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The Impact of Induction Therapy on Morbidity and Operative Mortality after Resection of Primary Lung Cancer
Nathaniel R Evans, III1, Shuang Li2, Cameron D Wright1, Mark S Allen3, Henning A Gaissert1
1Massachusetts General Hospital, Boston, MA;2Duke University, Durham, NC;3Mayo Clinic, Rochester, MN
Background: We sought to examine use and impact of chemotherapy and radiotherapy before major elective resection for primary lung cancer in the Society of Thoracic Surgeons’ National General Thoracic Database.
Methods: Lobectomy and pneumonectomy for primary lung cancer were identified between January 2002 and December 2007. Procedures with missing hospital mortality and length of stay, those treated with chemotherapy or radiation for unrelated disease, and clinical or pathologic M1 disease were excluded. The complication rate was expressed as a composite of 12 major events; prolonged length of stay was defined as > 14 days.
Results: In 796 of 8864 procedures (9%), chemotherapy (n=759) and/or radiotherapy (n=569) preceded resection. Compared to resection only, patients receiving induction therapy were younger (median age 61.8 vs. 66.9; p<0.0001), had fewer comorbidities, more reoperative surgery (10.7 vs. 3.95%; p<0.0001), and higher rates of pneumonectomy (18.2 vs. 5.9%; p<0.0001) and thoracotomy (84.6 vs. 75.1%; p<0.0001).
Four hundred twenty-seven patients had clinical N2 disease. Induction therapy in 247 (58%) was associated with lower patient age and comorbidity, with equivalent pneumonectomy rates. Center-specific rates of neoadjuvant therapy for clinical N2 varied from 25 to 89%.
Table 1 Event Rates by Treatment | Resection only | Induction therapy | | Stage | Outcome | Total N | Event N | % | 95% CI | Total N | Event N | % | 95% CI | | All | Hospital mortality | 8068 | 148 | 1.83 | 1.54-2.13 | 796 | 13 | 1.63 | 0.75-2.51 | | LOS >14 days | 8068 | 580 | 7.19 | 6.63-7.75 | 796 | 65 | 8.17 | 6.26-10.0 | | Complication rate | 8068 | 747 | 9.26 | 8.63-9.89 | 796 | 91 | 11.4 | 9.22-13.6 | | Clinical N2 | Hospital mortality | 179 | 1 | 0.56 | 0-1.65 | 247 | 3 | 1.21 | 0-2.58 | | LOS >14 days | 179 | 12 | 6.70 | 3.04-10.3 | 247 | 14 | 5.67 | 2.78-8.55 | | Complication rate | 179 | 14 | 7.82 | 3.89-11.7 | 247 | 25 | 10.1 | 6.36-13.8 |
Induction therapy for all stages was associated with longer hospital stay (median length 6 vs. 5 days; p=0.0012); rates for tracheostomy, wound infection, transfusion, and atelectasis were higher. Table 1 shows differences in hospital mortality, major complications, and prolonged hospital stay.
In clinical N2 disease, mortality, major complication, and prolonged hospital stay rates were comparable between the two groups. Pathologic staging of clinical N2 confirmed N0 in 27.9% (119/426), N1 in 13.1% (56/426), N2 in 49.3% (210/426), and N3 in 0.23% (1/426). A total of 800 patients had pathologic N2 disease, of whom 179 (22.5%) received neoadjuvant therapy.
Conclusions: A minority of patients receive neoadjuvant chemotherapy or radiation before major lung resection for primary carcinoma. There are marked variations in the use of induction therapy for clinical N2 disease associated with participating centers, comorbidity and patient age. The hospital mortality of lobectomy and pneumonectomy with or without neoadjuvant therapy is low.
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