Risk of pneumonectomy after induction therapy for locally advanced non-small cell lung cancer

Recent data from prospective multimodality trials have documented an unacceptable early mortality with pneumonectomy after induction chemotherapy. This finding has raised skepticism toward pneumonectomy as a surgical option for patients with regionally advanced nonsmall-cell lung cancer. In the current study, perioperative outcomes after pneumonectomy with or without neoadjuvant therapy are compared to determine the impact of induction therapy on perioperative mortality in this setting. Variables associated with increased perioperative risk are identified.

A review of 315 nonsmall-cell lung cancer patients (196 male [62%]) undergoing pneumonectomy over a 15-year period was undertaken. Patients were well matched for clinical variables other than receiving induction chemotherapy. Complications and operative mortality were analyzed for associations with laterality and induction chemotherapy.

Median age was 64 years, (range, 25 to 82). Age was predictive of mortality in 13 of 86 patients (15%) more than 70 years old, compared with 16 of 229 patients (7%) less than 70 years old (hazard ratio = 1.77, p = 0.046). Overall operative mortality was 9.2% (29 of 315). There were 115 left-sided (37%) and 200 right-sided (63%) pneumonectomies. Sixty-eight patients (22% [left = 31, right = 37]) received induction chemotherapy. Surgery alone was performed in 247 patients. Mortality among patients undergoing induction chemotherapy was 21% (odds ratio = 4.01; p = 0.0007). After induction chemotherapy, postoperative bronchopleural fistula associated with respiratory failure was predictive of operative mortality (hazard ratio = 148, p = 0.0001). Left-side pneumonectomy did appear to a have a greater incidence of postoperative arrhythmia.

Morbidity and mortality after pneumonectomy is substantial. Patients greater than 70 years old appear to be at increased risk. Induction chemotherapy also increases the risk of operative mortality after pneumonectomy. Patients should be advised of this increased operative risk, and the multidisciplinary team must consider this when pneumonectomy appears necessary after induction therapy for locally advanced nonsmall-cell lung cancer.