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Ann Thorac Surg 2006;81:2335
© 2006 The Society of Thoracic Surgeons
Thoracic Surgery Department, European Institute of Oncology, Via Ripamonti 435, Milan, 20100 Italy
(Email: francescoleo{at}interfree.it).
We read with interest the article by Perrot and colleagues [1] on respiratory complications after induction treatment, which concluded that preoperative chemotherapy does not increase postoperative mortality and morbidity after lung resection. We have two comments about this article [1].
First of all, as an author, I wonder if it is possible from a methodological point of view to analyze a group of 114 patients who had preoperative chemotherapy to report postoperative complications and to conclude that there is no increased risk. Where is the control group? In my opinion, the table summarizing international experience that the authors added to the article can not be considered adequate.
I would also like to know why the results from the literature are so controversial on this topic [2, 3]. This cannot be answered until we develop a hypothesis. When we mix together all postoperative complications, rarely is a clear effect of chemotherapy evident. The reason is that the majority of the postoperative complications, such as auricular fibrillation, are not chemotherapy related.
Let us try to think differently. We know that chemotherapy frequently impairs lung diffusion for carbon monoxide (DLCO) in a subclinical manner. Therefore if we assume that DLCO impairment can increase the risk of pulmonary complications, and if we focus on that, then we find that the rate of postoperative reintubation in patients who received induction treatment is higher than in control patients (17.6% vs 3%; p = 0.009) [3], and that the overall pulmonary risk seems to be related to the DLCO loss [4]. In the article by Perrot and colleagues [1] this aspect is not evaluated. Nevertheless the rate of major pulmonary events (ie, pneumonia and respiratory distress) was not negligible at 10%. As a collateral comment, we note that there is no mention of atelectasis requiring bronchoscopy, which is one of the most frequent complications in our speciality, suggesting that the overall rate of complications is underestimated.
Another example of the relationship between chemotherapy and postoperative complications is postoperative bleeding. From experience in liver surgery, we know that the likelihood of postoperative bleeding increases after induction treatment because of chemotherapy liver, which is a condition characterized by a transient reduction in hepatic function due to chemotherapy. Postoperative bleeding can occur after pneumonectomy due to the absence of the prosthesis effect of the remaining lung. These two factors combine to put patients who have pneumonectomy after chemotherapy at greater risk of bleeding.
At the thoracic surgery department of the European Institute of Oncology, 202 standard pneumonectomies have been performed since January 1998, with 97 that were performed after induction chemotherapy (cisplatin and gemcitabine in 95% of cases). Re-thoracotomy for hemostasis was 2 times higher in the group of patients who received preoperative chemotherapy, reaching almost a statistical significance (p = 0.06). We do not believe that this association is simply chance.
After recent studies showing chemotherapy benefit in early-stage lung cancer [5], induction treatment will probably become a standard of treatment. We need strong evidence that it will not increase the rate of potentially lethal events as postoperative respiratory complications. With this goal in mind, we are preparing a prospective randomized trial to compare induction with adjuvant chemotherapy in the setting of stage II non-small cell lung cancer.
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  D. Galetta, A. Cesario, S. Margaritora, and P. Granone Reply Ann. Thorac. Surg., June 1, 2006; 81(6): 2336 - 2336. [Full Text] [PDF]
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