Bronchial sleeve lobectomy is a lung parenchyma saving

ORIGINAL ARTICLE Quality of Life after Lung Cancer Surgery: A Prospective Pilot Study comparing Bronchial Sleeve Lobectomy with Pneumonectomy Bram Balduyck, MD, Jeroen Hendriks, MD, PhD, Patrick Lauwers, MD, and Paul Van Schil, MD, PhD Objective: To prospectively evaluate quality of life (QoL) evolution after sleeve lobectomy and pneumonectomy with the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and LC-13. Methods: From January 2003 till December 2005, QoL was prospectively recorded after 10 sleeve lobectomies and 20 pneumonectomies. Questionnaires were administered before surgery and 1, 3, 6, and 12 months postoperatively (MPO) with response rates of 100%, 90.0%, 76.7%, 80.0% and 73.3%, respectively. Results: Sleeve lobectomy was characterized by a 1 month temporary decrease in physical and social functioning scores after surgery (1MPO p 0.026 and p 0.048, respectively). After sleeve lobectomy, quality of life scores approximated baseline preoperative values 1 month after surgery. In the 12 months follow-up period after pneumonectomy, there was no return to baseline in physical and role functioning (12MPO p 0.001 and p 0.011, respectively). Pneumonectomy patients reported a significant increase in postoperative dyspnea (1MPO p 0.027, 6MPO p 0.025, 12MPO 0.021), general pain (1MPO p 0.006, 3MPO p 0.008, 6MPO p 0.005, 12MPO p 0.036), thoracic pain (6MPO p 0.019) and shoulder dysfunction (6MPO p 0.04, 12MPO p 0.026). Comparing both resections, significant differences in evolution of physical functioning (1MPO p 0.014, 3MPO p 0.008, 6MPO p 0.004), role functioning (1MPO p 0.041), cognitive functioning (6MPO p 0.005, 12MPO p 0.013) and shoulder dysfunction (12MPO p 0.049) were reported in favor of sleeve lobectomy. Conclusions: The high burden of dyspnea, general pain, thoracic pain and shoulder dysfunction reported after pneumonectomy, is not seen after sleeve lobectomy. In patients with anatomically appropriate early-stage lung cancer, sleeve lobectomy offers better quality of life than does pneumonectomy. University Hospital of Antwerp, Edegem, Belgium. Disclosure: The authors declare no conflict of interest. Address for correspondence: Bram Balduyck, MD, Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium. E-mail: bram.balduyck@uza.be Copyright 2008 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/08/0306-0604 604 Key Words: Quality of life, EORTC, QLQ-C30, QLQ LC-13, Bronchial sleeve lobectomy, Pneumonectomy, Lung cancer. (J Thorac Oncol. 2008;3: 604 608) Bronchial sleeve lobectomy is a lung parenchyma saving procedure indicated for central tumors and represents an alternative to pneumonectomy. Recent studies suggest that sleeve resection should be used routinely in the management of patients with anatomically appropriate centrally located tumors, even in patients with sufficient pulmonary reserve to permit pneumonectomy. 1 9 The long-term survival after sleeve lobectomy is favorable to that after pneumonectomy with lower postoperative risks and better preservation of lung function. 10 13 Pneumonectomy is associated with significant morbidity and mortality, 10 14 including postpeumonectomy lung edema, acute respiratory distress syndrome (ARDS), bronchopleural fistula, and postpeumonectomy syndrome. A recent meta-analysis of Zhiyuan Ma et al. demonstrated that sleeve lobectomy is effective and can be accomplished safely in selected patients without increasing the morbidity and mortality when compared with pneumonectomy. 10 The aim of any cancer treatment extends well beyond increasing survival. Palliation of symptoms and the maintenance or improvement of quality of life (QoL) are equally important goals of treatment. The benefits of existing cancer treatment need to be weighed against the side-effects and possible impairment of patients QoL. For many patients, the risk of an impaired QoL after surgery is an important consideration when deciding whether to proceed with surgery. Some patients may regard immediate postoperative complications as an acceptable risk, but are not prepared to accept significant postoperative functional disability. 15 The last few decades, there has been an increased recognition of the need to complement surgical treatment with an assessment of QoL, in addition to the impact of treatment, survival and side effects. Collection of postoperative QoL data has been advocated in follow-up of patients with cancer 16 and most published studies encourage the assessment of QoL in evaluating treatment outcomes. 15,17 In clinical lung cancer trials, several instruments have been validated, including the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ). 18 Limited information Journal of Thoracic Oncology Volume 3, Number 6, June 2008

Journal of Thoracic Oncology Volume 3, Number 6, June 2008 Quality of Life after Lung Cancer Surgery is available regarding the long-term QoL evolution after bronchial sleeve lobectomy. The objective of the present study is to prospectively evaluate QoL evolution after sleeve lobectomy and pneumonectomy for lung cancer, which has not been studied prospectively until now. PATIENTS AND METHODS From January 2003 to December 2005, 30 consecutive patients with a clinical diagnosis of non-small cell lung cancer (NSCLC) underwent bronchial sleeve lobectomy (n 10) or pneumonectomy (n 20). Sixteen patients underwent a left pneumonectomy and four patients a right pneumonectomy. Sleeve lobectomy was considered and performed in any case that could be completely resected by this technique. Pneumonectomy was performed for lesions that could not be removed by a lesser bronchoplastic procedure. Patients characteristics for the two surgical procedures are listed in Table 1. Quality of Life Assessment QoL was assessed using the Dutch version of the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30 (cancer core questionnaire) and the Dutch version of the EORTC QLQ-LC13 lung cancer-specific questionnaire module. 18,19 The questionnaires were administered one day before surgery and at 1, 3, 6, and 12 months postoperatively. The questionnaires were sent to the patients by mail, accompanied by a letter with general information and the aim of the study. EORTC QLQ-C30 The EORTC QLQ-C30 is a self-rating questionnaire composed of 30 questions/items and incorporates 9 multiitem scales: five functional scales (physical, role, cognitive, emotional, and social), three symptom scales (fatigue, pain, nausea/vomiting), a global health/qol scale, and several single items assessing additional symptoms (dyspnea, sleep disturbance, constipation, and diarrhea). A final item evaluates the perceived economic consequences of the disease. 18 Reliability and validity of the EORTC QLQ-C30 questionnaires have been confirmed in international studies. 19,20 TABLE 1. Patients Characteristics Sleeve Lobectomy (n 10) Pneumonectomy (n 20) Age ( SD) 65.3 7.3 yr 63.3 10.6 yr TNM classification Stage I 2 (20%) 3 (15%) Stage II 1 (10%) 9 (45%) Stage III 7 (70%) 8 (40%) Histology squamous cell carcinoma 6 (60%) 14 (70%) adenocarcinoma 4 (40%) 6 (60%) Induction chemotherapy 4 (40%) 5 (25%) Adjuvant radiotherapy 5 (50%) 4 (20%) Adjuvant chemotherapy 3 (30%) 4 (20%) EORTC QLQ-LC13 The EORTC QLQ-LC13 is a supplementary questionnaire module that was designed for use among patients receiving treatment with chemotherapy and/or radiotherapy. It contains 13 questions/items assessing lung cancer-associated symptoms (cough, hemoptysis, dyspnea, and site-specific pain), chemotherapy/radiotherapy-related side effects (sore mouth, dysphagia, peripheral neuropathy, and alopecia), and pain medication. 21 Chemotherapy/radiotherapy-related side-effects were not included in the analysis. Reliability and validity of the EORTC-LC13 module have been confirmed in international studies. 18 20 Statistical Analysis Statistical analysis was performed using statistical software (SPSS, version 15.0, Chicago, IL). In accordance with procedures recommended by the EORTC, scores were linearly converted to a scale ranging from 0 and 100 for each patient. For the global health/qol and functional scales, higher scores represent a higher level of functioning. For the symptom scales, higher scores represent a greater symptom burden. Results were reported as mean. The Wilcoxon-signed rank test was used to compare the mean value before and after surgery. A Student s t-test was used to compare parametric QoL data between groups. The Mann-Whitney U test was performed to compare nonparametric QoL data between groups. A p value of less than 0.05 was considered as statistically significant. RESULTS Response Rate to QoL Questionnaire and Comparison of Patients Groups The preoperative response rate to the QoL questionnaire was 100%, at 1 month 90.0%, at 3 months 80.0%, at 6 months 80.0%, and at 12 months 70.0% in the sleeve lobectomy group. The preoperative response rate was 100%, at 1 month 90.0%, at 3 months 75.0%, at 6 months 80.0%, and at 12 months 75.0% in the pneumonectomy group. No statistical differences were observed between the sleeve lobectomy and pneumonectomy group regarding age, sex, adjuvant therapy, TNM classification, tumor histology and response rate, with exception of a borderline significant higher number of T3N1M0 tumors in the sleeve lobectomy group (p 0.046). Preoperative QoL Both resections were comparable in preoperative QoL subscale scores. In general, patients complained of dyspnea and coughing and had a median impaired physical, social and emotional functioning preoperatively. There were no statistical differences in baseline QoL items between the two resection groups. QoL at baseline and evolution is shown in Table 2. Operative Morbidity and Mortality No operative mortality was observed, neither after sleeve lobectomy or pneumonectomy. After a mean follow-up of 43.7 months (range, 24 64 months), 5-year survival rates were 0.60 0.12 in the sleeve lobectomy group Copyright 2008 by the International Association for the Study of Lung Cancer 605

Balduyck et al. Journal of Thoracic Oncology Volume 3, Number 6, June 2008 TABLE 2. Mean Baseline QoL Functioning Scores and Mean Changes from Baseline as Measured by the EORTC QLQ-C30 and LC-13 Mean Baseline Mean Score Change from Baseline ([Delta]T0 a ) Domain QoL Scores 1mo 3mo 6mo 12mo QoL functioning scores a Physical functioning Sleeve lobectomy 80.6 10.9, p 0.027 1.0 NS 1.9 NS 8.4 NS Pneumonectomy 89.4 22.7, p 0.000 20.0, p 0.002 19.8, p 0.001 17.3, p 0.001 Role functioning Sleeve lobectomy 75.1 5.8, p 0.027 8.5 NS 0.1 NS 21.6 NS Pneumonectomy 88.3 40.6, p 0.000 28.9, p 0.006 32.3, p 0.002 27.7, p 0.011 Emotional functioning Sleeve lobectomy 83.4 8.3 NS 13.4 NS 2.1 NS 6.0 NS Pneumonectomy 65.5 14.3 NS 19.4, p 0.020 9.7 NS 2.8 NS Cognitive functioning Sleeve lobectomy 83.1 0.2 NS 4.3 NS 8.5, p 0.045 7.3 NS Pneumonectomy 95.8 7.4 NS 3.3 NS 8.4, p 0.033 20.0, p 0.020 Social functioning Sleeve lobectomy 78.3 20.2, p 0.048 6.4 NS 10.6 NS 4.9 NS Pneumonectomy 82.5 4.5 NS 11.0 NS 6.1 NS 11.1 NS Global Qol Sleeve lobectomy 62.5 3.6 NS 4.7 NS 8.5 NS 1.1 NS Pneumonectomy 62.9 10.8 NS 5.3 NS 0.6 NS 7.7 NS Symptom scores b Dyspnea Sleeve lobectomy 24.9 6.4 NS 0.9 NS 1.3 NS 7.1 NS Pneumonectomy 16.6 15.7, p 0.027 13.4 NS 16.8, p 0.026 18.4, p 0.021 Coughing Sleeve lobectomy 24.9 1.8 NS 6.25 NS 6.3 NS 7.2 NS Pneumonectomy 24.9 4.6 NS 9.9 NS 37.5 NS 8.9 NS Pain in general Sleeve lobectomy 12.1 5.1 NS 0.5 NS 4.7 NS 7.1 NS Pneumonectomy 8.7 11.3, p 0.006 12.5, p 0.008 15.7, p 0.005 13.1, p 0.036 Thoracic pain Sleeve lobectomy 10.0 0.1 NS 4.1 NS 8.1 NS 9.4 NS Pneumonectomy 11.6 7.3 NS 4.5 NS 16.9, p 0.019 8.9 NS Shoulder dysfunction Sleeve lobectomy 9.9 11.1 NS 0.0 NS 4.1 NS 0.0 NS Pneumonectomy 3.3 9.3 NS 8.9 NS 14.6, p 0.041 26.3, p 0.026 Enclosed are the p values, indicating significance between the baseline value and the value after 1, 3, 6, and 12 mo. No significance (NS) indicates return to baseline values. a Mean changes from baseline: positive numbers indicate a higher functioning score at follow-up (i.e., improvement) compared to baseline, while negative numbers indicate a reduction in the mean score (i.e., deterioration). b Mean changes from baseline: positive numbers indicate more symptom burden at follow-up (i.e., deterioration), while negative numbers indicate a reduction in the symptom burden (i.e., improvement). and 0.66 0.16 in the pneumonectomy group. There was no significant difference in 5-year survival between both groups. Regarding morbidity during the first postoperative year, three patients (30.0%) had pneumonia and three (30.0%) had persistent atelectasis necessitating repeat bronchoscopic treatment after sleeve lobectomy. There was one wound hematoma, necessitating arterial ligation in the latissimus dorsi muscle. Three patients (30.0%) had supraventricular tachycardia. Bronchial stenosis at the site of the anastomosis developed in two patients (20.0%) requiring several bronchoscopic dilatations. No patient required completion pneumonectomy. After pneumonectomy, four patients (20.0%) developed pneumonia at the contralateral side and two patients (10.0%) had a wound infection. After pneumonectomy, one immediate reoperation was necessary because of acute hemothorax. Four patients (20.0%) had supraventricular tachycardia. There was one case of vocal cord palsy. In the 12 month follow-up period, no local recurrences were observed. No significant difference in postoperative complication rate has been found between both groups with exception of a significantly higher occurrence of atelectasis (p 0.011) in the sleeve lobectomy group. 606 Copyright 2008 by the International Association for the Study of Lung Cancer

Journal of Thoracic Oncology Volume 3, Number 6, June 2008 Quality of Life after Lung Cancer Surgery QoL Evolution after Sleeve Lobectomy Sleeve lobectomy was characterized by a 1 month temporary decrease in physical and social functioning scores after surgery. Role function was significantly lower 12 months after surgery. After sleeve lobectomy, global quality of life, symptom and pain scores approximated baseline preoperative values 1 month after surgery. QoL Evolution after Pneumonectomy Pneumonectomy had a significant impact on physical and role functioning. In the 12 months follow-up period, there was no return to baseline in physical and role functioning. Pneumonectomy patients reported a significant increase in postoperative dyspnea, general pain, thoracic pain, and shoulder dysfunction, not recorded after sleeve lobectomy. comparing QoL Evolution after Sleeve Lobectomy and Pneumonectomy Comparing sleeve lobectomy to pneumonectomy, significant differences in evolution of physical functioning (1MPO p 0.014, 3MPO p 0.008, 6MPO p 0.004), role functioning (1MPO p 0.041), cognitive functioning (6MPO p 0.005, 12MPO p 0.013) and shoulder dysfunction (12MPO p 0.049) were reported in favor of sleeve lobectomy. DISCUSSION Bronchoplastic procedures are accepted as an alternative to pneumonectomy to preserve lung function. 2,5 Initially performed in patients with compromised pulmonary function, bronchial sleeve lobectomy was progressively adopted by most thoracic surgeons. Advocates for sleeve lobectomy point out the disadvantages of pneumonectomy including a higher occurrence of postoperative complications, cardiopulmonary dysfunction, long-term morbidity, and a poor QoL. Five years postoperative results by Deslaurier and colleagues, indicate that the reimplanted lobe(s) significantly contribute(s) to the remaining lung function. 22 The literature reports that sleeve lobectomy is followed by similar morbibity and mortality when compared with pneumonectomy but is associated with better lung function preservation. 23 In recent series, operative mortality has ranged from 0% to 5.2% which is similar to the range after standard lobectomy and lower than after standard pneumonectomy. 1,2,5 7,11,24 Little is known about the QoL evolution in lung cancer patients who have undergone lung resection. Quality of life in patients operated for lung cancer tends to deteriorate significantly with increasing extent of resection. Zieren et al. found more pronounced breathlessness on effort after pneumonectomy than after lobectomy. When compared with the preoperative assessment, QoL had deteriorated on discharge from hospital but was restored within 3 to 6 months after pneumonectomy. 25 Data concerning the QoL after sleeve lobectomy are rare. Ferguson et al. compared sleeve lobectomy and pneumonectomy in a meta-analysis of 99 articles and calculated postoperative quality-adjusted life years (QALY) using a statistical decision model. The authors concluded that sleeve lobectomy provides a favorable overall QoL and QALY advantage to pneumonectomy. 1 The present study aimed at determining difference according to surgical procedure within the first year after operation using standardized and validated questionnaires, which has not been studied prospectively until now. Both resections are comparable in patient characteristics and baseline QoL, with exception of a higher number of stage III patients in the pneumonectomy group. Sleeve lobectomy has a temporary negative impact on physical and social functioning scores of 1 month after surgery. After sleeve lobectomy, quality of life, symptom and pain scores approximated baseline values 1 month after surgery. In contrast, pneumonectomy has a significant impact on physical and role functioning. In the 12 months follow-up period, there is no return to baseline in physical and role functioning. Pneumonectomy patients report a significant increase in postoperative dyspnea, general pain, thoracic pain, and shoulder dysfunction, not seen after sleeve lobectomy. Comparing both resections in QoL evolution, significant differences in evolution of shoulder dysfunction, physical, role, and cognitive functioning are reported in favor of sleeve lobectomy. The present study has several limitations. A valid and reliable measurement of QoL is of utmost importance. In the present study, QoL was assessed by the QLQ-C30 and LC- 13. The reliability and validity of the EORTC questionnaires have been confirmed in stage III and IV lung cancer patients only. 19,20 It is unknown whether these standardized questionnaires are also applicable to patients who undergo thoracic surgery. In the present study, 30% of data were missing at 1 year follow-up in both groups. This could introduce a certain bias. The results of the present study need to be interpreted with caution because of the rather limited number of patients included in the study. Larger multicenter prospective studies comparing both resections need to be planned. In addition, the patients were not randomized between the two treatment groups. This prospective study represents a first step in documenting intermediate to long-term QoL evolution in patients undergoing bronchial sleeve lobectomy and pneumonectomy. As both access techniques are not comparable, the results are not intended to influence the choice of resection technique, which depends mostly on the specific presentation. Despite the mentioned limitations, the findings of the study offer valuable information in understanding the evolution in QoL after sleeve lobectomy and pneumonectomy and in that way may create realistic postoperative objectives for patients. In conclusion, the present pilot study prospectively documents quality of life evolution profiles comparing preoperative status with deficits and changes at 1, 3, 6, and 12 months after sleeve lobectomy and pneumonectomy. With exception of a 1 month temporary decrease in physical and social functioning, sleeve lobectomy patients return to their baseline quality of life in less than 1 month after surgery. In contrast, pneumonectomy patients report a sustained decrease of physical and role functioning in the 12-month follow-up period. The higher degree of dyspnea, general pain, thoracic pain and shoulder dysfunction reported after pneumonectomy, is not seen after sleeve lobectomy. In patients with anatomically appropriate early-stage lung cancer, sleeve lobec- Copyright 2008 by the International Association for the Study of Lung Cancer 607

Balduyck et al. Journal of Thoracic Oncology Volume 3, Number 6, June 2008 tomy offers better quality of life than does pneumonectomy. The authors are grateful to Gina Clerx, Sarah Balduyck and Annelies Masschelin for their help in the data management. ACKNOWLEDGMENTS This study has been supported by a Young Investigator Travel Award by the International Association for the Study of Lung Cancer (IASLC) and was presented as an oral presentation at the 12th World Conference on Lung Cancer, September 2 to 6, 2007 in Seoul, Korea. REFERENCES 1. Ferguson MK, Lehman AG. Sleeve lobectomy or pneumonectomy: optimal management strategy using decision analysis techniques. Ann Thorac Surg 2003;76:1782 1788. 2. Gaissert HA, Mathisen DJ, Moncure AC, et al. Survival and function after sleeve lobectomy for lung cancer. J Thorac Cardiovasc Surg 1996;11:948 953. 3. Van Schil PE, de la Rivière AB, Knaepen PJ, et al. Long-term survival after bronchial sleeve resection: univariate and multivariate analysis. Ann Thorac Surg 1996;61:1087 1091. 4. Icard P, Regnard JF, Guibert L, et al. Survival and prognostic factors in patients undergoing parenchymal saving bronchoplastic operation for primary lung cancer: a series of 110 consecutive cases. Eur J Cardiothorac Surg 1999;15:426 432. 5. Massard G, Kessler R, Gasser B, et al. Local control of disease and survival following bronchoplastic lobectomy for non-small cell lung cancer. Eur J Cardiothorac Surg 1999;16:276 282. 6. Suen HC, Meyers BF, Guthrie T, et al. Favorable results after sleeve lobectomy or bronchoplasty for bronchial malignancies. Ann Thorac Surg 1999;67:1557 1562. 7. Tronc F, Grégoire J, Rouleau J, et al. Long-term results of sleeve lobectomy for lung cancer. Eur J Cardiothoracic Surg 2000;17:550 556. 8. End A, Hollaus P, Pentsch A, et al. Bronchoplastic procedures in malignant and non-malignant disease: multivariate analysis of 144 cases. J Thorac Cardiovasc Surg 2000;120:119 127. 9. Fadel E, Yildizeli B, Chapelier AR, et al. Sleeve lobectomy for bronchogenic cancers: factors affecting survival. Ann Thorac Surg 2002;74: 851 859. 10. Ma Z, Dong A, Fan J, et al. Does sleeve lobectomy concomitant with or without pulmonary artery reconstruction (double sleeve) have favorable results for non-small cell lung cancer compared with pneumonectomy? A meta-analysis. Eur J Cardiothorac Surg 2007;32:20 28. 11. Okada M, Yamagishi H, Satake S, et al. Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy. J Thorac Cardiovasc Surg 2000;119:814 819. 12. Terzi A, Lonardoni A, Falezza G, et al. Sleeve lobectomy for non-small cell lung cancer and carcinoid: results in 160 cases. Eur J Cardiothorac Surg 2002;21:888 893. 13. Martin-Ucar AE, Chaudhuri N, Edwards JG, et al. Can pneumonectomy of non-small cell lung cancer be avoided? An audit of parenchymal sparing lung surgery. Eur J Cardiothorac Surg 2002;21:601 605. 14. Bernard A, Deschamps C, Allen MS, et al. Pneumonectomy for malignant disease: factors affecting early morbidity and mortality. J Thorac Cardiovasc Surg 2001;121:1076 1082. 15. Handy JR, Asaph JW, Skolon L, et al. What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery. Chest 2002;122:21 30. 16. Rocco G, Vaughan R. Outcome of lung surgery: what patients don t like. Chest 2000;117:153 162. 17. Fergusson RJ, Cull A. Quality of life measurement for patients undergoing treatment for lung cancer. Thorax 1991;46:671 675. 18. Aaronson NK, Ahmedzai S, Bergman B, et al. The European Organisation for Research and Treatment of Cancer QLQ-C30: a quality of life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993;85:365 376. 19. Montazeri A, Gillis CR, McEwen J. Quality of life in patients with lung cancer: a review of literature from 1970 to 1995. Chest 1998;113:467 481. 20. Bergman B, Aaronson NK. Quality of life and cost-effectiveness assessment in lung cancer. Curr Opin Oncol 1995;7:138 143. 21. Bergman B, Aaronson NK, Ahmedzai S, et al. The EORTC QLQ-LC13: a modular supplement to the EORTC core Quality of Life Questionnaire (QLQ-C30) for use in lung cancer clinical trials. Eur J Cancer 1994; 30A:635 642. 22. Deslauriers J, Gaulin P, Beaulieu M, et al. Long term clinical and functional results of lobectomy for primary lung cancer. J Thorac Cardiovasc 1986;92:871 879. 23. Tedder M, Anstadt MP, Tedder SD, et al. Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy. Ann Thorac Surg 1992;54:387 391. 24. Ginsberg RJ, Hill LD, Eagan RT, et al. Modern thirty-day operative mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 1983;86:654 658. 25. Zieren HU, Müller JM, Hamberger U, et al. Quality of life after surgical therapy of bronchogenic carcinoma. Eur J Cardiothorac Surg 1996;10: 233 237. 608 Copyright 2008 by the International Association for the Study of Lung Cancer