The Safety and Efficacy of Second Pulmonary Resections for Lung Cancer

H. Reddington¹, I. Emmerick¹, C. Briskin¹, L. Suh¹, A. Crawford¹, M. Maxfield¹, K. Uy¹, F. Lou^2
1University of Massachusetts Chan Medical School, worcester, Massachusetts ²University of Massachusetts Chan Medical School, Northborough, Massachusetts

Purpose: As second operations for lung cancers become more common, the safety profile and factors associated with negative postoperative outcomes remain to be defined. We aim to identify the incidence of 30-day postoperative composite morbidity or mortality (M&M) and identify predictors M&M among patients who had a secondary pulmonary resection.

Methods: We performed a retrospective cohort study of individuals 18 and older who underwent lung resections for non-small cell lung cancer (NSCLC) between 2012 and 2023, registered in the Society of Thoracic Surgeons (STS) General Thoracic Surgery Database. Patients with second pulmonary resections were identified as those with two unique resection entries for stage I-IIIa cancer. The main outcome was 30-day postoperative composite major morbidity or mortality (M&M). Major morbidity was defined as reintubation, need for tracheostomy, initial ventilator support > 48 hours, ARDS, pneumonia, pulmonary embolus, bronchopleural fistula, bleeding requiring reoperation, or myocardial infarction within 30 days of surgery. Univariate associations were determined using chi-square, Mann-Whitney U, or Student’s t tests. A multivariable logistic regression model was constructed using backward selection.

Results: A total of 145,096 individuals were analyzed; 2729 (1.9%) had 2 pulmonary resections. Patients who underwent second pulmonary resections were older, more likely to be women, had lower predicted forced expiratory volume (FEV1), lower predicted diffusing capacity (DLCO), and were more likely to receive sub-lobar resections. They were also more likely to have their resections performed via a minimally invasive approach and have a lower clinical stage (Table 1). The incidence of 30-day-M&M was 5.9% and 4.6% for individuals with one and two resections respectively. (p-value = 0.004)
Considering only the cohort with second lung resections in a multivariable model (Figure 1) with composite M&M as the outcome of interest, patients with lower FEV1 or DLCO had a higher risk of M&M, whereas those with a history of interstitial fibrosis had a 3-fold increased risk. When compared to wedge resections, segmentectomies, lobectomies and pneumonectomies resulted in over 2, 4, and 8-fold increase in M&M, respectively. Patients who had any complication after their first surgery, or who had an unexpected escalation of care after their first surgery, similarly had increased M&M after their second resection. The model had a c-statistic of 0.717.

Conclusion: The incidence of 30-day-M&M was not higher among the individuals who underwent second pulmonary resections. Preoperative factors associated with increased 30-day-M&M after a second resection included lower FEV1 or DLCO, interstitial fibrosis, any complication after the first resection or an anatomic resection.

Identify the source of the funding for this research project: University of Massachusetts Chan Medical School, Department of Surgery