LIMITED RESECTION FOR BRONCHOGENIC CARCINOMA IN HIGH-RISK PATIENTS

Minimal resection for stage I bronchogenic carcinoma has been recently emphasised for patients with compromised respiratory function. The employ of Nd:YAG laser dissection is expected to improve the results for this group of patients. Between 1987 and 1994 inclusive we have performed minimal resection of stage I lung cancer in 43 patients with poor pulmonary function. Pulmonary impairment included at least one of the following criteria: forced expiratory volume in one second (FEV1) less than or equal to 1 liter, forced expiratory flow between 25 and 75% (FEF 25-75%) less than or equal to 0.6, maximum breathing capacity (MBC) less than 35 to 40% of predicted. The patients were randomised for conventional surgery (Group A, n=25), stapler and/or diathermy, and number for Nd:YAG laser (Group B, n=18). Histological types were adenocarcinoma (n=15), squamous cell carcinoma (n=18), large cell carcinoma (n=8) and small cell carcinoma (n=2). There were no perioperative mortality. Postoperative complications were mainly cardiac arrhythmias (n=10), prolonged air leak (n=16, only 2 from Group B) and atelectasis (n=7). All patients underwent local postoperative radiation therapy of approximately 3,000 cGy in 10 to 20 fractions beginning one month after resection. Two patients with small cell lung cancer were sent also for additive chemotherapy. Five year actuarial survival had been globally 56.2%. Twenty-nine (67%) patients are at the present moment alive and free of tumor, 5 with a follow-up longer than 5 years and 12 longer than 3 years. Fourteen patients relapsed, but only 5 (11.6%) recurred on the resection site, only one from the Group B but with a different histotype. Nine patients died. Resective pattern did not significantly influence long term survival (p=0.95). Nevertheless Group B presented a lower complication rate with a faster recovery in term of air leak control and hospital stay. These findings suggest that minimal resection can offer an acceptable risk/benefit ratio for stage I lung cancer in patients with marked impairment of pulmonary function and Nd:YAG device may allow safe, air proof and more radical resection