title: Additional pulmonary resections after pneumonectomy: actual long-term survival and functional results.
abstract: OBJECTIVE
  Pulmonary resections after pneumonectomy due to metastases or metachronous non-small cell lung cancer (NSCLC) are rare because of the high potential risk of the second procedure and uncertain long-term results. On the basis of our series (largest in Europe) we tried to assess the long-term survival of patients treated in stage IV NSCLC.
  
  
  METHODS
  Retrospective analysis was carried out on 18 patients treated at our department by pneumonectomy followed by additional resection in the years 1981-2002 (15 males and 3 females, 44-69 years, mean 57). Eleven pneumonectomies were performed on the right side and seven on the left. Twelve squamous cell carcinomas and six adenocarcinomas were diagnosed. All patients were staged postoperatively as IIB-IIIA (four were N2). Their WHO status ranged between 0 and 1. The second surgical procedure (16 wedge resections, 2 chest wall resections) was performed 4-106 months later (mean 26). The patients staged N2 were radiated postoperatively.
  
  
  RESULTS
  There were no early postoperative deaths. The morbidity rate after second surgery was comparable to that observed after ordinary wedge resection. Histology of the lesions removed during the second operation was the same as after pneumonectomy in all patients. The pulmonary function tests (PFT) results worsened significantly but still reached 56-63% of the predicted values. Sixteen resected tumors of the remaining lung were staged T1 (<3cm), 2 - T3 (<3cm but infiltration of the parietal pleura on an area of 2-4cm(2)). Three patients revealed N2 disease (they were all N0 after pneumonectomy). All patients were considered M1 after second surgery. WHO status after the second procedure remained the same in 8 patients (44%) and worsened in 10 patients (56%). The survival rates were as follows: 11 patients survived 2 years (61%) while 8 patients survived 5 years (44%). The majority of patients died due to lung cancer (70%) but all the rest (30%) due to circulatory or respiratory insufficiency. There was a significant difference (p<0.05) in 5-year survival for N0-N1 vs N2 status (63% vs 14% - 1 patient) and also regarding the time interval between surgeries: less than 12 months vs more than 12 months (0% vs 63%).
  
  
  CONCLUSIONS
  Pulmonary resections performed after pneumonectomy due to NSCLC are rare procedures but with an acceptable perioperative risk. The second procedure should be limited to wedge resection. The prognosis is poor for patients with N2 status and for those treated by second surgery earlier than 12 months after the first procedure.
authors.affiliation: Pomeranian Medical University, Thoracic Surgery Department of the Regional Hospital for Lung Diseases, Sokołowskiego str 11, PL 70-891 Szczecin Zdunowo, Poland. grodzki@grodzki.szczecin.pl
authors.forename: Tomasz
authors.initials: T
authors.lastname: Grodzki
authors.forename: Jacek
authors.initials: J
authors.lastname: Alchimowicz
authors.forename: Anna
authors.initials: A
authors.lastname: Kozak
authors.forename: Bartosz
authors.initials: B
authors.lastname: Kubisa
authors.forename: Jarosław
authors.initials: J
authors.lastname: Pieróg
authors.forename: Janusz
authors.initials: J
authors.lastname: Wójcik
authors.forename: Michał
authors.initials: M
authors.lastname: Bielewicz
authors.forename: Dominika
authors.initials: D
authors.lastname: Witkowska
mesh_terms: D000230:Adenocarcinoma / Q000473:pathology / Q000601:surgery; D000328:Adult; D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000473:pathology / Q000601:surgery*; D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000601:surgery; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D008175:Lung Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D011013:Pneumonectomy / Q000009:adverse effects / Q000379:methods*; D011379:Prognosis; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome; D014797:Vital Capacity