Ann Thorac Surg 2001;72:1154
© 2001 The Society of Thoracic Surgeons
Invited commentary
Jean Deslauriers, MD, FRCS(C)a
a Centre de Pneumologie de l’Hôpital Laval, Thoracic Surgery 2725, Chemin Sainte-Foy, Sainte-Foy, QC G1V 4G5, Canada
In this paper, Martin and associates analyze the risk of pulmonary resection done for lung cancer in the context of induction (neoadjuvant) therapy. The number of cases included in the series is very significant and is certainly a tribute to the pioneer work in this field of Dr Nael Martini. Overall, the operative mortality (3.8%) and morbidity (38.1%) are similar to what would be expected after pulmonary resection done without induction chemoradiation.
Obviously, the real "eye-opener" in this paper and undoubtedly the main reason as to why the editor of the Annals of Thoracic Surgery asked me to write this commentary is the unusually high operative mortality associated with right pneumonectomy (11 of 46 patients, 23.9%).
As has often been said by Dr Harold C. Urschel Jr, pneumonectomy is "a disease" in itself, and from my point of view, right pneumonectomy is a "very bad disease" when compared to left pneumonectomy or lesser resections. This relates to the resection of more lung parenchyma (versus left pneumonectomy) resulting in added stress being placed on the right heart. In addition, due to more limited vascular supply, the right main bronchus is more susceptible than the left to dehiscence. In patients who have received induction treatments, additional factors that are likely to increase the risk of lung injury include more extensive nodal dissection and pulmonary toxicities of chemotherapy drugs such as mitomycin.
Clearly an operative mortality of 24% is huge, especially when surgeons working in one of the best cancer centers in the world report it. Does this mean that one should stop doing right pneumonectomy? Obviously, the answer is no because for some individuals it is the only available option if one is to completely resect the cancer. There are, however, a variety of options that can be looked at in order to decrease the likelihood of pulmonary deaths after right pneumonectomy done in the context of induction therapies. These include the use of sleeve resections or bronchovascular reconstructions instead of pneumonectomy whenever possible, avoidance of chemotherapy drugs known to have pulmonary toxicities, avoidance of oxygen which can act in synergy with drugs to create lung damage, reinforcement of all right main bronchus stump with autologous tissue, and use of prophylactic steroids over a short period of time. One should also try to avoid fluid overload although the relationship between overhydratation and postpneumonectomy edema is still unclear.
Related Article
-
Morbidity and mortality after neoadjuvant therapy for lung cancer: the risks of right pneumonectomy
- Jocelyne Martin, Robert J. Ginsberg, Amir Abolhoda, Manjit S. Bains, Robert J. Downey, Robert J. Korst, Tracey L. Weigel, Mark G. Kris, Ennapadam S. Venkatraman, and Valerie W. Rusch
Ann. Thorac. Surg. 2001 72: 1149-1154.
[Abstract]
[Full Text]
[PDF]
