/j.healun.2010.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2010] [Revised: 10/24/2010] [Accepted: 10/24/2010] [Indexed: 11/29/2022] Open
|
18
|
Patel A, Anraku M, Darling GE, Shepherd FA, Pierre AF, Waddell TK, Keshavjee S, de Perrot M. Venous thromboembolism in patients receiving multimodality therapy for thoracic malignancies. J Thorac Cardiovasc Surg 2009; 138:843-8. [DOI: 10.1016/j.jtcvs.2009.02.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 01/10/2009] [Accepted: 02/09/2009] [Indexed: 11/30/2022]
|
19
|
Coonar AS, Hughes JA, Walker S, dePerrot M, Waddell TK, Pierre AF, Darling GE, Johnston MR, Keshavjee S. Implementation of Real-Time Ultrasound in a Thoracic Surgery Practice. Ann Thorac Surg 2009; 87:1577-81. [DOI: 10.1016/j.athoracsur.2008.12.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2008] [Revised: 11/27/2008] [Accepted: 12/01/2008] [Indexed: 11/26/2022]
|
20
|
Anraku M, Waddell TK, de Perrot M, Lewis SJ, Pierre AF, Darling GE, Johnston MR, Zener RE, Rampersaud YR, Shepherd FA, Leighl N, Bezjak A, Sun AY, Hwang DM, Tsao MS, Keshavjee S. Induction chemoradiotherapy facilitates radical resection of T4 non–small cell lung cancer invading the spine. J Thorac Cardiovasc Surg 2009; 137:441-447.e1. [DOI: 10.1016/j.jtcvs.2008.09.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 08/27/2008] [Accepted: 09/14/2008] [Indexed: 10/21/2022]
|
21
|
Anraku M, Cameron MJ, Waddell TK, Liu M, Arenovich T, Sato M, Cypel M, Pierre AF, de Perrot M, Kelvin DJ, Keshavjee S. Impact of human donor lung gene expression profiles on survival after lung transplantation: a case-control study. Am J Transplant 2008; 8:2140-8. [PMID: 18727701 DOI: 10.1111/j.1600-6143.2008.02354.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Primary graft dysfunction (PGD) continues to be a major cause of early death after lung transplantation. Moreover, there remains a lack of accurate pretransplant molecular markers for predicting PGD. To identify distinctive donor lung gene expression signatures associated with PGD, we profiled human donor lungs using microarray technology prior to implantation. The genomic profiles of 10 donor lung samples from patients who subsequently developed clinically defined severe PGD were compared with 16 case-matched donor lung samples from those who had a favorable outcome without PGD (development set, n = 26). Selected PCR validated predictive genes were tested by quantitative reverse transcription-polymerase chain reaction in an independent test set (n = 81). Our microarray analyses of the development set identified four significantly upregulated genes (ATP11B, FGFR2, EGLN1 and MCPH1) in the PGD samples. These genes were also significantly upregulated in donor samples of the test set of patients with poor outcomes when compared to those of patients with good outcomes after lung transplantation. This type of biological donor lung assessment shows significant promise for development of a more accurate diagnostic strategy to assess donor lungs prior to implantation.
Collapse
Affiliation(s)
- M Anraku
- Latner Thoracic Surgery Research Laboratories, Toronto General Research Institute, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Fischer S, Darling G, Pierre AF, Sun A, Leighl N, Waddell TK, Keshavjee S, de Perrot M. Induction chemoradiation therapy followed by surgical resection for non-small cell lung cancer (NSCLC) invading the thoracic inlet☆. Eur J Cardiothorac Surg 2008; 33:1129-34. [DOI: 10.1016/j.ejcts.2008.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 02/20/2008] [Accepted: 03/04/2008] [Indexed: 10/22/2022] Open
|
23
|
de Perrot M, McRae K, Anraku M, Karkouti K, Waddell TK, Pierre AF, Darling G, Keshavjee S, Johnston MR. Risk Factors for Major Complications After Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma. Ann Thorac Surg 2008; 85:1206-10. [DOI: 10.1016/j.athoracsur.2007.11.065] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Revised: 11/23/2007] [Accepted: 11/26/2007] [Indexed: 11/30/2022]
|
24
|
Abstract
Lymphomatoid granulomatosis is a rare lymphoproliferative disorder which affects extranodal sites, most commonly lung. Radiologically, it typically presents with multiple nodular opacities that may wax and wane. The reversed halo sign has previously been reported in cryptogenic organizing pneumonia and more recently in South American blastomycosis. We describe a case of histologically proven lymphomatoid granulomatosis in a patient who presented initially with the more typical nodular opacities, which subsequently progressed into the reversed halo sign. To the best of our knowledge, this association has not been previously described.
Collapse
Affiliation(s)
- R E Benamore
- Department of Medical Imaging, Toronto General Hospital, NCSB, 1C- 571, 585 University Avenue, Toronto, Ontario, M5G 2N2, Canada.
| | | | | | | | | | | | | |
Collapse
|
25
|
Uy KL, Darling G, Xu W, Yi QL, De Perrot M, Pierre AF, Waddell TK, Johnston MR, Bezjak A, Shepherd FA, Keshavjee S. Improved results of induction chemoradiation before surgical intervention for selected patients with stage IIIA-N2 non–small cell lung cancer. J Thorac Cardiovasc Surg 2007; 134:188-93. [PMID: 17599507 DOI: 10.1016/j.jtcvs.2007.01.078] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 01/04/2007] [Accepted: 01/18/2007] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Optimal management of stage IIIA-N2 non-small cell lung cancer remains controversial. The surgical arm of the North American Intergroup 0139 trial was adopted as the standard treatment for patients with resectable N2 disease at the University Health Network. Results after 7 years of experience are reported. METHODS This is a retrospective study of consecutive patients with biopsy-proved T1-3 N2 M0 lung cancer who underwent induction chemoradiation before surgical intervention from January 1997 through August 2004. Induction chemotherapy consisted of cisplatin, 50 mg/m2, on days 1 and 8; etoposide, 50 mg/m2, on days 1 to 5, weeks 1 and 5; and concurrent daily external beam radiotherapy to 45 Gy. Lung resection was performed within 6 weeks of completion of chemoradiation, followed by 2 further cycles of consolidation chemotherapy. RESULTS Between January 1997 and August 2004, 40 patients were treated according to this protocol (25% T1, 62.5% T2, 7.5% T3, and 5% T4). Overall and disease-free median survivals were 40 and 37.1 months, respectively, whereas overall and disease-free 3-year survivals were 51.7% and 52.3%, respectively. R0 resection was achieved in 92.5%. The overall operative mortality rate was 7.5% (0% for lobectomy and 27% for pneumonectomy). Notably, all mortalities occurred within the first 2 years of our experience with this regimen. CONCLUSION Chemoradiation before pulmonary resection in carefully selected patients with surgically resectable stage IIIA (N2) non-small cell lung cancer can lead to improved overall and disease-free survival.
Collapse
Affiliation(s)
- Karl L Uy
- Division of Thoracic Surgery, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Fischer S, Bohn D, Rycus P, Pierre AF, de Perrot M, Waddell TK, Keshavjee S. Extracorporeal membrane oxygenation for primary graft dysfunction after lung transplantation: analysis of the Extracorporeal Life Support Organization (ELSO) registry. J Heart Lung Transplant 2007; 26:472-7. [PMID: 17449416 DOI: 10.1016/j.healun.2007.01.031] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2006] [Revised: 01/09/2007] [Accepted: 01/15/2007] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Some patients with severe primary graft dysfunction (PGD) after lung transplantation (LTx) require gas exchange support using an extracorporeal membrane oxygenator (ECMO) as a life-saving therapy. A few single-center experiences have been reported with relatively few cases of ECMO after LTx. METHODS We reviewed outcomes of ECMO in lung transplant recipients included in the Extracorporeal Life Support Organization (ELSO) registry, which was established with the intention to improve quality and outcome of extracorporeal life support (ECLS) in patients treated with ECMO applied for all indications. RESULTS The ELSO registry currently includes 31,340 ECMO cases, of which 151 were post-LTx patients with primary graft dysfunction (PGD). The mean age was 35 +/- 18 years. Indications for LTx were acute respiratory distress syndrome, (15%), cystic fibrosis (15%), idiopathic pulmonary fibrosis (8%), primary pulmonary hypertension, (10%), emphysema (15%), acute lung failure (11%), other (23%), and unknown (3%). ECMO run time was 140 +/- 212 hours. Venovenous ECMO was used in 25, venoarterial in 89, and other modes in 15 patients (unknown in 22). ECMO was discontinued in 93 patients owing to lung recovery. It was also discontinued in 29 patients with multiorgan failure, in 22 patients that died with no further specification, and in 7 patients for other reasons. In total, 63 (42%) patients survived the hospital stay. Major complications during ECMO included hemorrhage (52%), hemodialysis (42%), neurologic (12%), and cardiac (28%) complications, inotropic support (77%), and sepsis (15%). CONCLUSIONS Although the ELSO registry was not primarily established to study ECMO in LTx, it provides valuable insights and evidence that there is indeed an appreciable salvage rate with the use of ECMO for PGD after LTx. Clearly, this is a very high-risk patient population, and no single center can accumulate a large experience of ECMO for this specific indication. These data, however, underscore the importance of developing a specific registry for patients put on ECLS devices so that we can better study the outcomes, determine optimum treatment strategies, and optimize patient and device selection, and thus improve the outcomes of patients requiring this unique therapy.
Collapse
Affiliation(s)
- Stefan Fischer
- The Toronto Lung Transplant Program, Division of Thoracic Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
27
|
de Perrot M, Uy K, Anraku M, Tsao MS, Darling G, Waddell TK, Pierre AF, Bezjak A, Keshavjee S, Johnston MR. Impact of lymph node metastasis on outcome after extrapleural pneumonectomy for malignant pleural mesothelioma. J Thorac Cardiovasc Surg 2007; 133:111-6. [PMID: 17198794 DOI: 10.1016/j.jtcvs.2006.06.044] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Revised: 04/29/2006] [Accepted: 06/07/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Extrapleural pneumonectomy is a therapeutic option for selected patients with malignant pleural mesothelioma. The impact of lymph node metastasis on the site of recurrence and the role of mediastinoscopy in the selection of patients for extrapleural pneumonectomy, however, remain unclear. METHODS We reviewed 50 consecutive patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma in our institution between January 1993 and March 2005. RESULTS The median survival was 11 months, with a 3-year survival of 24%. Survival was significantly worse for patients with N2 disease than for those with no lymph node metastasis (median survival 10 months vs 29 months, respectively, P = .005). Patient sex, histologic cell type, stage, and N2 disease, but not mediastinoscopy, had significant impacts on survival according to univariate analysis. In a multivariate analysis, however, only the presence of N2 disease remained a significant predictor of poor outcome. The proportion of patients with N2 disease and the long-term survival was similar regardless of whether preoperative mediastinoscopy yielded a negative result. The initial site of recurrence was determined in 28 patients (locoregional in 10 and distant in 18). The presence of N2 disease had no impact on the site of recurrence. Adjuvant hemithoracic radiation therapy, however, significantly decreased the risk of locoregional recurrence. CONCLUSIONS The presence of N2 disease negatively affects the prognosis of patients with malignant pleural mesothelioma. Mediastinoscopy, however, seems to have a limited role in patient selection for extrapleural pneumonectomy. Adjuvant hemithoracic radiation therapy but not N2 disease affects the risk of locoregional recurrence.
Collapse
Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Canada.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
De Perrot M, Waddell TK, Shargall Y, Pierre AF, Fadel E, Uy K, Chaparro C, Hutcheon M, Singer LG, Keshavjee S. Impact of donors aged 60 years or more on outcome after lung transplantation: results of an 11-year single-center experience. J Thorac Cardiovasc Surg 2006; 133:525-31. [PMID: 17258592 DOI: 10.1016/j.jtcvs.2006.09.054] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2006] [Revised: 08/16/2006] [Accepted: 09/05/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We examined the outcome of lung transplantation with the use of donors aged 60 years or more. METHODS From May 1994 to May 2005, 467 lung transplants were performed at our institution. A total of 60 recipients received lungs from donors aged 60 years or more (range 60-77 years, median 65 years), whereas 407 recipients received lungs from younger donors (range 9-59, median 39 years). RESULTS A total of 48 patients (10%) died within 30 days of surgery: 10 (17%) in the older donor group versus 38 (9%) in the younger donor group (P = .08). The operative mortality varied with the underlying lung disease and was higher in recipients presenting with pulmonary hypertension and pulmonary fibrosis than with emphysema or cystic fibrosis. A total of 210 patients died after a median follow-up of 25 months (range 0-136 months). The overall 5- and 10-year survivals were 57% and 38%, respectively. However, the 10-year survival tended to be worse in the older donor group (16% vs 39% in the younger donor group, P = .07). Bronchiolitis obliterans syndrome was the predominant cause of death in recipients of older donors who survived for more than 90 days after surgery (11/17, 65% vs 45/132, 34% in recipients of younger donors surviving for >90 days after surgery, P = .01). CONCLUSIONS Given the lack of organ donors, lungs from donors aged 60 years or more should be considered for transplantation. However, the use of donors aged 60 years or more is associated with a lower 10-year survival, and bronchiolitis obliterans syndrome plays a significant role as the cause of late death.
Collapse
Affiliation(s)
- Marc De Perrot
- Toronto Lung Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Canada.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW The purpose of this paper is to highlight new developments in donor and recipient lung transplant issues for the critical care physician. RECENT FINDINGS A shortage of suitable lung donors has led to the use of extended donors and the development of novel techniques such as live-donor lung transplantation and the use of non-heart-beating donors. The increased experience and success with lung transplantation has also resulted in the extension of this therapy to patients previously considered unsuitable for transplantation. Postoperative outcomes can be affected by many of these recent donor and recipient changes. Improved preservation solutions and techniques to reduce reperfusion injury may be able to ameliorate some of the new perioperative graft dysfunction, but morbidity is still potentially significant, and extraordinary interventions such as extracorporeal membrane oxygenation may be required in selected cases. SUMMARY Patients undergoing lung transplantation continue to be very challenging in the intensive care unit. A multidisciplinary approach to care, and early recognition of serious problems, will help improve outcomes.
Collapse
Affiliation(s)
- Andrew F Pierre
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | | |
Collapse
|
30
|
de Perrot M, Chernenko S, Waddell TK, Shargall Y, Pierre AF, Hutcheon M, Keshavjee S. Role of Lung Transplantation in the Treatment of Bronchogenic Carcinomas for Patients With End-Stage Pulmonary Disease. J Clin Oncol 2004; 22:4351-6. [PMID: 15514376 DOI: 10.1200/jco.2004.12.188] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To determine the role of lung transplantation in the treatment of patients presenting with bronchogenic carcinoma and end-stage lung disease. Methods An international survey was conducted to determine the outcome of patients with bronchogenic carcinoma in the explanted lung at the time of transplantation. A group of 69 patients was collected from 33 centers. Results Twenty-six patients underwent 29 lung transplantations for advanced multifocal bronchioloalveolar carcinoma (BAC) as the primary indication for transplantation, and 13 developed a recurrence, with an overall 5-year actuarial survival of 39%. Incidental bronchogenic carcinomas classified as stage I (n = 22), II (n = 12), and III (n = 2), or as incidental multifocal BAC (n = 7), were found in the explanted lung of the remaining 43 patients. The 5-year actuarial survival was 51% in patients with stage I carcinomas, and was significantly better than for patients with stage II and III carcinomas (survival of 14%) or with incidental multifocal BAC (survival of 23%). Time from transplantation to recurrence and from recurrence to death was significantly longer in patients with multifocal BAC than in patients with other types of bronchogenic carcinoma. In addition, the site of recurrence was limited to the transplanted lung in 88% of the patients with multifocal BAC, whereas it was always widespread in patients with other types of bronchogenic carcinoma. Conclusion This study demonstrates that long-term survival can be achieved after lung transplantation in patients with stage I bronchogenic carcinoma or with advanced multifocal BAC.
Collapse
Affiliation(s)
- Marc de Perrot
- Toronto Lung Transplant Program, University of Toronto, Canada
| | | | | | | | | | | | | |
Collapse
|
31
|
de Perrot M, Chaparro C, McRae K, Waddell TK, Hadjiliadis D, Singer LG, Pierre AF, Hutcheon M, Keshavjee S. Twenty-year experience of lung transplantation at a single center: influence of recipient diagnosis on long-term survival. J Thorac Cardiovasc Surg 2004; 127:1493-501. [PMID: 15116013 DOI: 10.1016/j.jtcvs.2003.11.047] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The objective of this study was to examine the long-term patient outcomes of lung transplantation in a single center. METHODS Between 1983 and 2003, 521 lung transplants were performed in 501 patients. Major indications were cystic fibrosis (n = 124), chronic obstructive pulmonary disease (n = 88), alpha-1 antitrypsin deficiency (n = 63), pulmonary fibrosis (n = 97), primary pulmonary hypertension (n = 35), Eisenmenger syndrome (n = 21), and miscellaneous end-stage lung diseases (n = 93). RESULTS The 5-, 10-, and 15-year survivals for all recipients were 55.1% (95% confidence interval: +/-5%), 35.3% (+/-6%), and 26.5% (+/-11%), respectively. The most common causes of death were sepsis and bronchiolitis obliterans syndrome. Despite an increased postoperative mortality rate, patients with primary pulmonary hypertension achieved the best long-term survival (10-year survival: 59%). Recipients with cystic fibrosis without Burkholderia cepacia infection achieved significantly better long-term survival (10-year survival: 52%) than those with Burkholderia cepacia infection (10-year survival: 15%). The 10-year survival was also significantly better in recipients with chronic obstructive pulmonary disease (43%) than in recipients with alpha-1 antitrypsin deficiency (23%). Although the incidence of bronchiolitis obliterans syndrome was similar between recipients with chronic obstructive pulmonary disease (39%) and alpha-1 antitrypsin deficiency (46%), recipients with alpha-1 antitrypsin deficiency died of sepsis more frequently than recipients with chronic obstructive pulmonary disease (27% vs 6%, respectively; P =.0003). CONCLUSIONS Although bronchiolitis obliterans syndrome and sepsis still limit the durability of the benefit, lung transplantation returns many patients with end-stage lung disease to active and productive lives. Differences in the complications and long-term survival show the important contribution of the recipient diagnosis to the success of lung transplantation.
Collapse
Affiliation(s)
- Marc de Perrot
- Toronto Lung Transplant Program, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
32
|
Sekine Y, Waddell TK, Matte-Martyn A, Pierre AF, de Perrot M, Fischer S, Marshall J, Granton J, Hutcheon MA, Keshavjee S. Risk quantification of early outcome after lung transplantation: donor, recipient, operative, and post-transplant parameters. J Heart Lung Transplant 2004; 23:96-104. [PMID: 14734133 DOI: 10.1016/s1053-2498(03)00034-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Because there is no reliable evaluation system of recipient acuity after lung transplantation, comparing patients among centers is difficult. The purpose of our study was to identify risk factors for 30-day mortality and prolonged intensive care unit stay and to develop a scoring system to evaluate the severity of impairment and to predict surgical outcomes. METHODS We prospectively collected data from 122 lung transplant recipients and from 119 donors from January 1997 to June 2000. We assessed donor, recipient, and operative factors; ischemic time; and immediate post-operative physiologic parameters to identify risk factors for 30-day mortality and prolonged intensive care unit stay. Furthermore, we sub-classified these factors into grades to develop a scoring system for predicting surgical outcomes. RESULTS Cardiopulmonary bypass use, body mass index >25 kg/m2, immediate post-operative systolic pulmonary arterial pressure, trend of oxygenation index from 12 to 24 hours after transplantation, and the Acute Physiology and Chronic Health Evaluation II score correlated significantly with outcomes, and the sum of these 5 scores correlated strongly with outcomes (p < 0.0001). CONCLUSIONS We conclude that the total score of these 5 risk factors could be used to predict 30-day mortality and prolonged intensive care unit stay. This scoring system also will facilitate standardization among transplant centers in evaluating post-transplant severity of illness.
Collapse
Affiliation(s)
- Yasuo Sekine
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Abstract
BACKGROUND This study assesses the risk of bronchogenic carcinoma after solid organ transplantation. Although the overall incidence of malignancy is increased after solid organ transplantation, the risk of bronchogenic carcinoma in the transplant population has not been systematically studied. METHODS Among a cohort of 3,374 patients transplanted in our institution between 1985 and 2000 (1,735 kidney recipients, 930 liver, 313 heart, and 396 lung recipients), 9 patients (0.3%) had a bronchogenic carcinoma develop. Lung carcinoma occurred in 3 kidney recipients, 3 liver recipients, 2 heart recipients, and 1 lung recipient. RESULTS Time to diagnosis after the transplant procedure ranged from 9 to 126 months (mean, 63 months). Aside from the lung transplant candidate, all recipients had a smoking history. Seven patients underwent thoracotomy and 6 had a complete resection. Tumors were classified as stage IA (n = 1), IB (n = 2), IIB (n = 2), IIIA (n = 2), IIIB (n = 1), and IV (n = 1). Genotyping demonstrated that the carcinoma arising in the lung transplant recipient originated from the donor and may have been transmitted at the time of transplantation. Two patients were alive without recurrence 21 and 42 months after the operation. CONCLUSIONS The risk of bronchogenic carcinoma is low and occurs mainly in recipients with a smoking history. However, bronchogenic carcinoma can also be transmitted from donor lungs at the time of transplantation. Hence careful examination of chest roentgenograms, and computed tomographic chest scan if available, as well as meticulous assessment of the lung, and biopsy of any suspicious lesions, are important to limit the risk of lung cancer transmission, especially with the liberalization of donor criteria.
Collapse
Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
34
|
de Perrot M, Fischer S, Waddell TK, Strueber M, Harringer W, Pierre AF, Spiliopoulos A, Haverich A, Keshavjee S. Management of lung transplant recipients with bronchogenic carcinoma in the native lung. J Heart Lung Transplant 2003; 22:87-9. [PMID: 12531417 DOI: 10.1016/s1053-2498(02)00446-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Experience with lung transplantation for bronchogenic carcinoma is limited. In our experience, 3 of 6 patients died of recurrent carcinoma within 5 to 35 months after transplantation. Hence, we currently do not support lung transplantation for patients with pre-transplant diagnosis of bronchogenic carcinoma, with the exception of bronchioloalveolar carcinoma (BAC) confined to the lung. Patients with BAC should be staged thoroughly with chest and abdominal computerized tomography, brain magnetic resonance imaging, and bone scan repeated every 3 months while on the waiting list, and should undergo mediastinoscopy at the time of transplantation, with a plan for a backup recipient if metastatic lymph nodes are detected. Proposal for lung transplantation for patients with bronchogenic carcinoma, with the exception of BAC, probably should be performed in the setting of a clinical trial developed with input from the lung transplant community.
Collapse
Affiliation(s)
- M de Perrot
- Toronto Lung Transplant Program, Toronto General Hospital, University of Toronto, University Health Network, Toronto, Canada
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Pierre AF, Luketich JD, Fernando HC, Christie NA, Buenaventura PO, Litle VR, Schauer PR. Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients. Ann Thorac Surg 2002; 74:1909-15; discussion 1915-6. [PMID: 12643372 DOI: 10.1016/s0003-4975(02)04088-2] [Citation(s) in RCA: 174] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Giant paraesophageal hernias (GPEH) have traditionally required open operations. Increasingly, a laparoscopic approach is being applied to more complex esophageal surgery. Our objective was to update our growing experience with laparoscopic repair of GPEH. METHODS We performed a retrospective review at our institution of patients undergoing laparoscopic repair of GPEH from July 1995 to July 2001. The GPEH was defined as greater than one-third of the stomach in the chest. RESULTS Elective laparoscopic repair of a GPEH was attempted in 203 patients. Mean age was 67 years. The most common symptoms included heartburn (96 patients), dysphagia (72), epigastric pain (56), and vomiting (47 patients). Laparoscopic procedures included 69 Nissens, 112 Collis-Nissens, and 19 other procedures. There were three open conversions due to adhesions, but no intraoperative emergencies. Median length of stay was 3 days (range, 1 to 120 days). Minor or major complications occurred in 57 patients (28%). There were six postoperative esophageal leaks (3%), and 1 death. Median follow-up was 18 months. Five patients required reoperation for recurrent hiatal hernia. Excellent results were reported in 128 (84%) patients, 12 (8%) had a good result, 7 (5%) fair, and 5 (3%) poor (based on postoperative follow-up and GERD questionnaire). The mean postoperative GERD Health-related Quality of Life Score was 2.4 (scale 0 to 45; 0 = no symptoms, 45 = worst). CONCLUSIONS Laparoscopic repair of GPEH is possible in the majority of patients with acceptable morbidity, a median length of hospital stay of 3 days and excellent intermediate-term results in an experienced center.
Collapse
Affiliation(s)
- Andrew F Pierre
- Division of Thoracic Surgery and Minimally Invasive Surgery Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA
| | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
Esophagectomy remains the standard of care in most centers for patients with resectable esophageal cancer. The choice of incision and conduit has remained the subject of much discussion. Open surgical approaches include the Ivor Lewis, transhiatal, left thoracoabdominal, three-hole, and left thoracoabdominal with left neck anastomosis. These techniques will be covered in the article by. Regardless of the approach, esophagectomy has been associated with considerable morbidity and mortality. Although modern anesthetic and surgical care has reduced the risks of esophagectomy, the incidence of major or minor complications is still approximately 70% to 80%, and the hospital mortality rate is 4% to 7% at experienced centers. In the hopes of reducing perioperative morbidity, minimally invasive techniques have been increasingly applied to esophageal surgery. Experience with laparoscopic antireflux surgery has allowed us to perform more and more complex surgery on the stomach and esophagus and, in 1995, surgeons began to report their experiences with minimally invasive esophagectomy using various techniques.
Collapse
Affiliation(s)
- Andrew F Pierre
- Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA 15213, USA.
| | | |
Collapse
|
37
|
Abstract
OBJECTIVE Lung transplantation is limited by the shortage of suitable donors. To overcome this problem, many programs have begun to use marginal or extended donors after reports suggesting equivalent outcomes with no additional risk. As our use of extended donor lungs increased and our recipient selection criteria expanded, we believed it was appropriate to reevaluate outcomes with extended donor lungs compared with outcomes with standard donor lungs and recipients outside of the currently accepted guidelines. METHODS We performed a retrospective review of 128 consecutive lung or heart-lung transplants from January 1, 1997, to June 30, 2000. The primary endpoint was 30-day mortality. Donors were considered extended if any one of the following criteria were met: age greater than 55 years, smoking longer than 20 pack-years, presence of chest radiographic film infiltrate, PO (2) of less than 300 mm Hg, or purulent secretions on bronchoscopy. Guideline and nonguideline recipients were defined on the basis of previously published criteria. RESULTS Of a total of 123 donors, 63 (51%) were extended. Forty-eight donors failed 1 criterion, 10 failed 2 criteria, and 5 failed 3 criteria. One hundred twenty-eight transplants were performed. The 30-day mortality for the standard donor group was 4 (6.2%) of 65 versus 11 (17.5%) of 63 for the extended donor group (P =.047). CONCLUSIONS Although many extended donor lungs will result in acceptable postoperative function, caution needs to be exercised in the uses of certain extended donor lungs because there seems to be an increased early mortality rate in that group of recipients. Nonguideline recipients appear to have acceptable early mortality, except when they received extended donor lungs.
Collapse
Affiliation(s)
- Andrew F Pierre
- Toronto Lung Transplant Program, Toronto General Hospital, University of Toronto, 200 Elizabeth Street, EN 10-224, Toronto, Ontario M5G 2C4, Canada
| | | | | | | | | |
Collapse
|
38
|
Abstract
We report on a case of successful bilateral sequential lung transplantation using a donor with the right upper lobe bronchus arising from the trachea. After en-bloc donor lung retrieval, the right bronchial stump was fashioned to create one lumen including the bronchus intermedius and the aberrant right upper lobe bronchus. A carinoplasty was performed in the recipient with resection of a portion of the lateral wall of trachea. The anastomosis was completed using a telescoping technique without any complication. This case demonstrates the possibility of successfully using donor lungs with such anatomic abnormality for transplantation.
Collapse
Affiliation(s)
- Yasuo Sekine
- Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
| | | | | | | | | |
Collapse
|
39
|
Liu M, Tremblay L, Cassivi SD, Bai XH, Mourgeon E, Pierre AF, Slutsky AS, Post M, Keshavjee S. Alterations of nitric oxide synthase expression and activity during rat lung transplantation. Am J Physiol Lung Cell Mol Physiol 2000; 278:L1071-81. [PMID: 10781440 DOI: 10.1152/ajplung.2000.278.5.l1071] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Decreased nitric oxide (NO) production has been reported during lung transplantation in patients. To study the effects of ischemia and reperfusion on endogenous NO synthase (NOS) expression, both an ex vivo and an in vivo lung injury model for transplantation were used. Donor rat lungs were flushed with cold low-potassium dextran solution and subjected to either cold (4 degrees C for 12 h) or warm (21 degrees C for 4 h) ischemic preservation followed by reperfusion with an ex vivo model. A significant increase in inducible NOS and a decrease in endothelial NOS mRNA was found after reperfusion. These results were confirmed in a rat single-lung transplant model after warm preservation. Interestingly, protein contents of both inducible NOS and endothelial NOS increased in the transplanted lung after 2 h of reperfusion. However, the total activity of NOS in the transplanted lungs remained at very low levels. We conclude that ischemic lung preservation and reperfusion result in altered NOS gene and protein expression with inhibited NOS activity, which may contribute to the injury of lung transplants.
Collapse
Affiliation(s)
- M Liu
- Thoracic Surgery Research Laboratory, Toronto General Hospital, Toronto M5G 2C4, Canada.
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
OBJECTIVE Rapid reperfusion may be injurious to the ischemic lung. Our aim was to confirm that slow reperfusion improves postischemic pulmonary function and to elucidate the ultrastructural changes associated with slow versus rapid reperfusion. METHODS. We used an ex vivo perfused rat lung transplant model to study the effect of slow versus rapid reperfusion on subsequent lung function and morphologic conditional. Functional assessment was performed in (1) fresh lung, slowly reperfused; (2) fresh lung, rapidly reperfused; (3) ischemic lung (4 hours at 22 degrees C), slowly reperfused; and (4) ischemic lung, rapidly reperfused. RESULTS In group 4, the shunt fraction (P=.001), airway pressure (P=.001), and wet/dry ratio (P=.01) were significantly higher than in groups 1 through 3. Light and electron microscopy of slowly reperfused ischemic lungs (n=4) appeared normal. Rapidly reperfused ischemic lungs (n=4) demonstrated massive alveolar edema hemorrhage, and epithelial "blebbing" by light microscopy. Electron microscopy identified the blebbing as separation of the epithelial layer from an intact basement membrane by edema fluid. The epithelial layer was disrupted in numerous locations. Complete disruption of all layers of the blood-gas barrier was occasionally present. CONCLUSION Rapid reperfusion of the ischemic lung is an important contributing factor to reperfusion lung injury resulting in mechanical stress failure of the alveolar/capillary barrier. Gradual reintroduction of blood flow to the ischemic lung improves oxygenation.
Collapse
Affiliation(s)
- A F Pierre
- Division of Thoracic Surgery, The Toronto Hospital; the Department of Pathology, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | | | | | | |
Collapse
|
41
|
Pierre AF, Xavier AM, Liu M, Cassivi SD, Lindsay TF, Marsh HC, Slutsky AS, Keshavjee SH. Effect of complement inhibition with soluble complement receptor 1 on pig allotransplant lung function. Transplantation 1998; 66:723-32. [PMID: 9771835 DOI: 10.1097/00007890-199809270-00006] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lung dysfunction after transplantation continues to be a significant clinical problem. Soluble complement receptor 1 (sCR1) is a potent inhibitor of complement activation. We evaluated the inhibitory effect of sCR1 on complement activation and reperfusion injury in pig lung allografts. METHODS In a randomized and blinded study, left lung transplantation was performed in 13 pigs. Donor lungs were flushed and then stored for 30 hr at 4 degrees C. Control pigs (n=7) received saline, and the treatment group (n=6) received 15 mg/kg sCR1 1 hr before reperfusion. One hour after reperfusion, the right pulmonary artery was clamped for 10 min to assess the function of the transplanted lung. Pulmonary function was assessed again on day 3. RESULTS Complement inhibition was 93% in the sCR1 group and returned to baseline (8% inhibition) after 3 days. There was a trend toward a higher partial pressure of oxygen at 1 hr in the sCR1 group compared with the control group (mean +/- SE: 408+/-42 mmHg vs. 288+/-69 mmHg, P = 0.19). Alveolar ventilation was better in the sCR1 group than in the control group (P = 0.01) at 1 hr. Mixed venous saturation was significantly lower in the control group at both 1 hr (P = 0.02) and 3 days (P = 0.001). The wet/dry weight of the lung tissue was lower in the sCR1 group compared with the control group on day 3 (P < 0.05). Chemiluminescence, an index of phagocyte priming, was lower in the sCR1 group when cells were stimulated with complement opsonized zymosan but not when stimulated with zymosan or phorbol myristate acetate. CONCLUSION sCR1 improves ventilation, reduces pulmonary edema, and may be beneficial in improving posttransplant lung oxygenation.
Collapse
Affiliation(s)
- A F Pierre
- Division of Thoracic Surgery, The Toronto Hospital, Ontario, Canada
| | | | | | | | | | | | | | | |
Collapse
|