Key risk factors for mortality after pneumonectomy for lung cancer: insights from a large single-center cohort study

Abstract

Background: Surgery remains the most effective treatment for patients with non-small cell lung cancer (NSCLC). However, pneumonectomy is usually associated with high mortality and morbidity rates. Defining post-operative death after such extensive procedures remains controversial. This study aimed to assess the 30- and 90-day post-pneumonectomy mortality rates. The secondary aim was to identify the most critical factors determining early post-pneumonectomy mortality.

Methods: This retrospective, single-institution cohort study was conducted at a high-volume center and included a large group of 514 patients who underwent pneumonectomy for NSCLC from 2006 to 2020. Our analysis considered patient comorbidities, staging, surgical techniques, neoadjuvant chemotherapy, and major complications, and examined their associations with 30- and 90-day mortality rates. We initially performed a univariable Cox regression analysis, followed by multivariable analyses, including variables with P<0.1.

Results: The 30- and 90-day mortality was equal to 4.3% and 9.1%, respectively. For 30-day mortality, statistically significant factors included the occurrence of a bronchopleural fistula (BPF) [hazard ratio (HR) =5.128; 95% confidence interval (CI): 2.009-13.087; P<0.001], positive bronchial resection margin (HR =7.917; 95% CI: 2.61-24.01; P<0.001) and the prolonged intubation (>48 hours) (HR =3.822; 95% CI: 1.06-13.785; P=0.041). For the 90-day mortality, the presence of the BPF (HR =5.284; 95% CI: 2.706-10.318; P<0.001), positive bronchial resection margin (HR =3.528; 95% CI: 1.370-9.083; P=0.009), chest wall infiltration (HR =3.770; 95% CI: 1.121-12.676; P=0.03), and prolonged intubation (>48 hours) (HR =2.912; 95% CI: 1.102-7.649; P=0.03) were the statistically significant risk factors.

Conclusions: A 90-day follow-up period should be considered when assessing short-term mortality rates after major pulmonary resections. Monitoring long-term mortality is important, as the mortality rate in our group doubled after 3 months. BPF, prolonged intubation, chest wall infiltration, and positive bronchial resection margin significantly increase the risk of 30- and 90-day mortality rates.

Keywords: 30-day mortality; 90-day mortality; bronchopleural fistula (BPF); non-small cell lung cancer (NSCLC); pneumonectomy.

Figure 1

Flowchart diagram presenting the successive steps of creating the group of 514 patients after pneumonectomy due to NSCLC, finally included in the analysis. NSCLC, non-small cell lung cancer; SCLC, small cell lung cancer; VATS, video-assisted thoracoscopic surgery.

Figure 2

Kaplan-Meyer curves showing the impact of a bronchopleural fistula development on the risk of death in the first 90 days after pneumonectomy.

Figure 3

Kaplan-Meyer curves showing the impact of a prolonged intubation (>48 hours) on the risk of death in the first 30 days after pneumonectomy.

Figure 4

Kaplan-Meyer curves showing the impact of a positive bronchial resection margin on the risk of death in the first 90 days after pneumonectomy.

Figure 5

Kaplan-Meyer curves showing the impact of the chest wall infiltration on the risk of death in the first 90 days after pneumonectomy.

Figure 6

Kaplan-Meier survival curves comparing the differences in 90-day survival of patients operated on before and after 2013.