II
JOURNAL
BRITISH MEDICAL
Influence of
1329
1978
NOVEMBER
postoperative
empyema
survival after
on
pulmonary resection for bronchogenic carcinoma HARVEY MINASIAN,
B3i,iti'slz
LEWIS,
C T
Medical 7ournal, 1978, 2,
S
J W EVANS
1329-1331
paired
with patients from the parent group who had
thereby
empyema and who
Summary
fered
individually paired this complication.
possible
for
tumour,
extent
age,
and
spread,
use
patients
with
Pairs
extent
sex,
of
as
far
extent
of
postoperative radiotherapy. Analysis
pairs and for the significant difference
of survival times both for the matched groups of
two
patients
showed
no
Survival
long-term survival.
in
The results suggest that any
immunological suppression
ineffective in
sepsis
due to
in the
pleural
is
space
taken
paired been
Le
suggested
Roux'
prolong
survival
carcinoma impression
fistula
of the when
this
at
These
and
to
operated
the
of
results
to
attempts
generate
study
were
the
same
year.
studies
have cases were
no
tried
based
attempt
on
to
carried
We have therefore
to
with
hut
manage-
the
in
each
same
paired
In the
study the
the date of the last
to
study)
a
outpatient were
control patients who had
year. One other patient
with
of six
period
the empyema group
in
two
case
survival
the empyema
in
still alive
were
the time of
at
patient who had had his
operation
in
The overall
periods of
pared.
statistical
analysis
For
were
of the
both rank
used. The groups 2
test was
data
according
test
sign
time
were
(Wilcoxon's
tests
unmatched. The
in
patients,
operation.
of the
was
to
used
also
(t tests) and nonmatched-pairs signed compared both matched and
parametric sum
were
and
Sequential sequential
compare percentages.
to
carried
out
with
a
closed
the method described.7
conflicting results.3 relatively
few patients
match individual
out
pleura only, (b)
and 10-year and five-year survival rates in compared with those in the control group. survival in the matched pairs were also com-
parametric ranks tests)
anamnestic
survival
compare
six
The overall survival
analysis
uninfected
the visual
as
in the control group who
the empyema group
bronchopleural
an
on
one
Lewiss
and
time
the date of operation
Of these
the
might
primary
response.
studies, however,
pairs.
Williams
also
for
resection
If confirmed it could influence
with empyema and made in
was
they reviewed
credence
small
Several infected
TIhis
lung.
after
patients
some
hospital.
give immunological and
ment
that postoperative chronic empyema
in
the
at
with live (at the time of the
group and
Introduction
still alive
were
as
attendance.
survival.
prolonging
far
as
measured from the date of
w,as
patients who was
of carcinoma cells
invading
or
to
(histological)-namclv, (a) no deposits in lymph nodes, (b) deposits in intrapulmonary lymph nodes only, (c) deposits in hilar lymph nodes, and (d) deposits in mediastinal lymph nodes; and (7) use of postoperative radiotherapy.
lymphatic
of
lung
to
parietal pleura, (c) extending to parietal pleura, ribs, and intercostal muscles, and (d) invading mediastinum; (5) histology of the neoplasm-namely, (a) squamous-cell carcinoma, (b) undifferentiated carcinoma, (c) oat-cell carcinoma, (d) adenocarcinoma, and (e) alveolar-cell carcinoma; (6) extent of spread to lymph nodes
as
operation, histology
of
extending
who had not suf-
matched
were
primary spread,
of
(a) confined
developed empyema after pulprimary carcinoma of the lung
had
for
resection
monary were
who
developed
not
controls.
as
Pairs were matched for the following variables: (1) age; (2) sex; (3) type of operation (pneumonectomy or lobectomy, including sleeve resection); (4) extent of growth of the primary neoplasm-namely,
and conclusions
Fifty patients
served
a
study based
Results
patients on
our
The durations of
hospital records in which each patient with empyema accurately matched and paired with an uninfected patient.
was
181
months
cases
the empyema
The
pairs. Age
Patients and methods
and
(mean
following at
time
control
58-60±654
sepsis in the empyema group ranged from 19 months, median 7-7 months-table I). was
results
of
due were
to
bronchopleural fistula. analysis of the
obtained from
operati'on-The
groups
at
mean
the time of
were
to
In 40
50 matched
(± SD) in the
ages
operation
one
empyema
58-78±+685
and
respectively (table II). This difference was not significant (P= 0-89). In 41 matched pairs the age difference between the patients was five years or less (in half of these the patient with empyema was older); in eight the age difference was 6-12 years (the patient with empyema being older in five); and in one matched pair the patient with empyema was 41 and the control patient 61
patients who had undergone thoracotomy for lung neoplasms at this hospital during 1950-76, only 50 cases were found suitable for the empyema group. Except for the initial infection, all these patients had made a satisfactory postoperative recovery and been discharged from hospital. These 50 patients were Out of the records of 3450
years
years of age.
Sex-There
were only two Type of operation-Perfect
The London
Hospital,
London El
HARVEY MINASIAN, MB,
cT'
LEWIS,
FRCS,
senior
1BB
36 had
FRCS, surgical
registrar,
registrar
department
of cardiovascular and thoracic
Hospital Medical College, in
in the was
series; these
achieved
were
for all
undergone pneumonectomy, and 14 lobectomy. of growth of primiary neoplasnm-Forty-one
perfectly.
matched
lung
S J W EVANS, BA, lecturer
match
had invaded the visceral
or
parietal pleura;
London El 2AD
were
medical statistics
In 37 of these the carcinoma
nine
pleura; in
was
one
50
paired. pairs:
pairs
E-xtent
surgery
The London
women
confined
were
to
the
it had extended to
and in three it had invaded the mediastinum. There
imperfect matches,
most
of them
differing
in
only
one
category.
TABLE
I-Duirati'ons of sepsis in the 50 patients zwho developed empyema after thoracotomy for luing neoplasms I
No ofpatients
of sepsis (months) ~~~~~~~~~~~~~Duration
1-3
-6
-9
-12
-15
18-21
-24
34
36
48
66
71
180
181
8
10
8
6
7
2
2
1
1
1
1
1
1
1
~~~~~~~~~~~~Total 50
1330 TABLE
~~~~~~~~~~~~~~~~~BRITISH
ii-Ages
at ti'me
of operati'on i'n the emipyema and control groups
(P= 0-66). variables
Total
~~
40-
45-
50-
55-
60-
65-
70-75
2 2
2 2
7 5
17 21
10 11
8 8
4 1
pairs matched
the 30
(P=~0-62).
result
similar
Age in years No in empyerna group Noof controls
between the patients with empyema and controls
tes-t applied
to
skew, logarithms of survival times
very
50 50
The
Histology of nteoplasm-A complete match was possible in all except one of the pairs, in which a patient with empyema and alveolar-cell carcinoma was matched with a control patient with adenocarcinoma. Thirty-three pairs had squamous-cell carcinoma, eight undifferentiated carcinoma, five oat-cell carcinoma, and three adenocarcinoma. Extent of spread to lymiph nodes-There were 43 pairs who matched perfectly, 19 of whom did not have deposits in lymph nodes. Of the remaining pairs, one had deposits in intrapulmonary lymph nodes, 13 deposits in hilar lymph nodes, and 10 deposits in mediastinal lymph nodes. Most of the seven pairs of imperfect matches varied in only one category. Postoperati've r-adiotherapy-Four pairs of patients had received radiotherapy, and a complete match was possible. In 32 matched pairs the same surgeon had performed the operation. At the time none of the patients had clinical or radiological evidence of secondary carcinoma, neuropathy, or myopathy. Altogether 30 pairs of patients matched perfectly for all seven variables and categories (matching for age being assumed to be perfect when the difference was five years or less). Of the remaining 20 pairs, 12
commonest
There
Ps
0-65 0-93
1-64 0-30 2-76 0-60 0-61 1-94 2-39 18-04 0-48 0-31
1-21 1-27 1-31 1-31 1-56 1-64 1-93 2-05 2-06 2-10 2-12 2-52 2-61 2-67
1-08
0-16 5-30 0-36 0-57 4-44 1-51
2-93 2-96 3-13 3-51 5-07 5-12 5-59 5-92 6-00 7-47 8-34 10-63 15-24 15-24 15-99 18-93
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
was
in
greater
was
statistically meaningful
a
of organism.
type
to
survival
in
infected
patients
results
Our
favour of the
in
E coli'
with
and
considered
their
pairing patients
possi'ble
effect of age and
vidual pairs
was
perfect
49 pairs. In
in
matching
pairs
Comparisons to
was
than
perfect.
in these
cases
seven
was
made
variables
were
therefore
influence survival
Our
differ
Takita,' and Ruckdeschel
Keehan.3
and rates
40
in
and found that
this
Cady
and
patients
with
13",,
of
rates
difference
from
54,',
may have
those
Clifton
35(,,
34
in
with
at
pathological
was
Clifton,'
and
five-year
survival
patients
without
333
1,(',
the
rates
concluded
level
in
14 patients
without,
patients
18
in
patients.
empyema
The
classification.
Survivals
of
patients
regional
to
in
in survival
in
significant.
be
growth
in
the four groups
as
et
al
patients
patients
Feinstein's,-
with
found
survival. Ruckdeschel
rate
to
patients
6-72).
2j
only
according
considered
were
between
pulmonary
groups
compared. Differences
groups
even
empyema
and conclkuded that empyema
on
survival
combinations of these groups and
1-51 20-82 1-89 0-64 7-02 0-39 5-44 0-54 5-10 13-21 10-33
and
178
respectively
non-empyema
four
into
were
respectively. 'Fhey
significant
five-year
the
Cady
of
analysed
empyema
favourable influence
a
that
divided
27',,
and
sig-
a15 and agree with those of Lawton
et
compared
empyema
of
rates
times a
pairs matched
postoperative
Takita, who analysed five-year survival with
showed
carcinoma.
and
was
of
the
within
as
survival
patients who have had
in
bronchogenic
conclusions
in
comparisons
that
out
minor.
considered the differences
conclude
does
for
of the
20
well
as
survival, anid when the 30
in
We
not
relatively
was
and number in
Nevertheless,
between groups
None
smaller.
resection
that
significant difference
that any
nificant difference for all
less
overlooked.
not
Any indi-
diversity
surprising
were
ensure
of the
view
not
it
was
non-correspondence pairs
survival.
by matching
dingly. Histology was considered to be a most influencing survival, and in this respect match-
considered
of variables 50
excluded
was
sex
chosen because
were
influencing
in
accor
important factor ing
importance
were
clinicovarious a
whole
favour of the empyema The
confined
difference
largest
lung
to
and
those
lymph nodes. In our study there were 22 such pairs of patients who matched for all seven variables: the mean period of survival in the
with
intrathoracic
empyema group
4-81
was
years. This difference
0-18
0-60 2-19 6-39 10-49
was
Lawton and Keehan
patients
34 empyema rates
of
17-6)),
and was
years not
and in the control group 4-85
significant (P
JOURNAL
BRITISH MEDICAL
Influence of
1329
1978
NOVEMBER
postoperative
empyema
survival after
on
pulmonary resection for bronchogenic carcinoma HARVEY MINASIAN,
B3i,iti'slz
LEWIS,
C T
Medical 7ournal, 1978, 2,
S
J W EVANS
1329-1331
paired
with patients from the parent group who had
thereby
empyema and who
Summary
fered
individually paired this complication.
possible
for
tumour,
extent
age,
and
spread,
use
patients
with
Pairs
extent
sex,
of
as
far
extent
of
postoperative radiotherapy. Analysis
pairs and for the significant difference
of survival times both for the matched groups of
two
patients
showed
no
Survival
long-term survival.
in
The results suggest that any
immunological suppression
ineffective in
sepsis
due to
in the
pleural
is
space
taken
paired been
Le
suggested
Roux'
prolong
survival
carcinoma impression
fistula
of the when
this
at
These
and
to
operated
the
of
results
to
attempts
generate
study
were
the
same
year.
studies
have cases were
no
tried
based
attempt
on
to
carried
We have therefore
to
with
hut
manage-
the
in
each
same
paired
In the
study the
the date of the last
to
study)
a
outpatient were
control patients who had
year. One other patient
with
of six
period
the empyema group
in
two
case
survival
the empyema
in
still alive
were
the time of
at
patient who had had his
operation
in
The overall
periods of
pared.
statistical
analysis
For
were
of the
both rank
used. The groups 2
test was
data
according
test
sign
time
were
(Wilcoxon's
tests
unmatched. The
in
patients,
operation.
of the
was
to
used
also
(t tests) and nonmatched-pairs signed compared both matched and
parametric sum
were
and
Sequential sequential
compare percentages.
to
carried
out
with
a
closed
the method described.7
conflicting results.3 relatively
few patients
match individual
out
pleura only, (b)
and 10-year and five-year survival rates in compared with those in the control group. survival in the matched pairs were also com-
parametric ranks tests)
anamnestic
survival
compare
six
The overall survival
analysis
uninfected
the visual
as
in the control group who
the empyema group
bronchopleural
an
on
one
Lewiss
and
time
the date of operation
Of these
the
might
primary
response.
studies, however,
pairs.
Williams
also
for
resection
If confirmed it could influence
with empyema and made in
was
they reviewed
credence
small
Several infected
TIhis
lung.
after
patients
some
hospital.
give immunological and
ment
that postoperative chronic empyema
in
the
at
with live (at the time of the
group and
Introduction
still alive
were
as
attendance.
survival.
prolonging
far
as
measured from the date of
w,as
patients who was
of carcinoma cells
invading
or
to
(histological)-namclv, (a) no deposits in lymph nodes, (b) deposits in intrapulmonary lymph nodes only, (c) deposits in hilar lymph nodes, and (d) deposits in mediastinal lymph nodes; and (7) use of postoperative radiotherapy.
lymphatic
of
lung
to
parietal pleura, (c) extending to parietal pleura, ribs, and intercostal muscles, and (d) invading mediastinum; (5) histology of the neoplasm-namely, (a) squamous-cell carcinoma, (b) undifferentiated carcinoma, (c) oat-cell carcinoma, (d) adenocarcinoma, and (e) alveolar-cell carcinoma; (6) extent of spread to lymph nodes
as
operation, histology
of
extending
who had not suf-
matched
were
primary spread,
of
(a) confined
developed empyema after pulprimary carcinoma of the lung
had
for
resection
monary were
who
developed
not
controls.
as
Pairs were matched for the following variables: (1) age; (2) sex; (3) type of operation (pneumonectomy or lobectomy, including sleeve resection); (4) extent of growth of the primary neoplasm-namely,
and conclusions
Fifty patients
served
a
study based
Results
patients on
our
The durations of
hospital records in which each patient with empyema accurately matched and paired with an uninfected patient.
was
181
months
cases
the empyema
The
pairs. Age
Patients and methods
and
(mean
following at
time
control
58-60±654
sepsis in the empyema group ranged from 19 months, median 7-7 months-table I). was
results
of
due were
to
bronchopleural fistula. analysis of the
obtained from
operati'on-The
groups
at
mean
the time of
were
to
In 40
50 matched
(± SD) in the
ages
operation
one
empyema
58-78±+685
and
respectively (table II). This difference was not significant (P= 0-89). In 41 matched pairs the age difference between the patients was five years or less (in half of these the patient with empyema was older); in eight the age difference was 6-12 years (the patient with empyema being older in five); and in one matched pair the patient with empyema was 41 and the control patient 61
patients who had undergone thoracotomy for lung neoplasms at this hospital during 1950-76, only 50 cases were found suitable for the empyema group. Except for the initial infection, all these patients had made a satisfactory postoperative recovery and been discharged from hospital. These 50 patients were Out of the records of 3450
years
years of age.
Sex-There
were only two Type of operation-Perfect
The London
Hospital,
London El
HARVEY MINASIAN, MB,
cT'
LEWIS,
FRCS,
senior
1BB
36 had
FRCS, surgical
registrar,
registrar
department
of cardiovascular and thoracic
Hospital Medical College, in
in the was
series; these
achieved
were
for all
undergone pneumonectomy, and 14 lobectomy. of growth of primiary neoplasnm-Forty-one
perfectly.
matched
lung
S J W EVANS, BA, lecturer
match
had invaded the visceral
or
parietal pleura;
London El 2AD
were
medical statistics
In 37 of these the carcinoma
nine
pleura; in
was
one
50
paired. pairs:
pairs
E-xtent
surgery
The London
women
confined
were
to
the
it had extended to
and in three it had invaded the mediastinum. There
imperfect matches,
most
of them
differing
in
only
one
category.
TABLE
I-Duirati'ons of sepsis in the 50 patients zwho developed empyema after thoracotomy for luing neoplasms I
No ofpatients
of sepsis (months) ~~~~~~~~~~~~~Duration
1-3
-6
-9
-12
-15
18-21
-24
34
36
48
66
71
180
181
8
10
8
6
7
2
2
1
1
1
1
1
1
1
~~~~~~~~~~~~Total 50
1330 TABLE
~~~~~~~~~~~~~~~~~BRITISH
ii-Ages
at ti'me
of operati'on i'n the emipyema and control groups
(P= 0-66). variables
Total
~~
40-
45-
50-
55-
60-
65-
70-75
2 2
2 2
7 5
17 21
10 11
8 8
4 1
pairs matched
the 30
(P=~0-62).
result
similar
Age in years No in empyerna group Noof controls
between the patients with empyema and controls
tes-t applied
to
skew, logarithms of survival times
very
50 50
The
Histology of nteoplasm-A complete match was possible in all except one of the pairs, in which a patient with empyema and alveolar-cell carcinoma was matched with a control patient with adenocarcinoma. Thirty-three pairs had squamous-cell carcinoma, eight undifferentiated carcinoma, five oat-cell carcinoma, and three adenocarcinoma. Extent of spread to lymiph nodes-There were 43 pairs who matched perfectly, 19 of whom did not have deposits in lymph nodes. Of the remaining pairs, one had deposits in intrapulmonary lymph nodes, 13 deposits in hilar lymph nodes, and 10 deposits in mediastinal lymph nodes. Most of the seven pairs of imperfect matches varied in only one category. Postoperati've r-adiotherapy-Four pairs of patients had received radiotherapy, and a complete match was possible. In 32 matched pairs the same surgeon had performed the operation. At the time none of the patients had clinical or radiological evidence of secondary carcinoma, neuropathy, or myopathy. Altogether 30 pairs of patients matched perfectly for all seven variables and categories (matching for age being assumed to be perfect when the difference was five years or less). Of the remaining 20 pairs, 12
commonest
There
Ps
0-65 0-93
1-64 0-30 2-76 0-60 0-61 1-94 2-39 18-04 0-48 0-31
1-21 1-27 1-31 1-31 1-56 1-64 1-93 2-05 2-06 2-10 2-12 2-52 2-61 2-67
1-08
0-16 5-30 0-36 0-57 4-44 1-51
2-93 2-96 3-13 3-51 5-07 5-12 5-59 5-92 6-00 7-47 8-34 10-63 15-24 15-24 15-99 18-93
35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
was
in
greater
was
statistically meaningful
a
of organism.
type
to
survival
in
infected
patients
results
Our
favour of the
in
E coli'
with
and
considered
their
pairing patients
possi'ble
effect of age and
vidual pairs
was
perfect
49 pairs. In
in
matching
pairs
Comparisons to
was
than
perfect.
in these
cases
seven
was
made
variables
were
therefore
influence survival
Our
differ
Takita,' and Ruckdeschel
Keehan.3
and rates
40
in
and found that
this
Cady
and
patients
with
13",,
of
rates
difference
from
54,',
may have
those
Clifton
35(,,
34
in
with
at
pathological
was
Clifton,'
and
five-year
survival
patients
without
333
1,(',
the
rates
concluded
level
in
14 patients
without,
patients
18
in
patients.
empyema
The
classification.
Survivals
of
patients
regional
to
in
in survival
in
significant.
be
growth
in
the four groups
as
et
al
patients
patients
Feinstein's,-
with
found
survival. Ruckdeschel
rate
to
patients
6-72).
2j
only
according
considered
were
between
pulmonary
groups
compared. Differences
groups
even
empyema
and conclkuded that empyema
on
survival
combinations of these groups and
1-51 20-82 1-89 0-64 7-02 0-39 5-44 0-54 5-10 13-21 10-33
and
178
respectively
non-empyema
four
into
were
respectively. 'Fhey
significant
five-year
the
Cady
of
analysed
empyema
favourable influence
a
that
divided
27',,
and
sig-
a15 and agree with those of Lawton
et
compared
empyema
of
rates
times a
pairs matched
postoperative
Takita, who analysed five-year survival with
showed
carcinoma.
and
was
of
the
within
as
survival
patients who have had
in
bronchogenic
conclusions
in
comparisons
that
out
minor.
considered the differences
conclude
does
for
of the
20
well
as
survival, anid when the 30
in
We
not
relatively
was
and number in
Nevertheless,
between groups
None
smaller.
resection
that
significant difference
that any
nificant difference for all
less
overlooked.
not
Any indi-
diversity
surprising
were
ensure
of the
view
not
it
was
non-correspondence pairs
survival.
by matching
dingly. Histology was considered to be a most influencing survival, and in this respect match-
considered
of variables 50
excluded
was
sex
chosen because
were
influencing
in
accor
important factor ing
importance
were
clinicovarious a
whole
favour of the empyema The
confined
difference
largest
lung
to
and
those
lymph nodes. In our study there were 22 such pairs of patients who matched for all seven variables: the mean period of survival in the
with
intrathoracic
empyema group
4-81
was
years. This difference
0-18
0-60 2-19 6-39 10-49
was
Lawton and Keehan
patients
34 empyema rates
of
17-6)),
and was
years not
and in the control group 4-85
significant (P
