Lung Cancer.pdf

250 A.A. Vaporciyan, J.F. Kelly, and K.M.W. Pisters
count below 4 x 10 9 /L or an absolute neutrophil count below 2 x 10 9 /L is
considered a relative contraindication to surgery. In patients with persistent
low white blood cell counts after chemotherapy, either the recovery
interval is prolonged (if the white blood cell count is slightly diminished)
or recombinant granulocyte colony-stimulating factor (e.g., Neupogen) is
administered (if the white blood cell count is significantly diminished). In
patients with persistent anemia after chemotherapy, recombinant erythropoietin
(e.g., Procrit) is administered to restore normal hemoglobin levels
and minimize the need for perioperative transfusions. Patients with
prechemotherapy weight loss and those who sustain weight loss during
chemotherapy benefit from aggressive nutritional support during the interval
between chemotherapy and surgery. Patients with extreme weight
loss may require enteral access and continuous feedings. All these maneuvers
to restore adequate bone marrow function and nutritional status are
performed efficiently only if the oncologist and the surgeon maintain close
communication. If either functions without knowledge of the other’s
treatment plan, then potentially correctable problems may go uncorrected
or result in delay of the planned treatment.
After radiation therapy, the recovery interval before surgery is at least 1
week for each 10 Gy delivered. Earlier attempts at surgery are associated
with increased morbidity due to the still-resolving inflammation, which
makes dissection more difficult, and radiation-associated edema and
pneumonitis. As in patients treated with preoperative chemotherapy, the
recovery period in patients treated with preoperative radiation therapy is
spent maximizing the patient’s condition for surgery. For example, patients
with nutritional impairment due to esophagitis (see the section Radiation
Oncology earlier in this chapter) are given aggressive nutritional
support. Communication between the radiation oncologist and the surgeon
is of paramount importance. If the delay between completion of radiation
therapy and surgery is greater than 2 months, the technical difficulty
of surgery is greatly magnified because of increasing fibrosis. By
maintaining good communication, the radiation oncologist and the surgeon
can identify and correct problems early, thus avoiding unnecessary
delays in surgery and minimizing postoperative morbidity.
Surgical Technique
In patients treated with preoperative chemotherapy or radiation therapy,
the technical details of pulmonary resection are adjusted to reduce the risk
of specific postoperative complications.
Meticulous Dissection
The most important technique is meticulous dissection. Gentle handling of
the tissue, a surgical axiom, cannot be stressed enough in patients undergoing
thoracic surgery after preoperative chemotherapy or radiation therapy.