Chapter 70: Pneumonectomy

INTRODUCTION

Rationale for Performing Pneumonectomy

It is not unusual to attend a medical conference and hear a medical or radiation oncologist (or even a thoracic surgeon) argue that pneumonectomy is no longer a viable treatment for lung cancer based on the high operative mortality reported in an intergroup trial for stage IIIA disease.¹ This impression was recently confirmed in a multicenter study from Spain comparing surgery plus chemoradiation to chemoradiation alone.² Although the Spanish study found that patients undergoing lobectomy versus pneumonectomy after chemoradiation survived longer than those treated with chemoradiation alone, and the overall analysis favored the surgical arm (median overall survival was 57 months for the surgical arm versus 29 months for the chemoradiation arm, p < 0.0001), the subset analysis of pneumonectomy outcomes found no benefit for surgery.

In a meta-analysis by Shapiro and colleagues, increased risk for pneumonectomy was also demonstrated in patients receiving neoadjuvant therapy.³ This finding has not been consistently confirmed in other reports.^4–7 And some studies have shown that pneumonectomy can be performed safely after chemoradiation. Yang and colleagues, for example, reported no 30-day mortality in pneumonectomy patients after chemoradiation.⁸ White evaluated 240 patients undergoing pneumonectomy, of whom 137 (57%) received neoadjuvant chemoradiotherapy, and the two groups had identical 90-day mortality (7.94%). Moreover, long-term survival improved after chemoradiation for patients with involvement of mediastinal nodes.⁹

Taken together, these articles suggest that patients receiving preoperative chemoradiation can still be resected, but with the possibility of increased operative risk. None of this discussion applies, of course, to the many patients who can be safely resected without neoadjuvant therapy, and large or proximal lesions treated with definitive chemoradiation alone still have a cure rate of only about 15%, even without nodal involvement. Hence, surgery remains the treatment most likely to cure these patients with lung cancer.

Factors Affecting Perioperative Risk

Perhaps no other surgery carries as high a risk of perioperative mortality as pneumonectomy. For this reason, appropriate selection, operative technique, and postoperative management of patients who may potentially undergo this procedure are crucial. Depending on the findings at surgery, some patients may not be suitable for the procedure; some may undergo sleeve resection instead, or exploration without resection.

The operative mortality of pneumonectomy is somewhere between 5% and 20%. This is a conservative estimate, however, because the majority of published articles report only 30-day mortality. The true hospital or 90-day operative mortality is likely higher.^10–16 In a meta-analysis of 27 studies, Kim et al. found that 90-day mortality for right pneumonectomy was 20%, but only 9% for left pneumonectomy, yielding an overall mortality rate of 11%.¹⁷

Surprisingly, poor preoperative lung function has not been consistently shown to affect the perioperative risk of pneumonectomy. Some studies report that it increases the ...