Pneumonectomy for stage i (T1N0 and T2N0) nonsmall cell lung cancer has potent, adverse impact on survival

doi:10.1016/S0003-4975(03)00883-X

The Annals of Thoracic Surgery

Volume 76, Issue 4, October 2003, Pages 1023-1028

https://doi.org/10.1016/S0003-4975(03)00883-X Get rights and content

Abstract

Background

Surgically treated, stage I (T1N0 and T2N0) nonsmall cell lung cancer has a relatively favorable prognosis. Our aim was to determine whether performing a pneumonectomy in this group of patients has an impact on survival.

Methods

Four hundred eighty-five patients with stage I nonsmall cell lung cancer undergoing lung resection between 1991 and 2000 were studied. Three hundred seventy-four patients underwent a smaller resection than a pneumonectomy and 111 had a pneumonectomy.

Results

Patients undergoing less extensive resections were older (mean age, 65 vs 63 years) (p = 0.01); these patients were also more likely to have a history of chronic obstructive airway disease (9% vs 2%) (p = 0.01) or asthma (10% vs 3%) (p = 0.04), nonsquamous cell type (56% vs 27%) (p < 0.0001), and T1 tumor stage (66% vs 17%) (p = 0.002) than patients having a pneumonectomy. Operative mortality was 2.4% versus 8% (p = 0.01). Overall 1-, 3-, and 5-year Kaplan-Meier survival rates (95% confidence interval [CI]) after less extensive resections were 85% (CI, 82% to 90%), 63% (CI, 56% to 69%), and 50% (CI, 42% to 57%), respectively, and after pneumonectomy the survival rates were 66% (CI, 53% to 73%), 47% (CI, 35% to 57%), and 44% (CI, 32% to 55%), respectively (p = 0.0006). When the Cox proportional hazards model was applied to all study patients (n = 485), pneumonectomy (p = 0.001), T2 stage (p = 0.006), older age (p = 0.03), and male gender (p = 0.03) were independent adverse predictors of survival. When the analysis was limited to the patients having T1N0 disease (n = 145), pneumonectomy (p = 0.0008), older age (p = 0.05), and nonsquamous cell type (p = 0.02) were independent adverse determinants of survival. When only the patients with T2N0 disease were analyzed (n = 340), male gender (p = 0.0005) and pneumonectomy (p = 0.01) were independent negative predictors of survival.

Conclusions

In this study, the patients who underwent pneumonectomy for stage T1N0 or T2N0 nonsmall cell lung cancer had a significantly poorer survival than those patients who underwent smaller lung resections.

Section snippets

Patients and methods

We studied a total of 485 patients undergoing lung resection for Stage I NSCLC. Of these patients, 405 were operated on at Nottingham City Hospital from 1991 to 2000, and 80 patients were operated on at Northern General Hospital (Sheffield) from 1997 to 2000.

These patients (n = 485) were divided in two groups according to the extent of their lung resections. Group A consisted of 374 patients who underwent a resection smaller than a pneumonectomy (24 bi-lobectomies, 272 lobectomies, 11 sleeve

Clinical features, histology, and pathologic staging

Male gender predominated in both groups, but there were significantly more male patients in group B (p = 0.02). Group A patients were older (p = 0.01) and they were more likely to have chronic obstructive airway disease (p = 0.01) and asthma (p = 0.04) and a higher mean body mass index (p = 0.02) than patients in group B (Table 1).

There were no significant differences between the two groups in their preoperative spirometry (forced expiratory volume in 1 second, forced vital capacity) and the

Comment

The significance of tumor size for survival in surgically treated stage I (T1N0 and T2N0) NSCLC is recognized by the revised international TNM classification system [7], and patients with T1 status (tumor < 3cm) are expected to live longer than their counterparts with T2 status of the disease. The importance, however, of several other factors in early disease stages (including the extent of lung resection) is less clear.

The procedure of choice for stage I lung cancer is anatomic lobectomy.

References (25)

B. Burrows et al.
The postpneumonectomy state
Am J Med
(1960)
M.K. Ferguson et al.
Does pneumonectomy for lung cancer adversely influence long-term survival?
J Thorac Cardiovasc Surg
(2000)
P. Thomas et al.
Stage I non-small cell lung cancera pragmatic approach to prognosis after complete resection
Ann Thorac Surg
(2002)
D.E. Williams et al.
Survival of patients surgically treated for stage I lung cancer
J Thorac Cardiovasc Surg
(1981)
C.F. Mountain
Revisions in the international system for staging lung cancer
Chest
(1997)
M. De Perrot et al.
Sex differences in presentation, management, and prognosis of patients with non-small cell lung carcinoma
J Thorac Cardiovasc Surg
(2000)
H. Wagner
Postoperative adjuvant therapy for patients with resected non-small cell lung cancerstill controversial after these years
Chest
(2000)
R.J. Ginsberg et al.
Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer
Ann Thorac Surg
(1995)
C.C.W. Hsia et al.
Physiology and morphology of postpneumonectomy compensation
D.J. Sugarbaker et al.
Extent of surgery and survival in early lung carcinoma
Cancer
(2000)

D.H. Harpole et al.

Stage I non-small cell lung cancer. A multivariate analysis of treatments methods and patterns of recurrence

Cancer

(1995)

H. Wertzel et al.

Results after surgery in stage-I bronchogenic carcinoma

Thorac Cardiovasc Surg

(1998)

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Original article: general thoracicPneumonectomy for stage i (T1N0 and T2N0) nonsmall cell lung cancer has potent, adverse impact on survival

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and methods

Clinical features, histology, and pathologic staging

Comment

Am J Med

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Chest

J Thorac Cardiovasc Surg

Chest

Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer

Ann Thorac Surg

Physiology and morphology of postpneumonectomy compensation

Extent of surgery and survival in early lung carcinoma

Cancer

Stage I non-small cell lung cancer. A multivariate analysis of treatments methods and patterns of recurrence

Cancer

Results after surgery in stage-I bronchogenic carcinoma

Thorac Cardiovasc Surg

Original article: general thoracic
Pneumonectomy for stage i (T1N0 and T2N0) nonsmall cell lung cancer has potent, adverse impact on survival