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Ann Thorac Surg 2005;79:385-386
© 2005 The Society of Thoracic Surgeons
Servei de Cirurgia, IMAS, PS Maritim, 25-29, Barcelona, BA 08003, Spain
95183{at}imas.imim.es
To the Editor:
Alexiou and co-workers [1] warned about the adverse effect that pneumonectomy (versus lesser resection) exerted on the long-term survival of 485 patients operated on for stage I primary non–small cell lung cancer (N–SCLC). Differences were significant in the univariate and multivariate analyses. Previously, Ferguson and Karrison [2] analyzed the results in 442 patients undergoing operation for stages I through III primary N–SCLC. Lesser long-term survival after pneumonectomy (versus lobectomy or bilobectomy) was significant in the univariate analysis, but not in the multivariate analysis. It was not completely clear whether the difference in survival simply reflected a higher mortality after pneumonectomy or whether some other factor or factors (eg, poorer remaining respiratory function or different rate of local or systemic recurrence or both) might also be implicated. Nevertheless, because complete resection remains the gold standard of operations for lung cancer (which sometimes makes pneumonectomy unavoidable), the question remains how to reduce morbidity and mortality after lung resection.
Pastorino and colleagues [3], writing for the International Registry of Lung Metastases, reported less postoperative mortality among 5,206 patients having surgical intervention for lung metastases. Possibly, a higher rate of comorbidity related to tobacco abuse (eg, chronic obstructive pulmonary disease and coronary or peripheral artery insufficiency or both), which often accompanies primary N–SCLC, makes the difference. Other high-risk factors are advanced age, diabetes mellitus, hypertension, chronic heart failure, and chronic failure of any other organ or system.
Postoperative risk of death after lung resection in the presence of coexisting chronic obstructive pulmonary disease has been accurately stratified [4]. Yet, the additive effect of several coexisting risk factors, which sometimes do not contraindicate surgical intervention one by one, is not known with precision. We suggest that with a more accurate stratification of surgical risk when multiple comorbid illnesses are present, a new subgroup or new subgroups with a very high risk or a prohibitive risk might be defined. For such patients, lung resection should be performed with maximum caution or should even be denied. It is possible that postoperative morbidity and mortality resulting from lung resection might be reduced overall if patients in a very high or prohibitive risk subgroup were spared surgical intervention.
References
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