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Survival after resection of synchronous bilateral lung cancer

^a Department of Thoracic Surgery, University Hospitals and Leuven Lung Cancer Group, Herestraat 49, 3000 Leuven, Belgium
^b Department of Pneumology, University Hospitals and Leuven Lung Cancer Group, Leuven, Belgium
^c Department of Pathology, University Hospitals and Leuven Lung Cancer Group, Leuven, Belgium

Received 20 May 2008; received in revised form 10 July 2008; accepted 14 July 2008.

^_* Corresponding author. Tel.: +32 16 34 68 22. (Email: Paul.Deleyn{at}uzleuven.be).

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A References

 
Objective: Due to recent advances in imaging, the incidence of patients presenting with bilateral lung lesions is increasing. A single contralateral lung lesion can be an isolated metastasis or a synchronous second primary lung cancer. For the revision of the TNM in 2009, the International Association for the Study of Lung Cancer Staging Committee proposes that patients with contralateral lung nodules remain classified as M1 disease. In this retrospective study, the survival after resection of synchronous bilateral lung cancer is evaluated. Methods: From our database of bronchial carcinoma, all patients with bilateral synchronous lung lesions between 1990 and 2007 were retrieved. We analysed 57 patients in which, after functional assessment and thorough staging, the decision was taken to treat the disease with bilateral resection. All these files were retrospectively reviewed. Twenty-one patients were excluded from this analysis because only one side was resected (n = 15) or one of the lesions was non-neoplastic on final pathology (n = 6). Results: Thirty-six patients underwent bilateral resection for synchronous multiple primary lung cancer. All resections were performed as sequential procedures. In 23 patients, one side was anatomically resected (2 pneumonectomies) and the contralateral side was resected by limited resection. In 10 patients a bilateral lobectomy was performed, and 3 patients had bilateral limited resections. Postoperative mortality was 2.8%. Eighteen patients had a tumour with a different histological pattern, confirmed by comparing both specimens by an experienced senior pathologist. The median survival after resection of synchronous bilateral lung cancer in our series was 25.4 months with a 5-year survival rate of 38%. There was no significant difference in survival between patients with different versus same histology. This survival is much higher compared to the survival of assumed stage IV disease. Conclusions: Our study shows that selected patients with bilateral lung cancer may benefit from an aggressive approach, with acceptable morbidity and mortality, and rewarding long-term survival. Patients with a single contralateral lung lesion should not be treated as disseminated disease (stage IV). After extensive searching for metastatic spread, bilateral surgical resection should be considered in fit patients.

Key Words: Lung cancer • Staging • Synchronous lesions • Multiple primary lung cancer • Resection

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A References

 
Due to recent advances in imaging techniques such as multi-slice spiral computed tomography (CT), positron emission tomography (PET) scanning and fluorescence endoscopy, the rate of detection of synchronous bilateral lung nodules has increased. The simultaneous discovery of additional pulmonary nodules in patients with proven lung cancer raises the clinical dilemma of whether this lesion represents multifocal disease, synchronous multiple primary lung cancer (MPLC), which can be potentially treated with curative intention, or whether it is a manifestation of haematogenous spread of the pulmonary lung cancer.

The sixth revision of the international system for the staging of lung cancer, adapted in 1997 assigned the T4 descriptor to separate tumour nodules in the same lobe, and the M1 descriptor to tumour nodules in a different lobe [1]. Consequently, bilateral tumour nodules are classified as stage IV disease. Patients with stage IV disease are considered to have a poor prognosis with surgical modality treatment.

For the upcoming revision of the TNM classification, the International Association for the Study of Lung Cancer (IASLC) initiated a new staging project. The lung cancer staging committee created a huge international dataset collecting data from lung cancer patients [2]. Based on these survival data, they proposed that patients with satellite nodules should be reclassified as T3 [3] and patients with additional nodes in same-side but separate lobes should be reclassified as T4 [3]. However, they propose that patients with contralateral lung nodules remain classified as M1a disease [4]. Their assumption is based on a small database (n = 362) of patients with synchronous bilateral lung cancer with only a small fraction of patients (2%, n = 7) that underwent bilateral surgery. It is the aim of this study to evaluate a single centre experience survival after resection of synchronous bilateral MPLC.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A References

 
2.1 Patient selection
In the Leuven Lung Cancer Group (LLCG) prospective database of bronchial carcinoma (n = 3399), we retrieved all patients who were considered for surgery at the weekly multidisciplinary round between 1990 and 2007 with bilateral synchronous lung lesions. We analysed those patients in which, after functional assessment and thorough staging, the decision was taken to treat the disease with bilateral resection. All these files were retrospectively reviewed. Patient characteristics (sex, age at the time of resection) were noted. Date and extent of surgery, postoperative mortality and morbidity, and pathologic staging according to the American Joint Committee on Cancer (AJCC) [5] were defined. Follow-up of the patients was obtained from our hospital records or from a telephone survey of referring physicians or general practitioners. In cases of external follow-up, the referring physician was contacted to check the patients’ status in December 2007.

For histological examination, 4 µm thick sections were prepared in a standard way and stained with haematoxylin and eosin. Staining for mucins was performed if necessary. Tumours were graded and classified according to the 1999 WHO classification. For the purpose of this analysis, archived tumour tissue specimens were reviewed by an experienced thoracic pathologist (EV), to determine whether the first and second lesion showed an identical or different histological pattern.

2.2 Preoperative and operative procedures
All patients with potentially resectable lung cancer were carefully screened for distant metastasis. In short, this consisted of a thorough clinical examination and history, blood tests including a complete blood count, serum calcium and liver function tests. All patients had a contrast-enhanced CT-scan of the thorax, and an upper abdominal CT or ultrasound. Bone scintigraphy was carried out in patients with bone pain, raised alkaline phosphatase or serum calcium, completed by bone radiographs, bone CT, or bone MRI in case of equivocal findings. Since 2000, PET scan was routinely performed in all patients with potentially operable lung cancer at our centre.

In patients with bilateral suspicious nodules, imaging of the brain (CT or MRI) and invasive mediastinal staging by mediastinoscopy was recommended, even in patients with normal nodes on CT or PET scan. The treatment strategy was decided at the weekly institutional lung cancer multidisciplinary meeting.

In case of anatomical resection and segmentectomy, a systematic nodal dissection was performed. On the right side this included removal of the hilar, the interlobar and mediastinal lymph node levels 2R, 4R, 7, 8 and 9 [6]. On the left side the hilar and interlobar nodes were removed as well as mediastinal lymph node levels 4L, 5, 6, 7, 8 and 9.

In case of wedge resection, no nodal dissection was performed but lymph node sampling was done. The choice between segmentectomy or wedge excision was mainly based on the anatomical location of the tumours in the lobe and on the pulmonary function tests. Small peripheral tumours (<2 cm) that were not confined to one segment or small peripheral tumours in patients with limited pulmonary function tests were treated by wedge resection.

All resections were performed as sequential procedures through posterolateral thoracotomy. Before the second procedure, spiral CT scan of the chest and new pulmonary function tests were performed. The intervention was only performed when the patient was fully recovered and sufficient pulmonary reserve for the second resection was anticipated.

2.3 Statistical analysis
Numeric values are expressed as mean ± standard deviation; range is reported where appropriate. Student’s t-test was used to compare the means of independent samples. Survival was defined as the interval between the date of the first resection and the date of death or of the most recent contact for censored cases. Survival rates were calculated by the Kaplan–Meier method. The log-rank test was used to compare survival curves. The alpha level has been set at 5% to detect significant differences. Postoperative mortality was included in the survival analysis.

All analysis were performed with the statistical package SPSS (version 10).

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A References

 
Fifty-seven patients with a synchronous bilateral lung lesion, suspicious for lung cancer in whom bilateral resection was planned were retrieved. In our centre, the incidence of synchronous bilateral lesions has more than doubled the last years; in the period 1990–1999, before introduction of routine FDG-PET scan, it was 1.0% (21/1999 resections for NSCLC). In the last 8 years it has risen to 2.6% (36/1400 resections for NSCLC).

The flow diagram of these 57 patients is shown in Fig. 1 . In 15 patients only one side was resected. In three patients the need for more extended first resection (pneumonectomy) than expected, and in three others the limited cardiopulmonary function after the first resection, impeded the contralateral resection. In these six patients, the contralateral side was treated with radical radiotherapy. In four patients the first resection was incomplete, and in three patients there was progressive disease on restaging before the second intervention. These seven patients were treated with palliative chemotherapy. Finally, two patients underwent contralateral thoracotomy but were not resected due to unexpected advanced disease (pleural metastasis in one and several malignant nodules in both lobes in another patient).

View larger version (21K): [in this window] [in a new window]   Fig. 1. Flow diagram of 57 patients with synchronous bilateral lung lesions.

The contralateral lesion was infectious in two, scar tissue in one, granuloma in one and in two patients it was a nodular presentation of bronchiolitis obliterans. The 36 patients who underwent bilateral resection for synchronous malignant lung cancers are further analysed.

The characteristics of these 36 patients are listed in Table 1 . There were 29 males and 7 females and the mean age was 64.5 years (range 37–80 years).

In 23 patients, one side was anatomically resected (twice by pneumonectomy) and the contralateral side was resected by limited resection. In 10 patients (28%) a bilateral lobectomy was performed and in 3 patients a bilateral limited resection was done. We performed 29 limited procedures (40.3%), 12 segmentectomies and 17 wedge resections. Mean time between two procedures was 2.4 (±1.9) months.

Overall mean postoperative hospital stay for all 72 interventions was 14.1 (±20.8) days (range 3–152 days). The mean postoperative hospital stay after the first intervention was 9.4 (±3.5) days (range 3–17 days), without any admittance to ICU for major complications. In this group, one patient underwent a reintervention for bleeding (within hours after surgery).

After the second intervention mean postoperative hospital stay was substantially longer (18.6 ± 28.6 days, range 5–152 days); four patients were readmitted to ICU for major complications: respiratory insufficiency (2); thrombectomy for acute lower limb ischaemia (1) and ARDS (1), the latter one resulting in the only postoperative mortality. Mean ICU stay for these four patients was 60.3 days (range 28–99 days). The skewing of the hospital stay after the second intervention is solely attributed by these four patients readmitted to ICU; the mean hospital stay for the remaining 32 patients was 10.3 ± 5.3 days, which is not different (p = 0.38) from the hospital stay after the first intervention.

There was one operative mortality in 36 patients (2.8%) or in 72 thoracotomies (1.4%). Of all minor complications, persistent air leakage (n = 7 or 9.7%), atrial fibrillation (n = 5 or 7%) and respiratory infection (n = 4 or 5.5%) were most commonly recorded.

Fig. 2 depicts the histological patterns. Squamous cell carcinoma and adenocarcinoma were the predominant histology types, 53% and 32%, respectively. There was one patient with unilateral bronchioloalveolar carcinoma (BAC). Half of the patients had tumours with identical histology.

View larger version (35K): [in this window] [in a new window]   Fig. 2. Histologic type of first and second primary lung cancer in 36 patients with resected bilateral multiple primary lung cancer.

View larger version (9K): [in this window] [in a new window]   Fig. 3. Survival of 36 patients with bilateral MPLC who underwent resection compared to 15 patients with bilateral MPLC who underwent unilateral resection.

View larger version (12K): [in this window] [in a new window]   Fig. 4. Survival after resection of MPLC (n = 36). Comparison of survival curves of patients with same or different histological type.

View larger version (10K): [in this window] [in a new window]   Fig. 5. Survival after resection of MPLC (n = 36). Comparison of survival curves of patients who underwent anatomical resection compared to limited resection.

View larger version (12K): [in this window] [in a new window]   Fig. 6. Survival after resection of MPLC (n = 36). Comparison of recurrence free survival of patients who underwent anatomical resection compared to limited resection.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A References

There is a large variation in the literature but on average 2% of all lung cancer patients have a presentation of synchronous lung tumour lesion [8]. Two thirds of these lesions are found in the ipsilateral lung and many of them are unexpectedly found at thoracotomy or at pathological examination of the resection specimen [8]. In our series, the incidence of synchronous bilateral lung lesions has more than doubled the last years; for the period 1990–1999, it was 1.0%. The last 8 years it has risen to 2.6%, probably to be explained by better imaging techniques, mainly the use of FDG-PET scan which we have used routinely in all operable lung cancer patients since 2000.

The intent-to-treat median survival of all 57 patients who were planned for bilateral resection for bilateral synchronous lesions proven or suspicious for lung cancer was 25 months. Fifteen patients did not undergo bilateral resection due to several reasons, and as expected, had poor survival. The median survival after bilateral resection of synchronous bilateral pathological proven MPLC in our series was 49 months, with a 5-year survival rate of 38%. Our study shows that selected patients with bilateral lung cancer may benefit from an aggressive approach, with acceptable morbidity and mortality, and rewarding long-term survival. As far as we are aware, this is the largest study in the literature reporting results after resection of synchronous bilateral MPLC. A study from Marseille [9] reports their experience after resection of 125 patients with synchronous MPLC. Resection for bilateral synchronous MPLC was performed in 31 patients. The overall 5-year survival for the whole group was 34%. Survival after resection of bilateral MPLC is not given but extrapolation from their Figure 2 gives a 5-year survival of ±35% which is very much similar to the survival we obtained. Munn and Kohno [10] described their experiences with single-stage surgical treatment in 19 patients with synchronous bilateral lung cancer. They reported an excellent 5-year survival rate of 76%. However, 8 out of the 19 patients had bilateral BAC and additionally 9 out of 19 patients had BAC at one side. It is well known that BAC has a more indolent behaviour than other NSCLC types [11], and can be treated with limited resection [12].

Half of the patients in our series had bilateral identical histology. They had a 5-year survival rate of 31% which was not statistically significantly different from patients with different histology, and is clearly much better than expected by their current stage IV classification. Other studies in patients with ipsilateral MPLC have shown that survival is not significantly different when histology of both lesions is identical [13–15]. Chang and colleagues [16] evaluated p53/epidermal growth factor receptor somatic aberrations in 58 patients with MPLC. Although tumours had identical histology, nearly half of the cancers had different tumour clonality. This study amongst others [17] supports the independent field cancerisation theory and reveals diagnosis of multifocal lung cancer in the majority of patients despite similarities in histopathological features. In the absence of easily available genetic or molecular markers, differentiation between synchronous MPLC and isolated pulmonary metastasis will remain difficult in the clinical setting and will lead to controversy regarding multidisciplinary management. Therefore, after optimal staging and assessing of the patient’s operative risk, the question whether a patient has two distinct primaries or a primary with an isolated contralateral pulmonary metastasis becomes quite academic.

It is evident that patients with synchronous contralateral lung nodules can have widespread metastatic disease. Therefore, intensive search for metastatic disease should be performed including extensive mediastinal staging and search for haematogenous spread. There are no data on the accuracy of PET-scan in mediastinal staging of patients with synchronous MPLC. Due to its high negative predictive value, we recommend performing surgical staging by cervical mediastinoscopy in patients with synchronous bilateral MPLC [18].

When we consider our survival results, we should keep in mind that the very extensive staging and preoperative evaluation of patients who are candidates for bilateral resection might select patients with improved survival. Moreover, in about one quarter of the patients that were planned for bilateral resection, this could not be performed due to oncological or medical reasons.

We found that wedge or segmental resection was an acceptable alternative for patients with bilateral MPLC who were unable to tolerate bilateral anatomical resection. We performed limited resections in 40% of the procedures. The use of a limited resection procedure did not seem to have negative effects on survival. We choose to perform a sequential bilateral resection and made sure that the patient was recovered enough before the contralateral side was operated. In case of sequential procedures, it can be discussed which side to start with. We have the policy to start on the side where there is doubt on the extent of resection needed and/or complete resectability. This is usually the side of the largest lesion. If a complete resection can be achieved, the contralateral side is performed. Others adopt the approach of starting on the side where the lesion is less advanced to preserve the feasibility and safety of a contralateral resection [9].

One should be very cautious to deny patients with bilateral nodules the chance of potentially curative treatment. Many contralateral nodules are small and often there is no histological diagnosis available. In our series with 42 patients with bilateral surgical exploration for suspicious lung nodules, 6 patients had a benign lesion on one side. Although new imaging techniques such as FDG-PET may give additional information, the contralateral lesion can still be benign. The sensitivity of PET scan for identifying a malignant pulmonary nodule is high (80–100%) but the specificity of PET scan is lower and varies more across studies (40–100%) [19]. PET scan can also be false negative in small lung cancers (<1 cm) because of the limited spatial resolution of the current PET scanners. The additional information of PET scan in patients with bilateral lung lesions is to exclude distant metastatic disease. When PET scan is negative for a pulmonary nodule larger than 1 cm, we would suggest treating the contralateral side (if proven NSCLC or if PET positive). The side with the PET negative pulmonary nodule can be followed up and re-evaluated by CT scan.

The TNM classification of patients with synchronous lung cancer has always been difficult as shown by several adaptations of the classification. In 1974, a second lesion was regarded as an ominous sign (M1 disease). In the 1986 staging system, a second lesion in the same lobe was staged as the T-factor of the primary plus one, a lesion in another ipsilateral lobe as T4 (stage IIIB) and a contralateral nodule as M1 (stage IV). According to the most recent AJCC cancer staging handbook (1997), the presence of multiple or satellite tumours within primary tumour lobe should be classified T4. Intrapulmonary lesions in another lobe (ipsilateral or contralateral) are to be classified M1. Multiple synchronous tumours of different histological cell type should be considered separate primary lung cancers, and each should be staged separately [5].

For the next revision of the TNM, the IASLC lung cancer staging committee collected a huge database from lung cancer patients from all over the world. The 5-year survival of patients with satellite nodules was 28% and the 5-year survival of patients with ipsilateral other lobe MPLC was 22%. The lung cancer staging committee proposes to reclassify satellite (same-lobe) nodules as T3 and same side (other lobe) nodules as T4 [3]. In the database of the IASLC, the median survival of 362 patients with bilateral synchronous MPLC was 10 months, the 1-year survival was 45% and the 5-year survival was only 3% [4] but this was significantly better compared to survival of patients with metastases outside the lung (median survival of 6 months). Based on these figures, the lung cancer staging committee proposes that patients with bilateral lung nodules should be staged as M1a, patients with distant metastases should be designated M1b. However, in the database of the IASLC, only 7 of 362 patients were surgically treated and it was impossible from the database to differentiate single or multiple nodules in the contralateral lung. From a tumour-biological point of view, it is difficult to understand why patients with a same histology synchronous lesion found in another ipsilateral lobe than the primary tumour should have a much better survival compared to patients with a synchronous second lesion in a contralateral lobe. Hopefully more data on patients with bilateral MPLC that are surgically treated will be included in the upcoming prospective IASLC database so that prognosis of patients with these tumours can be defined.

Based on our findings, and in line with Postmus and colleagues [4], we feel that a patient with a single contralateral lung lesion should have extensive search for metastatic spread and thorough functional assessment. In appropriate cases, the clinician treating must then decide whether this patient is likely to have two primaries, and is a candidate for radical treatment with bilateral resection, rather than for an approach for disseminated stage IV disease.

	Appendix A

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A References

 
Conference discussion

Dr R. Rami-Porta (Barcelona, Spain): You have at least 18 patients with synchronous lung cancer because they have different histology. The other 18 of the same histology, we don’t really know; they may have metastases or they may have second primaries. This is a very difficult problem, and maybe the relative proportion of patients in this subgroup explains the better survival that they have compared to metastases, and also the trend towards a little bit worse prognosis compared with the other group of 18 patients with different histology. So this is a 31% and 45% difference, which is not statistically significant but it is clinically significant, indeed.

The first point I would like to emphasize is that contralateral lesions are not metastases until they are proven they are metastases. This is a very difficult point to prove either preoperatively or postoperatively, because the technology has to go down to a molecular analysis, and it is difficult and we don’t have it in all hospitals.

The low resection rate, the 2% that you quoted from the International Association for the Study of Lung Cancer (IASLC) database, reflects the reluctance to offer surgical treatment to patients with bilateral lesions, and as you showed in your experience, I think that a proactive attitude in these patients, offering the possibility of resection, is likely to benefit them, indeed. Your 30% 10-year survival rate and your low mortality are proof of this.

The second point I would like to mention is that the TNM classification does not dictate a certain treatment for a certain TNM subset or stage. It simply groups patients with tumours of similar anatomic extension. It is for the members of the multidisciplinary tumour committee to decide on the best therapeutic option. This is what you did. You had a proactive attitude towards these patients. You did not assume that these patients had disseminated disease. You studied them thoroughly, both from the staging side and from the functional capacity of these patients, and you offered them resection, which I think was the right thing.

The only question I have is that all these 57 patients that you assessed for surgical intervention, I understand that they are not the whole group of patients with bilateral lesions. I would like to know how many patients in your database have bilateral lesions, because that would give us a more panoramic view of the frequency of bilateral lesions.

Dr De Leyn: I fully agree that survival of patients with identical histology is better, although not statistically significant but that this is indeed clinically important.

Your question is very important: how many patients did really present with bilateral disease? This study is based on a surgical database and unfortunately for that period we only have correct information on patients who had at least surgery for one side, and this is a pitfall. For the last 4 years we have a database on all patients with NSCLC who were presented at the multidisciplinary meeting. In that period we have operated on 16 patients, and, additionally, three patients we did not operate, two because the mediastinal nodes were positive and one because pulmonary function was too limited. So I think, indeed, the prevalence of patients with bilateral lung cancer is somewhat higher compared to reported in our article. Although extrapolation is not correct to do, it seems that the true figures should be increased by about 25%.

Dr D. Wood (Seattle, WA): I really appreciate the conclusion of your paper, which I think is one that is useful for all of us. I want to challenge or question one concept, which is the concept of staged operations. You pointed out a very high morbidity, length of hospitalization, ICU time in your second procedure. I guess I would ask how much time did you have between procedures, and would you consider a more provocative approach of taking these on as a single operation rather than staged operations? That is what we have been doing, and I guess I would allege that the morbidity and mortality and hospitalization of a single procedure is substantially less than the cumulative morbidity, mortality and hospitalization of staged procedures.

Dr De Leyn: I think there can be discussion, and in the literature there are some people, like the series reported by Munn, who do indeed single-stage interventions. But if you look at these results, much more patients than in our series had bilateral limited resection or wedge resection. I question whether doing, at the same time a bilobectomy or a sleeve lobectomy on one side and another lobectomy on the contralateral side, would be well tolerated by the patients. We usually wait 6 weeks between the two interventions. We make a new CT scan, and if the tumour has progressed in 6 weeks or if there are more nodules, it would not have been useful to operate on these patients anyway. And we perform new pulmonary function test. If the patient is not fully recovered, we wait another few more weeks. There is a study from Marseille where they also used staged procedures.

Dr F. Detterbeck (New Haven, CT): I am surprised by several things. I am surprised that 50% of the patients had tumours of different histology. In general, if you look at papers of multiple primary tumours, most of them have the same histology. So I am a little bit surprised by that, and it makes me suspicious that perhaps there is more of a selection bias in how you selected these patients.

In addition, as I observe patients over many years, I see more patients now that have a second focus of cancer in the same lobe, in a different lobe, on the same-side, on the contralateral side, and often it is not just a simple second focus but multiple foci. I think that there is a type of tumour that is a multi-focal tumour that I am at least more aware of now than I was 10 years ago, and I think we have to study this more. Most of those are adenocarcinomas with mixed BAC histology. I am surprised you did not see more of those. Do you have any comments on that?

Dr De Leyn: In this series we had two patients with multi-focal adenocarcinoma who had multiple lesions in the lung: one patient was resected, one patient was at second thoracotomy not resected. But I agree, we do see more and more patients with multi-focal adenocarcinoma. As you mention, in many studies the majority of multiple primary lung cancers had the same histology. In our series, 50% of contralateral lung cancers had different histology. Is it due to selection? We didn’t select, but, of course, patients are referred to our hospital by referring pneumologists and probably there is also a selection bias there.

We did not routinely do transthoracic punctures of peripheral lesions if histology was unknown.

Dr S. Bolukbas (Bad Nauheim, Germany): Did you perform a mediastinal lymph node dissection, because in case of mediastinal lymph node involvement our pathologists define contralateral nodules with the same histology as metastatic spread. Can you comment on this?

Dr De Leyn: As I mentioned, about 90% of patients had mediastinoscopy, because we really wanted to exclude that patients have N2 disease, and at thoracotomy, if it was an anatomical resection – and this is lobectomy, pneumonectomy, segmentectomy – we performed a systematic nodal dissection. In case of wedge resections we did not do a systematic nodal dissection. But in all cases of anatomical resection, we did a systematic nodal dissection.

Dr S. Halezeroglu (Istanbul, Turkey): You have shown us that you perform bilobectomy on the right side and lobectomy on the left side. So you remove three lobes in one patient. But you don’t have any patients with pneumonectomy on one side, I mean left pneumonectomy, and a right lobectomy on the other side. Do you think that we shouldn’t perform pneumonectomy and lobectomy in these patients, because in total you will remove three lobes if you perform a left pneumonectomy and right upper lobectomy, for example. If the patient has a functional workup that shows that they can be capable of life, do you think that we shouldn’t perform or we can perform this?

Dr De Leyn: I think after pneumonectomy, and mainly after right pneumonectomy, you have to be very careful. And although pulmonary function can be very good, if you do a lobectomy, it is a problem of the vascular bed and it is a problem of the right ventricle. So I would be very careful in doing, after pneumonectomy, a lobectomy. We had some patients with metachronous lesions after right pneumonectomy, where we planned to do a segmentectomy or a wedge excision, but if your resection is more extensive, although the pulmonary function is perfect, you end up with reduced pulmonary vascular bed, pulmonary hypertension and a high morbidity and mortality. Maybe after left pneumonectomy you can do on the right side a right upper lobectomy, but we have not done that.

Dr B. Passlick (Freiburg, Germany): You told us that you used in most of the cases limited resections for the second primary. Were they atypical resections or were they segmentectomies, and if so, what were the local recurrence rates after each of these procedures?

Dr De Leyn: We used limited resection in 29 procedures, nearly half of them were segmentectomy, nearly half of them were a large wedge excision. In the paper we report the recurrences, local and systematic, and we found no difference. So we did not have more recurrences when we did a limited resection. We did not look at the difference between segmentectomy and wedge excision, and as you have shown in a paper, this might be relevant to do.

	Footnotes

 
Presented at the 16th European Conference on General Thoracic Surgery, Bologna, Italy, June 8–11, 2007.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A References

 

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