Medical complications of combined surgical and nonsurgical therapy

The poor prognosis of patients with preoperatively identified stage IIIa N2 non-small-cell lung cancer has led to the use of various combinations of chemotherapy, radiation, and surgery in phase II clinical trials and, more recently, as standard therapy. The survival benefits of these combination approaches have been noted, but the morbidity associated with these approaches has received less attention. Compared with surgery alone, combination treatments almost always lead to a higher percentage of patients requiring pneumonectomy and greater numbers of complex resections and technical problems. The risks for postoperative complications and death can also be expected to be higher. It is well documented, for example, that pulmonary morbidity related to the adult respiratory distress syndrome and bronchopleural fistulae is increased when pneumonectomy is done after chemoradiation therapy. Other toxicities that can affect the fate of the surgical patient include myelosuppression, cardiomyopathy, and renal disorders. Fortunately, the proper performance of anesthesia and surgery can minimize the incidence of these toxicities and reduce their effect on patients.