|Year : 2014 | Volume
| Issue : 1 | Page : 6-11
Early operative mortality of bronchogenic carcinoma
Nawab A. Khan, A. G. Ahanger, Mukhtar Thoker, Shyam Singh, Nayeemul Hassan, Lateef Wani, Shabeer A. Mir, Imtiaz Wani
Departments of CVTS, and General Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
|Date of Web Publication||21-May-2014|
Department of Surgery, Sheri Kashmir Institute of Medical Sciences, Srinagar 190 006, Kashmir
Source of Support: None, Conflict of Interest: None
Introduction: Lung cancer is the most common cancer in the world operative mortality rates for resection of lung cancer varies with type of resection carried out. Aim: The aim was to study the various causes of 30-day mortality, difference in the 30-day operative mortality between pneumonectomy, lobectomy and lesser resections and overall 30-day operative mortality following lung resection surgery of bronchogenic carcinoma. Materials and Methods: All those patients of bronchogenic carcinoma who were planned for lung resection surgery, from May 2008 to October 2010 in the department of cardiovascular and thoracic surgery, were included in the study protocol prospectively. Results: Lung carcinoma is predominantly a disease of males. The most common finding on X-ray chest is evidence of mass lesion. 91.1% had positive findings on bronchoscopic examination. Squamous cell carcinoma was present in the majority of patients (74.4%). Majority of patients underwent lobectomy (55.6%). Overall 30-day operative mortality was 4.4%. Mortality was more in patients who underwent pneumonectomy. Advanced age was associated with significant mortality. The most common postoperative complication was pneumonia followed by bronchopleural fistula. Conclusion: Surgery for bronchogenic carcinoma is associated with low mortality and morbidity and a good outcome, especially in patients with early stage disease.
Keywords: Cancer, early, lung, mortality
|How to cite this article:|
Khan NA, Ahanger AG, Thoker M, Singh S, Hassan N, Wani L, Mir SA, Wani I. Early operative mortality of bronchogenic carcinoma. Saudi Surg J 2014;2:6-11
|How to cite this URL:|
Khan NA, Ahanger AG, Thoker M, Singh S, Hassan N, Wani L, Mir SA, Wani I. Early operative mortality of bronchogenic carcinoma. Saudi Surg J [serial online] 2014 [cited 2020 Jul 11];2:6-11. Available from: http://www.saudisurgj.org/text.asp?2014/2/1/6/132894
| Introduction|| |
Lung cancer is the most common cancer in the world, and a leading cause of death in men and second most common cause in women.  It is responsible for 1.3 million deaths worldwide and accounts for nearly 13% of all new cancer diagnoses in both sexes combined. , By any conventional measure, the enormity of this global problem is immense. WHO estimates that by year 2025 tobacco-related deaths worldwide will exceed 10 million annually, with lung cancer expected to contribute at least 30% of that total. The presentation in lung cancer may be in the form of manifestation of a local disease, of a locally advanced disease or paraneoplastic syndrome.
Accurate staging is crucial for defining operability, selecting treatment regimens, and predicting survival treatment options include surgery for localized disease, chemotherapy for metastatic disease and radiation therapy for local control in patients whose condition is not amenable to surgery.  The principal of surgery is to remove all cancer, but to conserve as much lung as possible. This is usually done by lobectomy, but there is evidence that small peripheral lesions have as good an outcome if subjected to segmentectomy or simple wedge excision as lobectomy.
Operative mortality rates for resection of lung cancer averages 4%, with lobectomy having a mortality of 3% and pneumonectomy a mortality of 7-9%.  Mortality rate for lobectomy is 6.6% and 10% for pneumonectomy in patients aged 70 years and more.  These rates are obviously higher for younger patients and are more a function of comorbidity than of age alone.
The aim was to study the various causes of 30-day mortality, difference in the 30-day operative mortality between pneumonectomy, lobectomy and lesser resections and overall 30-day operative mortality following lung resection surgery for bronchogenic carcinoma.
| Materials and Methods|| |
This study was conducted in the Department of Cardiovascular and Thoracic Surgery (CVTS), Sher-i-Kashmir Institute of Medical Sciences, Srinagar from May 2008 to October 2010. All those patients of bronchogenic carcinoma who were planned for lung resection surgery were included in the study protocol prospectively. The informed consent was taken from all cases enrolled for the study. A detailed history and examination was taken in each patient. Radiological studies done were posteroanterior and lateral chest X-ray, the contrast-enhanced computed tomography of chest, the ultrasonography abdomen to look for any organomegaly or secondaries. Any patient suspected to have metastatic disease was not included in the study protocol. Bronchoscopy was performed in all patients and biopsy was taken. Computed tomography (CT)-guided biopsy was done in those cases where bronchoscopy was either negative or yield of bronchial biopsy was not confirmatory. After proper workup, all patients were subjected to surgery. Following were the procedures performed, lobectomy, pneumonectomy, and lesser resection. Pathological staging was done based on operative findings and histopathology. Any postoperative complication was recorded. Chest tubes were removed after lung was expanded and drain was minimal.
Patients were discharged and followed in CVTS outpatient department for a span of 1 month. Any complication or mortality was looked for; all the data were compiled and analyzed statistically after the completion of study period.
| Results|| |
A total of 90 bronchogenic carcinoma patients had lung resection surgery. Out of 90 patients, 80 were males and 10 females with male: female ratio of 8:1. Majority of patients (70%) were in the age group of 46-65 years, youngest being 35 years old. The mean age of males was 57.9 ± 10.316 and that of females was 58.9 ± 5.763.
More than 9/10 th of patients were smokers. Cough with expectoration was the most common presenting symptom (77.8%) followed by hemoptysis (51.1%), dyspnea (51.1%) loss of weight (50%), chest pain (50%), anorexia (13.3%), fever (11.1%), and generalized weakness (10%). Chronic obstructive pulmonary disease (COPD) (6.7%) was common comorbidity seen in this series of cases followed by hypertension (HTN) (5.6%), (50%), COPD with HTN (3.3%), COPD with HTN and diabetes mellitus (DM) (1.1%), COPD with DM (1.1%) and DM (1.1%). 80% of cases had no comorbidity The most common physical finding encountered was anemia (17.8%) followed by anemia (17.8%) and clubbing (7.8%). No patient in our study was found to exhibit any signs suggesting any endocrine syndrome associated with bronchogenic carcinoma. The most common chest sign encountered was features of collapse (24.4%) followed by consolidation (13.3%), collapse with consolidation (6.7%) and localized wheeze in 5.6% of total cases. Majority of patients in our study had (Hb) hemoglobin values in normal range with majority (42.2%) having Hb in the range of
10-12 g/dl and only 17.8% had anemia of varying severity. Most common finding on chest X-ray was evidence of mass lesion (44.4%); this was followed by evidence of atelectasis (22.2%) as the second common chest X-ray finding. Hilar enlargement was found in 16.7% of patients on chest X-ray. Bronchoscopy was performed in all patients of whom 82 (91.1%) had positive findings. Out of 82 bronchoscopic biopsy specimens, 80 patients had histopathologically documented bronchogenic carcinoma. 10 patients were diagnosed as lung cancer on CT-guided biopsy. Histopathological profile of patients revealed that majority (74.4%) had squamous cell carcinoma. 20% had adenocarcinoma while 5.6% had small cell carcinoma. Lobectomy was done in majority of patients (55.6%) followed by pneumonectomy (24.4%) and lesser resection in (20%). Pathological staging revealed that majority of patients were in Stage IIB (33.3%) followed by Stage IIIA (23.3%), Stage IB (17.8%), Stage IA (15.6%), and Stage IIA (10%) [Table 1].
Major complications occurred in a total of 29.8% of patients. Most common complication was pneumonia (5.6%) and the least common was respiratory failure (3.3%) [Table 2]. Most patients who underwent lesser resection were discharged in 1 st week (83.3%) and only 16.7% in 2 nd week. Among lobectomy group 56% patients were discharged in 2 nd week and 44% in 1 st week. Majority of patients in pneumonectomy group were discharged in 2 nd week (81.2%) and only 18.2% patients in 1 st week.
| Discussion|| |
Lung cancer is the most common cancer in the world and a leading cause of death from cancer in men and second most common in women. , In developing countries like India the incidence of lung cancer is increasing. Though, it is commonly seen in elderly males; however, no age or sex is exempted. In this study, overwhelming majority (88.9%) were males as compared with females (11.10%). This tremendous rise in incidence in females has been attributed to high incidence of smoking in females in the United States at present, a habit which the females in this region have not picked up. Lung cancer is rarely diagnosed in people younger than 40, but incidence rises steeply thereafter peaking in people aged 75-84 years. , Chest radiography, CT, magnetic resonance imaging, positron emission tomography (PET) and mediastanscopy are modalities used for diagnosing lung cancer.
Mediastanoscopy is used for staging of lymph nodes in carcinoma lung and enables direct visualization of mediastinum. This used to be gold standard investigation in lung cancer.  Advances in minimally invasive procedures and imaging and less invasive methods for biopsy have declined significantly use of mediatanoscopy. Endobronchial ultrasound enable needle aspiration sampling of nearly all mediastinal and hilar lymph nodes with less invasiveness compared to mediastanoscopy. 
Positron emission tomography is used mainly for diagnosis, staging of lung cancer disease and its spread.  PET easily distinguishes between benign and malignant lesions, predicts primary tumor response to induction therapy and for accurately assessing response to neo-adjuvant chemoradiotherapy in patients with stage III nonsmall cell carcinoma.  Moreover, it has been predictive for treatment outcome and patient survival in lung cancer patients by allowing reliable assessment of residual tumor viability after chemoradiotherapy. ,
In our study, lobectomy was done in 55.6% patients followed by pneumonectomy (24.4%) and lesser resection (20%). This is in keeping view with the trend followed by other surgeons nowadays because lobectomy has been proved to result in better survival than any other radical procedure,  in their retrospective review of pulmonary resection over 7 years showed that there were 55.94% lobectomies, 19.93% pneumonectomies and 24.11% lesser resections which is consistent with our study. Most common complication was pneumonia followed by bronchopleural fistula (BPF), empyema, pulmonary thromboembolism (PTE) and postoperative hemorrhage requiring blood transfusion and the least common complication was respiratory failure.
Most patients who underwent lesser resection were discharged in 1 st week. Among lobectomy group patients are discharged in 2 nd week and in 1 st week. Majority of patients in pneumonectomy group are discharged in 2 nd week. In this study, overall 30-day operative mortality was 4.4%. Kadri and Dussek  have reported operative mortality to be 5% while as Wada et al.,  Licker et al.,  Myrdal et al.,  Watanabe et al.  and Strand et al.  have reported 30-day operative mortality to be 1.3%, 3.2%, 2.9%, 0.6%, and 4.4%, respectively. These results are comparable with their study.
Mortality rate was highest for pneumonectomy (9.1%) followed by lobectomy (4%) [Table 3]. There was no death in patients who had undergone lesser resection. Weiss,  Vincent et al.  and Cook et al.  have reported mortality rates of 17%, 14.5%, and 1.6% for pneumonectomy and 10%, 1.9%, and 9.3% for lobectomy, respectively. Kadri and Dussek  have reported an overall operative mortality of 5%, 6.8% for pneumonectomy and 3.9% for lobectomy. Reported mortality rate for pneumonectomy, lobectomy, and lesser resections to be 9.6%, 4.5%, and 1.3%, respectively, which was not significant statistically. In this study, also mortality rate between pneumonectomy, lobectomy, and lesser resection was not statistically significant (P = 0.372) which can be due to the small sample size.
Mortality increased with age. There were four deaths, out of which mortality was 33.3% in the age group of >75 years and 16.7% in the age group of 65-75 years and 2.8% in the age group 56-65 years. There was no 30-day operative mortality below 55 years of age. There was a significant difference in operative mortality as the age advances (P = 0.033). Wada et al.  showed significant difference in operative mortality between <60-year and 60-69 years old group, and between 60- and 69-years old and 70-79 years old groups (P < 0.01 and P = 0.047, respectively) which is consistent with our study.
In our study, males had higher mortality than females. Among males the mortality was 5% and there was no death among females. Our results were in accordance with the results of Damhuis and Schόtte  who in their study showed a mortality of 3.6% for males and 0.4% for females. According to Strand et al.  male sex was identified as risk factor (odds ratio: 1.76) for postoperative mortality in multivariate analysis. Furthermore, in our study, female sample size was small.
Stage IIA was associated with higher mortality (11.1%) followed by Stage IIIA (9.5%) and stage IIB (3.3%). There was no mortality in Stage IA and Stage IB [Table 4]. Stoelben et al.  found mortality in Stage I to be 0.8%, Stage II 5.4%, Stage IIIA 4.9%, Stage IIIB 7.1%, and Stage IV 8.8%. Our results were most in concordance with their results. It could be because of differences in other variables like comorbidity or age and also the small sample size.
Small cell carcinoma was associated with higher mortality (20%) followed by adenocarcinoma (5.6%) and squamous carcinoma (3%) [Table 5]. However, the sample size of patients with small cell carcinoma was small. Damhuis and Schόtte  found highest mortality in patients with small cell carcinoma (3.9%) followed by squamous cell carcinoma (3.4%) and adenocarcinoma (2.7%). Our results were not in accordance with their results.
Two patients among pneumonectomy group died of respiratory failure, both patients required postoperative ventilation [Table 6]. Among pneumonectomy group, pneumonia was contributory factor and in other patient postoperative hemorrhage contributed to mortality. Among lobectomy group, one patient died of PTE and other died due to bronchopleural fistula with empyema being a contributory factor. There was no mortality among lesser resection group. Wada et al.  found Pneumonia and respiratory failure accounted for most deaths (n = 48, 51.6%), followed by cardiac complications, postoperative hemorrhage, and BPF/empyema in that order.
|Table 6: Comparison between operative procedures, etiology for early mortality, postoperative. Ventilation and other contributory factors for mortality |
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| Conclusion|| |
Surgery for bronchogenic carcinoma is associated with low mortality and morbidity and a good outcome, especially in patients with early stage disease. Although advanced age and advanced disease are associated with a higher mortality and morbidity, but these patients should not be denied the benefit of surgery, however extent of surgical resection should be kept as minimal as possible.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]