Asian Cardiovasc Thorac Ann 2006;14:123-127
© 2006 Asia Publishing EXchange Ltd
Value of Wedge Resection for Lung Cancer in Poor Cardiopulmonary Status Patients
Balakrishnan Mahesh, FRCS,
Christopher Forrester-Wood, FRCS,
Khalid Amer, FRCS,
Raimondo Ascione, MCh
Division of Thoracic Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
For reprint information contact: Balakrishnan Mahesh, FRCS Tel: 44 795 103 3090 Fax: 44 189 582 8900, Email: b.mahesh{at}imperial.ac.uk, Transplant Immunology, Heart Science Centre, Harefield Hospital, Harefield UB9 6JH, United Kingdom.
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ABSTRACT
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The strategic management of primary lung cancer in patients with poor cardiopulmonary status is still controversial. The aim of this study was to ascertain the early and late results of wide-margin wedge resection with curative intent in this group of patients. Between January 1995 and January 2002, 24 patients (13 males; mean age, 69.96 years) with baseline poor cardiopulmonary status underwent wide-margin wedge resection of preoperatively diagnosed primary lung cancer. All patients suffered from chronic obstructive pulmonary disease and 9 (37.5%) also had symptomatic ischemic heart disease. Eight patients were in New York Heart Association class III and 12 were in class IV. There were no post-operative deaths. Complications included chest infection in 3, surgical emphysema with prolonged air leak in 1, and atrial fibrillation in 6. Overall 7-year survival was 23.3%. Three patients with ischemic heart disease suffered late non-cancer-related death due to myocardial infarction at 48, 60, and 60 months postoperatively. Cancer-free 5-year survival was 54.3%, with 7/24 (29%) late recurrences. Our study suggests that wide-margin wedge resection is a valuable surgical option for primary lung cancer in patients with poor cardiopulmonary status.
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INTRODUCTION
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The management of primary lung cancer in patients with poor cardiopulmonary status remains controversial.1–6 Anatomical lung resection in the form of a lobectomy or pneumonectomy with clearance of the relevant hilar or mediastinal lymph nodes (LN) remains the treatment of choice in cases of proven malignancy with normal cardiopulmonary status.3,5,7–9 Patients presenting with poor cardiopulmonary status pose a particularly difficult problem as they are not suitable for this management strategy. Wide-margin wedge resection is a valuable surgical alternative for these patients.10,11 We present the early and mid-term results of a series of patients with poor cardiopulmonary status undergoing wide-margin wedge resection with curative intent.
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PATIENTS AND METHODS
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Data were collected prospectively in a database for all patients undergoing thoracic surgical procedures. The dataset included 5 different sections filled in consecutively by the anesthetist, surgeon, intensive care unit and high dependency unit staff, and ward nurses. The data of consecutive patients with poor cardiopulmonary status who had undergone wide-margin wedge resection of a primary lung cancer with curative intent were analyzed. Poor cardiopulmonary status was defined as: forced expiratory volume in one second (FEV1) < 1.5 L, or < 50% of predicted; poor performance status and inability to climb a single flight of stairs without becoming short of breath; dyspnea on minimal exertion and/or dyspnea at rest; history of untreated symptomatic ischemic heart disease; and history of myocardial infarction with impaired left ventricular function.4,12 The decision to perform wide-margin wedge resection was made by a multidisciplinary team comprising chest physicians, surgeons, and oncologists. Computerized tomography (CT) and positron emission tomography scans were used to evaluate the lesions. Diagnosis was established by CT-guided fine-needle aspiration cytology.
Standard anesthetic techniques were used. Analgesia was provided by a combination of patient-controlled analgesia, intercostal nerve block, and paravertebral nerve block, to ensure early mobilization in the postoperative period. All patients underwent preliminary rigid bronchoscopy to rule out involvement of the lobar bronchus, which would preclude wide-margin wedge resection. All patients were ventilated with double-lumen endotracheal tubes to enable single-lung ventilation during the procedure. Wide-margin wedge resection was performed via a muscle-sparing minithoracotomy through the 5th or 6th rib bed, depending on the location of the lesion. Single-lung ventilation was achieved with the side of interest being completely deflated for the shortest possible duration. Wedge resection was carried out with a linear stapler, fired more than once if necessary. The aim was to achieve a liberal wedge containing the nodule, ensuring at least 2 cm of visibly tumor-free surrounding margins of the deflated lung.3,13 Following resection of the primary tumor, lymph nodes (LN) were sampled from lobar, hilar, and relevant mediastinal territories, even if negative on gross inspection. Furthermore, enlarged LN > 1 cm on the longitudinal axis were sent separately for histopathology. Mediastinoscopy was not performed routinely preoperatively. At the end of the operation, patients were extubated in the operating room and managed according to standard unit protocols. All patients were carefully monitored with continuous electrocardiogram, arterial blood pressure, and central venous pressure monitoring for at least 48 hours postoperatively, in view of their poor cardiopulmonary status. Aggressive physiotherapy and frequent saline nebulizers were provided to prevent respiratory infection. Hospital mortality was defined as any death that occurred within 30 days of the operation.
Patients were regularly followed up at the outpatient clinic at 3-monthly intervals during the first year, 6-monthly intervals in the second year, and at yearly intervals thereafter. At each follow-up visit, symptoms were reviewed, a clinical examination was performed, and chest radiographs were carried out. Any suspicion of recurrence on chest radiography was systematically investigated with CT scans and CT-guided biopsies. If malignancy was proven, the patients were treated non-surgically in view of their poor cardiopulmonary status.
Statistical analysis was carried out using a Statistica software package (StatSoft, Inc., Tulsa, OK, USA). For continuous variables, differences between groups were evaluated using Student’s t test for parametric distributions and the Mann-Whitney U test for nonparametric distributions. The chi-squared test was used to evaluate differences between groups for discrete variables. Survival data was plotted by the Kaplan-Meier method.
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RESULTS
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Between January 1995 and January 2002, 24 patients with primary lung cancer and poor cardiopulmonary status underwent wide-margin wedge resection. Preoperative characteristics and lung function are summarized in Table 1
. All patients had chronic obstructive airway disease and were on regular inhaled steroids and bronchodilators. Preoperatively, 8 patients were dyspneic on minimal exertion (New York Heart Association class III) and 12 were dyspneic at rest (class IV). Symptomatic ischemic heart disease was present in 9 patients who were either unsuitable for percutaneous coronary intervention or had been refused coronary artery bypass grafting because they were medically unfit. Based on preoperative imaging, 22 (91.7%) patients were stage IA (T1N0M0) and 2 (8.3%) were stage IB (T2N0M0).
There were no neurological or gastrointestinal complications. Three patients developed a chest infection leading to septicemia in 2, which was controlled with intravenous antibiotics. One patient developed surgical emphysema due to an air leak, which was controlled by prolonged underwater suction drainage. Three patients developed a transient reduction in urine output and elevated serum creatinine levels, which improved on conservative therapy. Six patients developed atrial fibrillation; 4 responded to amiodarone infusion and correction of electrolyte imbalances, the other 2 deteriorated into ventricular tachycardia with significant hemodynamic instability and required cardioversion and infusion of amiodarone. Five patients with known ischemic heart disease developed postoperative angina with evidence of ischemia, but they responded to intravenous nitrate infusion and therapeutic anticoagulant doses of low-molecular-weight heparin. Postoperative hospital stay was 6.22 days (95% confidence interval, 4.51 to 7.93 days). Histology is reported in Table 2. Only 2 patients had malignant involvement of the draining LN station sampled. The postoperative pathological size was 1.79 cm (95% confidence interval, 1.17 to 2.41 cm).
Follow-up was complete in all patients, with a mean of 30.2 months (95% confidence interval, 19.7 to 40.7 months). Late recurrence was noted in 7 patients (29.2%). Four of them had a large locoregional recurrence corresponding to the site of previous wide-margin wedge resection, with mediastinal adenopathy detected by CT, and they were referred for palliative radiotherapy. The other 3 patients developed systemic metastases and were unsuitable for further management. Thus, 6 patients suffered late death within 22 months of their wide-margin wedge resection, mean survival was 13.2 months (95% confidence interval, 8.1 to 18.3 months). One patient who survived for 54 months died of systemic metastases. Five-year cancer-free survival was 54.3% following wide-margin wedge resection, although the number of patients at risk was rather small at this time point (Figure 1). However, the survivors had excellent quality of life following wide-margin wedge resection. Three patients suffered non-cancer-related deaths due to myocardial infarction at 48, 60, and 60 months postoperatively. These patients were cancer-free at their latest follow-up prior to this event. Thus, the 7-year actuarial cancer-free survival was 54.3%, while the overall 7-year survival, including all deaths related to cancer recurrence and poor cardiopulmonary status was 23.3%, although the number of patients at risk was small.
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Figure 1. The 5-year cancer-free survival following wide-margin wedge resection for primary lung cancer in patients with poor cardiopulmonary status.
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DISCUSSION
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Standard lobectomy with mediastinal LN sampling remains the gold standard operation for stage I lung cancer, with 5-year cancer-free survival of up to 80%.3,5,7–9 Ginsberg and colleagues3 stressed the importance of intraoperative mediastinal LN sampling because > 25% of clinically stage I lesions are upstaged after intraoperative assessment and LN sampling. Similar results have been shown by others, with normal-looking mediastinal LN being microscopically involved, even prior to involvement of lobar LN.14,15 If intraoperative LN sampling suggests involvement, then a standard lobectomy with LN dissection is the treatment of choice.4
There is still a lack of consensus on the use of limited resection, particularly because the decision-making process has to take comorbidities into account. In patients undergoing limited resection, a 75% increase in recurrence, 30% increase in overall mortality, and 50% increase in cancer-related death compared to those undergoing lobectomy was reported.3 This was attributed to failure to identify occult intrapulmonary microscopic and lymphatic spread. A similar finding was reported by Miller and colleagues,6 with 5-year survival for lobectomy, segmentectomy, and wedge resection being 92%, 75%, and 42%, respectively, in primary lung cancer < 1 cm. Various groups have advocated lesser degrees of resection in patients who cannot tolerate a lobectomy; these include wedge resection and segmentectomy, with or without mediastinal LN sampling.7,9,13 Kodama and colleagues4 felt that segmentectomy was acceptable for stage I lung cancer in patients with poor lung function. In their cohort of patients, there was an increased risk of locoregional recurrence with limited resection, but they felt that since most patients with locoregional recurrence died of distant metastases, survival was not affected. Ambrogi and colleagues1 examined the impact of cardiovascular comorbidity on the outcome of surgery for stage I and II primary lung cancer. They found that timing of the cardiac or vascular surgery had no bearing on the outcome of lung resection. They also found that patients who underwent a lobectomy or pneumonectomy had a poorer survival rate than those who underwent limited lung resection, irrespective of whether the cardiac or vascular procedure was performed before or after lung resection. Others have reported similar results, with survival rates being worse for those with poor cardiopulmonary status.16
In our study, the actuarial 5-year cancer-free survival rate of 54.3% compares favorably with the literature.1,2,17,18 Our management is in accordance with the British Thoracic Society, which suggests extensive investigations in patients with FEV1 < 1.5 L (or 50% of predicted) and poor cardiopulmonary status, and recommends limited resection for this subgroup.7 This view has been shared by others.9,18 One option might be to treat this group of patients non-surgically in view of their poor cardiopulmonary status and considerable comorbidities. Those with untreated lung cancer usually die within a few years after diagnosis, and surgery remains the only option, with overall survival of 13%.13,19,20 We achieved high survival rates with wedge resection of the malignancy, as well as much-improved quality of life. Thus, we stress the importance of surgical intervention even in this group of patients.
Segmentectomy was considered for these patients, especially because the results of segmentectomy have been reported to be better than those of wedge resection.4,6 However, our patients were unable to tolerate single-lung ventilation for long periods, and we felt that a quick wide-margin wedge resection would a better option. The other option was wedge resection using video-assisted thoracic surgery, as recommended by several groups.8,10,11 We felt that this technique would take longer than wedge resection through a minithoracotomy, and thus expose patients to longer single-lung ventilation and general anesthesia time, which they could not tolerate. Furthermore, our aim was to achieve at least 2-cm palpable tumor-free margins in the deflated lung, and this would be difficult with the video-assisted technique.
There are several limitations to our study, which deserve mention. First, the sample size is rather small despite a prolonged study period. This is related to our stringent selection criteria for poor cardiopulmonary status. A further limitation could be the lack of a randomized double-blind control, but that would be impossible to achieve given the weight of information establishing a standard lobectomy with mediastinal LN clearance as the gold standard for primary lung cancer, and with wide-margin wedge resection being restricted to the population with poor cardiopulmonary status.3–5,7–9,14,15 Our results suggest that wide-margin wedge resection is a valuable surgical procedure for primary lung cancer in patients presenting with poor cardiopulmonary status unsuitable for major lung resection, but further studies are need to confirm this.
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ACKNOWLEDGMENTS
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We wish to thank all the patients and the nursing staff of the Bristol Thoracic Center. We also thank the Garfield Weston Trust for support.
Presented at the 12th Annual Meeting of the Asian Society for Cardiovascular Surgery, Istanbul, Turkey, April 19–23, 2004.
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REFERENCES
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- Ambrogi V, Pompeo E, Elia S, Pistolese GR, Mineo TC. The impact of cardiovascular comorbidity on the outcome of surgery for stage I and II non-small-cell lung cancer. Eur J Cardio-thorac Surg 2003;23:811–7.[Abstract/Free Full Text]
- Errett LE, Wilson J, Chiu RC, Munro DD. Wedge resection as an alternative procedure for peripheral bronchogenic carcinoma in poor-risk patients. J Thorac Cardiovasc Surg 1985;90:656–61.[Abstract]
- Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995;60:615–22.[Abstract/Free Full Text]
- Kodama K, Doi O, Higashiyama M, Yokouchi H. Intentional limited resection for selected patients with T1 N0 M0 non-small-cell lung cancer: a single-institution study. J Thorac Cardiovasc Surg 1997;114:347–53.[Abstract/Free Full Text]
- Landreneau RJ, Sugarbaker DJ, Mack MJ, Hazelrigg SR, Luketich JD, Fetterman L, et al. Wedge resection versus lobectomy for stage I (T1 N0 M0) non-small-cell lung cancer. J Thorac Cardiovasc Surg 1997;113:691–8.[Abstract/Free Full Text]
- Miller DL, Rowland CM, Deschamps C, Allen MS, Trastek VF, Pairolero PC. Surgical treatment of non-small cell lung cancer 1 cm or less in diameter. Ann Thorac Surg 2002;73:1545–50.[Abstract/Free Full Text]
- British Thoracic Society; Society of Cardiothoracic Surgeons of Great Britain and Ireland Working Party. BTS guidelines: guidelines on the selection of patients with lung cancer for surgery. Thorax 2001;56:89–108.[Free Full Text]
- Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients: a case-control study. Ann Thorac Surg 1999;68:194–200.[Abstract/Free Full Text]
- Smythe WR; American College of Chest Physicians. Treatment of stage I non-small cell lung carcinoma. Chest 2003;123:181S–7S.
- Bernard A. Resection of pulmonary nodules using video-assisted thoracic surgery. The Thorax Group. Ann Thorac Surg 1996;61:202–4.[Abstract/Free Full Text]
- Jimenez MF; Spanish Video-Assisted Thoracic Surgery Study Group. Prospective study on video-assisted thoracoscopic surgery in the resection of pulmonary nodules: 209 cases from the Spanish Video-Assisted Thoracic Surgery Study Group. Eur J Cardio-thorac Surg 2001;19:562–5.[Abstract/Free Full Text]
- Mahesh B, Forrester-Wood C, Yunus A, Ahsan R, Amer K, Morgan A, et al. Value of wide-margin wedge resection for solitary pulmonary nodule: a single center experience. Eur J Cardio-thorac Surg 2004;26:474–9.[Abstract/Free Full Text]
- Macchiarini P, Fontanini G, Hardin JM, Pingitore R, Angeletti CA. Most peripheral, node-negative, non-small-cell lung cancers have low proliferative rates and no intratumoral and peritumoral blood and lymphatic vessel invasion. Rationale for treatment with wedge resection alone. J Thorac Cardiovasc Surg 1992;104:892–9.[Abstract]
- Takizawa T, Terashima M, Koike T, Akamatsu H, Kurita Y, Yokoyama A. Mediastinal lymph node metastasis in patients with clinical stage I peripheral non-small-cell lung cancer. J Thorac Cardiovasc Surg 1997;113:248–52.[Abstract/Free Full Text]
- Wu Y, Huang ZF, Wang SY, Yang XN, Ou W. A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer. Lung Cancer 2002;36:1–6.[Medline]
- Warren WH, Faber LP. Segmentectomy versus lobectomy in patients with stage I pulmonary carcinoma. Five-year survival and patterns of intrathoracic recurrence. J Thorac Cardiovasc Surg 1994;107:1087–93.[Abstract/Free Full Text]
- Koike T, Yamato Y, Yoshiya K, Shimoyama T, Suzuki R. Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer. J Thorac Cardiovasc Surg 2003;125:924–8.[Abstract/Free Full Text]
- Shennib H. Sublobar resection for lung cancer. Eur J Cardio-thorac Surg 1999;16(Suppl 1):S61–3.[Abstract/Free Full Text]
- Rossing TH, Rossing RG. Survival in lung cancer. An analysis of the effects of age, sex, resectability, and histopathologic type. Am Rev Respir Dis 1982;126:771–7.[Medline]
- Harpole DH Jr, Herndon JE, Young WG Jr, Wolfe WG, Sabiston DC Jr. Stage I nonsmall cell lung cancer. A multivariate analysis of treatment methods and patterns of recurrence. Cancer 1995;76:787–96.[Medline]
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ABSTRACT
INTRODUCTION
