Role of conventional pulmonary function tests and cardiopulmonary exercise test in the prediction of postoperative cardiopulmonary complications in high risk thoracic cancer patients / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To evaluate and compare the value of cardiopulmonary exercise test and conventional pulmonary function tests in the prediction of postoperative cardiopulmonary complications in high risk patients with chest malignant tumors.</p><p><b>METHODS</b>From January 2006 to January 2009, 216 consecutive patients with thoracic malignant tumors underwent conventional pulmonary function tests (PFT, spirometry + DLCOsb for diffusion capacity) and cardiopulmonary exercise test (CPET) preoperatively. The correlation of postoperative cardiopulmonary complications with the parameters of PFT and CPET were retrospectively analyzed using Chi-square test, independent sample t-test and logistic regression analysis. The P value < 0.05 was considered as statistically significant.</p><p><b>RESULTS</b>Of the 216 patients, 57 did not receive operation due to advanced stage diseases or poor cardiopulmonary function in most of them. The remaining 159 underwent different modes of operations. Thirty-six patients (22.6%) in this operated group had postoperative cardiopulmonary complications and 10 patients (6.3%) developed operation-related complications. Three patients (1.9%) died of the complications within 30 days postoperatively. The patients were stratified into groups based on V(O(2)) max/pred (≥ 65.0%, < 65.0%); V(O(2)) max×kg(-1)×min(-1) (≥ 20 ml, 15 - 19.9 ml, < 15 ml) and FEV1 (≥ 2.0 L, 1.2 - 1.99 L, < 1.2 L) according to the criteria in reported papers. There was statistically significant difference among these groups in the parameters (P < 0.05), the rates of postoperative cardiopulmonary complications were much higher in the groups with poor cardiopulmonary function (V(O(2)) max/pred < 65.0%; V(O(2)) max×kg(-1)×min(-1) < 15 ml or FEV1 < 1.2 L). It was shown by logistic regression analysis that postoperative cardiopulmonary complications were significantly correlated with age, associated diseases, poor results of PFT or CPET, operation modes and operation-related complications.</p><p><b>CONCLUSIONS</b>FEV1 in spirometry, V(O(2)) max×kg(-1)×min(-1) and V(O(2)) max/pred in cardiopulmonary exercise test can be used to stratify the patients' cardiopulmonary function status and is correlated well with FEV1. V(O(2)) max×kg(-1)×min(-1) is the best parameter among these three parameters to predict the risk of postoperative cardiopulmonary complications in patients with chest malignant tumors and borderline cardiopulmonary function.</p>

Comparison of the results of lymph node dissection via left versus right thoracotomy / 中华肿瘤杂志

<p><b>OBJECTIVE</b>Up to now surgical treatment has been still the most effective treatment for esophageal cancer. However, postoperative lymph node recurrence is still a frequent event and affects long term survival considerably. The aim of this study is to compare the results of lymph node dissection via left vs. right thoracotomies and to verify whether there is any essential difference in lymphadenectomy between these two approaches.</p><p><b>METHODS</b>Five hundred and fifty-nine cases with thoracic esophageal cancer were randomly selected from the database of esophageal cancer patients who underwent surgical treatment in our hospital between May 2005 and January 2011, including 282 cases through left thoracotomy and 277 cases through right thoracotomy. This series consisted of 449 males and 110 females with a mean age of 58.8 years (age range: 36 - 78 years). The pathological types were mainly squamous cell carcinoma (548 cases) and other rare types (11 cases). The data were analyzed and compared using Chi-square test. The P-value < 0.05 was considered as statistically significant. The actual 5-year survival rate was calculated based on the recent follow-up data of the patients who underwent surgery at least 5 years ago.</p><p><b>RESULTS</b>The average number of dissected lymph nodes was 23.4 via left versus 24.6 via right thoracotomies. The overall lymph node metastasis rate was 48.9% via left thoracotomy and 53.8% via right thoracotomy, and 34.8% vs. 50.5% in the chest (P < 0.001), 29.1% vs. 17.7% in the abdomen (P = 0.001). The pathologically confirmed lymph node metastasis rate was 45.9%, 44.0% and 34.9% in the upper, middle and lower segments of thoracic esophagus, respectively. The lymph node metastasis rates detected via left and right thoracotomy in the stage T1 cases were 14.7% (5/34) vs. 42.9% (12/28) (P < 0.001), and in the stage T2 cases were 35.4% (17/48) vs. 52.8% (28/53) (P = 0.007); in the station of para-thoracic esophagus were 9.6% vs. 13.4%, in the left upper mediastinum were 2.1% vs. 7.6%, and in the right upper mediastinum were 1.4% vs. 26.0%, respectively. The preliminary actual 5-year survival rate was 38.2% in the cases via left thoracotomy vs. 42.1% in those via right thoracotomy.</p><p><b>CONCLUSIONS</b>The results of this study demonstrate that lymph node dissection is more complete via right thoracotomy than via left thoracotomy, especially for the tracheoesophageal groove and para-recurrent laryngeal nerve nodes, which may eventually improve the survival of patients with esophageal cancer. Therefore, surgical treatment via right thoracotomy by Ivor-Lewis (two incisions) mode or Levis-Tanner (three incisions) mode with two-field or three-field complete lymph node dissection may become prevalent in the future.</p>

Cardiopulmonary exercise testing in the evaluation of high risk patients with lung cancer / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>It is still unclear whether pulmonary function tests (PFTs) are sufficient for predicting perioperative risk, and whether all patients or only a subset of them need a cardiopulmonary exercise test (CPET) for further assessment. Thus, this study was designed to evaluate the CPET and compare the results of CPET and conventional PFTs to identify which parameters are more reliable and valuable in predicting perioperative risks for high risk patients with lung cancer.</p><p><b>METHODS</b>From January 2005 to August 2008, 297 consecutive lung cancer patients underwent conventional PFTs (spirometry + single-breath carbon monoxide diffusing capacity of the lungs (DLCOsb) for diffusion capacity) and CPET preoperatively. The correlation of postoperative cardiopulmonary complications with the parameters of PFT and CPET was retrospectively analyzed using the chi-square test, independent sample t test and binary Logistic regression analysis.</p><p><b>RESULTS</b>Of the 297 patients, 78 did not receive operation due to advanced disease stage or poor cardiopulmonary function. The remaining 219 underwent different modes of operations. Twenty-one cases were excluded from this study due to exploration alone (15 cases) and operation-related complications (6 cases). Thus, 198 cases were eligible for evaluation. Fifty of the 198 patients (25.2%) had postoperative cardiopulmonary complications. Three patients (1.5%) died of complications within 30 postoperative days. The patients were stratified into groups based on VO(2)max/pred (≥ 70.0%, < 70.0%); VO(2)max×kg(-1)×min(-1) (≥ 20.0 ml, 15.0 - 19.9 ml, < 15.0 ml) and FEV1 (≥ 2.0 L, 1.2 - 1.99 L, < 1.2 L), respectively. The rate of postoperative cardiopulmonary complications was significantly higher in the group with VO(2)max/pred< 70.0% or VO(2)max×kg(-1)×min(-1) < 15.0 ml or FEV1 < 1.2 L than that in the group with VO(2)max/pred ≥ 70.0% or VO(2)max×kg(-1)×min(-1) ≥ 15.0 ml or FEV1 ≥ 1.2 L, respectively. Logistic regression analysis revealed that postoperative cardiopulmonary complications were significantly correlated with age, comorbidities, and poor PFT and CPET results.</p><p><b>CONCLUSIONS</b>FEV1 in spirometry, VO(2)max×kg(-1)×min(-1) and VO(2)max/pred in cardiopulmonary exercise tests can all be used to stratify the patients' cardiopulmonary function status and to predict the risk of postoperative cardiopulmonary complications for the high risk patients with lung cancer. FEV1 and VO(2)max×kg(-1)×min(-1) are better than VO(2)max/pred in predicting perioperative risk. If available, cardiopulmonary exercise testing is strongly suggested for high-risk lung cancer patients in addition to conventional pulmonary function tests, and both should be combined to assess cardiopulmonary function status.</p>

Treatment and prevention of bronchus-pleural fistula after pneumonectomy for lung cancer / 中华外科杂志

<p><b>OBJECTIVE</b>To explore the methods of the treatment and the principles of the prevention of bronchus-pleural fistula (BPF) after pneumonectomy.</p><p><b>METHODS</b>The clinical data of 15 cases of BPF after pneumonectomy in 815 lung cancer cases treated from July 1999 to June 2006 were analyzed retrospectively.</p><p><b>RESULTS</b>The occurrence rate of BPF after right pneumonectomy was 3.9% (12/310), higher than 0.6% (3/505) of left pneumonectomy (P < 0.01). The occurrence rate of BPF in cases with positive cancer residues in stump of bronchus was 22.7% (5/22), higher than 1.3% (10/793) of the cases with negative stump of bronchus (P < 0.01). The occurrence rate of BPF in the cases received preoperative radio- or chemotherapy was 5.0% (6/119), higher than 1.3% (9/696) of the cases received operation only (P < 0.05). There were no BPF occurred in the 76 cases whose bronchial stump were covered with autogenous tissues. All of the cases diagnosed as BPF were undertaken either closed or open chest drainage. Two cases were cured by thoracentesis aspiration and infusion antibiotics repeatedly. Two cases were cured by blocking the fistula with fibrin glue after sufficient anti-inflammatory treatment and hypertonic saline flushing. Six cases were discharged with a stable condition after closed drainage only. One case was discharged with open drainage for long time and 1 case was cured by hypertonic saline flushing after failure to cover the BPF using muscle flaps. Three cases died of multi-organs functional failure.</p><p><b>CONCLUSIONS</b>BPF are related to the bronchial stump management and positive or negative residue of tumor at the bronchial stump. Autogenous tissues covering of the bronchial stump is a effective method for decrease the rate of BPF and especially for those patients received preoperative radio- or chemotherapy and right pneumonectomy. It should be performed for early mild cases with repeated thoracentesis aspirations or blocking the fistula with fibrin glue together with antibiotics. Chest closed drainage immediately and flushing with hypertonic saline repeatedly are effective methods for BPF.</p>

Surgical therapeutic strategy for non-small cell lung cancer with (N2) mediastinal lymph node metastasis / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To evaluate the surgical therapeutic strategy for non-small cell lung cancer (NSCLC) with (N2) mediastinal lymph node metastasis.</p><p><b>METHODS</b>The clinical data of 325 patients with N2 NSCLC treated surgically between 1961 and 1995 were analysed.</p><p><b>RESULTS</b>The over-all 5-year survival rate was 19.6%. Survival was higher in patients with radical resection than with palliative resection, with squamous-cell carcinoma than with adenocarcinoma, with sleeve lobectomy and pneumonectomy than with regular lobectomy, with 1 to 3 mediastinal metastatic lymph nodes than those over 4, and with adjuvant therapy (chiefly postoperative radiotherapy) than without. All these differences were statistically significant (P < 0.05). There was no 5-year survivor in patients with T3 or T4 tumor, nor in those with distant metastasis.</p><p><b>CONCLUSION</b>It is suggested that surgery is the best choice for N2 NSCLC patients with T1 or T2 tumor, with non-adenocarcinoma, and with metastatic mediastinal lymph nodes less than 4 in number. Surgery is probably not a good choice in those with T3 tumor varieties. At operation, radical resection of the tumor and systematic removal of all hilar and mediastinal lymph nodes are essential for disease staging and survival improvement. Adjuvant therapy may improve long-term survival and is especially indicated in patients with residual tumor and/or metastatic mediastinal lymph nodes over 3 in number.</p>