Clinical patterns and trends of outcome of elderly patients with bronchogenic carcinoma.

OBJECTIVE: To investigate the clinical characteristics and determinants of operative mortality and long-term survival of elderly patients submitted to pulmonary resection for intended cure of lung cancer. METHODS: Retrospective analysis of 500 consecutive pulmonary resections performed in patients aged over 70 years from 1975 to 1996. Predictors of in-hospital mortality were identified by univariate and multivariate analyses. Determinants of long-term outcome were investigated in all survivors, with no patient being lost to follow-up. RESULTS: Mean age was 74 +/- 3 years (maximum: 90), and 36 patients were octogenarians. The sex-ratio M:F was 5:3. History of combined cardiovascular or previous neoplastic disease was noted in 193 and 63 patients, respectively. The predominant histology was squamous cell carcinoma (n = 243), with a significantly higher incidence in male than in female. Most patients received standard procedures, while 103 patients underwent extended resections for tumors involving the mediastinum (n = 44), the chest wall (n = 33), the carina (n = 2) or had a sleeve resection of the main bronchus (n = 24). Procedures were considered to be complete and curative in 459 patients, among whom 294 had a stage I disease. There were 37 (7.4%) in-hospital deaths. Mortality rates following pneumonectomy, bilobectomy, lobectomy and lesser resection were 11:136, 4:34, 22:291, and 0:39, respectively. Age, male gender, hypertension, low FEV1 and extended procedure were identified as independent predictors of early mortality. Overall survival rates were 33.7 and 12% at 5 and 10 years, respectively. Multivariate analysis demonstrated that the disease stage was the main prognosticator. During the follow-up period, cancer recurrence (n = 183; 39.5%) or second primary lung cancer (n = 20; 4.3%) occurred in 203 patients, among whom 18 (9%) had a second lung resection. Carcinoma in other systems occurred in 25 patients (5.3%), and major cardiovascular event in 51 (11%). CONCLUSIONS: Male and squamous cell carcinoma are characteristic of elderly patients with resected lung cancer. Operative mortality is acceptable for standard resection, and survival figures are concordant with those reported in other series which include younger patients.

Survival related to nodal status after sleeve resection for lung cancer.

Sleeve lobectomy is a lung-saving procedure indicated for central tumors for which the alternative is a pneumonectomy. The relation between survival and nodal status is controversial because, in most series, the presence of N1 disease adversely affects the prognosis with few or no long-term survivors. During the period 1972 to 1992, 142 patients underwent sleeve resection for lung cancer at our institution. Mean age (+/- standard deviation) was 60.7 +/- 9.1 years (range 11 to 78 years), and indications for operation were a central tumor in 112 patients (79%), a peripheral tumor in 18 patients (13%), and compromised pulmonary function in 12 patients (8%). Histologic type was predominantly squamous (72.5%) followed by nonsquamous (24.6%) and carcinoid tumors (2.8%). Resection was complete in 124 patients (87%) and incomplete in 18 (13%), and the operative mortality was 2.1% (n = 3). Follow-up was complete for the 139 remaining patients. Including operative deaths, survivals at 5 and 10 years for all patients were 46% (95% confidence intervals 38% to 55%) and 33% (95% confidence intervals 24% to 42%), respectively. For patients with N0 status (n = 73), 5- and 10-year survivals were 57% (95% confidence intervals 45% to 69%) and 46% (95% confidence intervals 32% to 60%); for patients with N1 status (n = 55), these rates were 46% (95% confidence intervals 32% to 60%) and 27% (95% confidence intervals 14% to 40%) (p = 0.13). No patient with N2 status (n = 14) survived 5 years. Local recurrences occurred in 23% of cases, but the prevalence was not statistically different between patients with N0 disease (16.6%) and N1 disease (23.1%) (p = 0.43). These data suggest that sleeve resection is an adequate operation for patients with resectable lung cancer and N0 N1 status. The presence of N2 disease significantly worsens the prognosis and may contraindicate the use of the procedure.

Current operative morbidity associated with elective surgical resection for lung cancer.

To determine the current operative morbidity for elective surgery of lung cancer, the authors reviewed the charts of 1076 consecutive patients who underwent pulmonary resection between 1978 and 1984 at two major Canadian teaching hospitals. Of these patients, 731 (68%) had a normal course. Minor complications occurred in 206 patients (19%); the majority were supraventricular arrhythmias (100 events) and atelectasis (41 events). Nonfatal major complications occurred in 105 patients (9.8%). The overall operative death rate was 3.2%. If supraventricular arrhythmias are excluded, nearly 80% of patients had a smooth postoperative course. In order to correlate the occurrence of complications with pre- and perioperative data, several possible risk factors were analysed. For major complications and death, the age, the forced expiratory volume, weight loss, coexisting disease, stage of cancer and extent of resection were significant risk factors (p less than 0.05). The data show that elective pulmonary surgery can be done safely and complications prevented. The necessary requirements are: proper selection of patients, a well-performed operation and prompt treatment of potential problems.

Carcinoma of the lung. Evaluation of satellite nodules as a factor influencing prognosis after resection.

Satellite nodules are considered to be predictive of poor prognosis in breast cancer and in melanoma. In lung cancer, there is no information as to their definition, prevalence, or implication as a prognosis factor of survival after resection. Over the past 18 years (1969 to 1987), 84 patients underwent pulmonary resection for primary lung cancer accompanied by satellite nodules. These nodules were defined as well-circumscribed accessory carcinoma foci clearly separated from the main tumor but with identical histologic characteristics. All were smaller than the primary carcinoma and most were located within the same lobe. Survival rates of patients with satellite nodules were compared to those of 1021 patients without satellite nodules who underwent resection during the same time interval. The 1-, 3-, and 5-year survival rates for all patients classified as having no satellite nodules were 78%, 54%, and 44%, respectively, and the median survival for the entire group was 30 months. In patients with satellite nodules, these survival rates were 60.9%, 32.7%, and 21.6%, respectively, with a median survival of 15 months. The deleterious effect of satellite nodules was more significant in patients with stage I disease (p = 0.0008) than in patients with stage II (p = 0.0354) or stage III (p = 0.0145) disease. Survival data obtained by comparison of satellite nodule status and histologic characteristics shows that 5-year survival figures are better for patients with no satellite nodules in both the squamous and the nonsquamous groups. This study demonstrates that satellite nodules associated with lung cancer are indicative of locally advanced and/or premetastatic disease. These patients should be included in the stage group IIIa of the TNM stage grouping classification.

[Multiple primary lung cancers. The importance of early diagnosis and survival after a new surgical excision]. / Le cancer broncho-pulmonaire successif. Importance du diagnostic précoce et survie après nouvelle exérèse chirurgicale.

In a series of 1.025 consecutive resections for bronchogenic carcinoma, 68 patients developed a second primary lung cancer identified as the first site of recurrence (median interval of 38 months). Thirty-nine patients (57%) were asymptomatic (detection by chest-X-Ray (N: 28] or sputum cytology (N: 11) and 22 had one or more symptoms. A reoperation was possible in 50% (N: 34) of all patients with an operative (30 day) mortality of 14.7% (5/34) as compared to 3.5% (26/1.025) for the first procedure. Cumulative survival following the second resection was 33% at 5 years while no inoperable patient survived longer than three years. Clinical presentation of the second carcinoma is a significant prognostic variable since no symptomatic patient survived more than two years while 30% of the asymptomatic group survived 5 years (p less than 0.021).

Thoracoplasty: its forgotten role in the management of nontuberculous postpneumonectomy empyema.

The role of thoracoplasty in the management of empyema complicating pneumonectomy is controversial because alternative techniques, such as pedicled muscle transplants or open-space sterilization, have now replaced the conventional collapse procedures. Among 46 patients treated for postpneumonectomy empyema during the years 1975 to 1984, 17 underwent space-reducing thoracoplasty as the final step in pleural space management. Technical considerations, critical in the success of the operation, were: (a) single-stage extramusculoperiosteal resection of the second to the seventh rib, (b) sparing of the first rib to maintain integrity of the neck and shoulder girdle, (c) intercostal muscle closure of large fistulas and (d) adequate drainage of pleural and extrapleural spaces. Immediate control of the empyema was obtained in 15 (88%) patients. Fourteen patients were alive at the time of follow-up (mean 4.5 years) and none had major thoracic deformity or residual infection. Our data show that thoracoplasty is an excellent therapeutic option for patients with chronic postpneumonectomy empyema. Adherence to strict surgical principles ensures that the space is obliterated and the cosmetic result is satisfactory.

Long-term clinical and functional results of sleeve lobectomy for primary lung cancer.

Sleeve lobectomy is a lung-saving operation in which a portion of main bronchus is removed in continuity with the involved lobe to preserve distal parenchyma. Current controversies relate to indication and safety of the procedure, adequacy as a cancer operation, and contribution of the reimplanted lobe to overall remaining lung function. Between 1975 and 1985, sleeve lobectomy was done electively in 72 patients with lung cancer. There were no operative deaths, but major complications occurred in 10% of patients. Most resected carcinomas were squamous (65/72). Complete resection was performed in all but five patients. A minimum of 1 year's follow-up information was available for all patients. For patients with N0 disease (n = 34) the cumulative 5 year survival rate was 67%, and for patients with N1 status (n = 34) it was 60%. Although postoperative pulmonary function studies at 5 years (n = 19) show subnormal values, they were not severely altered with regard to percent of predicted (forced vital capacity, 85.9% +/- 17.5%; forced expiratory volume in 1 second, 74.9% +/- 19.4%). Regional function was determined by ventilation/perfusion isotope scanning methods. For 15 patients with right lung bronchoplasties, perfusion ratios were 41.1% right lung/58.9% left lung. For four patients with left sleeve operations, these ratios were 29.3% left lung/51.7% right lung. Washout curves show comparable ventilation between the reimplanted lobe and the contralateral lung. The data show that sleeve lobectomy is a safe and adequate operation for patients with resectable lung cancer. The reimplanted lobe or lobes contribute significantly to the overall remaining lung function.

Role of mediastinoscopy in pretreatment staging of patients with primary lung cancer.

Since the introduction of mediastinoscopy, there has been a great deal of discussion regarding indications for this technique and the significance of positive findings. We undertook this study to determine the role of clinical staging and the value of routine mediastinoscopy in the treatment selection of patients with primary lung cancer. From 1975 to 1983, 1,259 consecutive patients with proven and operable lung cancer underwent preresection mediastinoscopy. Nodes were sampled at three levels, and findings were recorded by location, invasiveness, and histology. There were no operative deaths, but 3 patients had a major complication. Mediastinoscopy was positive in 339 (27%) patients and negative in 920 (73%). In the group with positive findings, 303 patients had no operation because a curative resection was not possible (extranodal metastases, 180; location, 76; histology, 47). No patient survived 5 years, and only 4% survived 2 years. Of the 36 patients considered to have operable disease, 28 underwent resection with a projected 5-year survival of 18%. In the group with negative findings, 89% had a curative resection with a hospital mortality of 3.2% and 5-year survival of 53%. When results of mediastinoscopy were correlated with findings at thoracotomy, the sensitivity of the test was 93% on nodes in the superior mediastinum and the specificity, 100%. This study shows that mediastinoscopy is safe and is an accurate indicator of the presence or absence of tumor in superior mediastinal nodes. If positive nodes are found, a curative resection is generally not possible, thoracotomy is avoided, and the overall survival is low.

High-flow catheter ventilation during major tracheobronchial reconstruction.

Anesthetic management during tracheobronchial reconstruction is a concern to the anesthetist, who must maintain satisfactory gas exchange while ensuring adequate exposure to the trachea. The technique for high-flow catheter ventilation was first described for bronchoscopy, and it involves positive-pressure breathing with a high flow (40 to 60 L/min) of oxygen. This flow is directed to a semirigid catheter inserted in the endotracheal tube and around which the tracheobronchial anastomosis can be done without interruption. The value of the technique was tested in 18 patients undergoing tracheobronchial reconstructions. Patients' ages ranged from 22 to 69 years and the average duration of catheter ventilation was 35 minutes. Regardless of the duration of high-flow catheter ventilation good arterial blood gas values were maintained in all patients. In six patients, the average oxygen tension (measured at 5 minute intervals) was 416 mm Hg and the average carbon dioxide tension was 34 mm Hg. One patient developed surgical emphysema during the procedure. The high-flow catheter ventilation provides specific advantages during tracheobronchial procedures: avoidance of endotracheal manipulations, unobstructed field during surgical reconstruction, and good oxygenation throughout the procedure.

Diagnosis and management of synchronous lung cancers.

The findings in 28 patients with synchronous lung cancers are reviewed. Mediastinoscopy and systemic staging were performed to exclude the possibilities that one pulmonary lesion was metastatic from the other or that both represented systemic metastases from another tumor. Nineteen patients underwent resection of both tumors. Median survival was 25 months for four patients with definite Stage I synchronous cancers (no nodal involvement; different cell types, bronchoscopically separate endobronchial lesions or arising from separate foci of carcinoma in situ) and was 27 months for seven patients with possible synchronous Stage I cancers (no nodal involvement; similar cell types; located in separate lobes). Median survival was 11 months for 16 patients having Stage II or III lung cancer accompanied by a second synchronous lung cancer. In the absence of hilar or mediastinal nodal involvement and systemic metastases, synchronous tumors should be considered separate primaries when located in different lobes, even if they have similar histologic features. Prognosis of synchronous cancers is related to the presence or absence of nodal metastases. Pneumonectomy is the operation of choice for synchronous unilateral tumors. With bilateral tumors, sequential resection starting with the most advanced lesion is appropriate. Preservation of lung tissue without compromising the cancer operation is critical.

Tracheal sleeve pneumonectomy for carcinomas of the proximal left main bronchus.

Although most primary cancers of the left main bronchus extending to the carina are inoperable, some patients with such a tumour may benefit from an extended, curative surgical procedure. This type of resection presents specific problems in reconstruction and physiologic management during operation. Between 1977 and 1983, five such patients were managed by left pneumonectomy followed by resection of the carina. They ranged in age from 49 to 65 years. None were irradiated before the procedure. In all cases, an end-to-end anastomosis was made between the right main bronchus and the mediastinal trachea. The high-flow catheter technique was used for ventilation during reconstruction. There were no operative deaths. Excessive bronchorrhea was noted in all patients and was aggravated by left recurrent nerve palsy in two. This report indicates that modern techniques of tracheobronchial reconstruction can be successfully applied in patients with locally advanced carcinoma of the proximal left main bronchus. This type of resection may be the treatment of choice in selected cases.