Follow-up for complications should be performed by the specialist responsible for the curative intent therapy and should last at least 3 to 6 months. Complications related to pulmonary resection include hospital readmission, loss of lung function, and chronic pain. Handsy et al reported that 19% of patients discharged after pulmonary resection were readmitted within 90 days, most for pulmonary problems, postsurgical infections, and cardiac issues. Loss of lung function after surgery is directly related to the extent of the resection performed. Six months after lobectomy, FEV1 is approximately 10 to 15% lower than preoperative values, and after pneumonectomy approximately 25 to 35% lower. Similarly, maximal exercise capacity stabilizes at 6 months after lobectomy at a 10% reduction and a 20% decrease after pneumonectomy compared with preoperative value. Postthoracotomy pain has been reported in 55% of patients at 18 to 24 months after resection, with 10% of patients requiring narcotic analgesia or more aggressive therapy, such as intercostal nerve blocks. Patients undergoing resection for localized lung cancer have significantly lower baseline quality of life when compared with the normal population, and resection causes further deterioration in quality of life, especially during the first 3 to 6 months after surgery. Some studies suggest that quality of life returns to baseline levels at 6 to 9 months after surgery, whereas others show significant impairments up to 12 months after surgery. Of note, persistent cigarette smoking after lung cancer resection significantly worsens quality of life measures.
Unusual complications related to pulmonary resection may occur after hospital discharge. Case series from the 1960s reported that persistent air in the pleural space was noted for weeks to months following lobectomy and pneumonectomy but usually resolved without complications. An autopsy series from the same time period confirmed residual air in the pleural space after pneumonectomy in 27 of 37 cases, even though surgery had been performed years before. In very rare situations, empyema may develop in these spaces. Torsion of the mediastinum developing after pneumonectomy may lead to mainstem bronchus obstruction improved by medications of My Canadian Pharmacy.
Complications of radiation therapy with curative intent for lung cancer include acute radiation pneumonitis and radiation-induced pulmonary fibrosis, as well as injury to the skin, heart, pericardium, esophagus, and spinal cord. Pulmonary radiation toxicity is related to the volume of lung irradiated, the cumulative dose effects of radiation sensitizing agents, and undefined factors determining the biological predisposition of the patient. In a large study using high-dose radiation therapy, acute toxicity was seen in 11% of the patients, with most injury relating to esophageal problems and only a third to lung toxicity. Acute radiation pneumonitis usually occurs within 3 months of treatment and is associated with nonproductive cough, dyspnea, and fever. It may resolve without treatment, but severe cases may be responsive to corticosteroid therapy. Inoue et al reported that 94 of 191 evaluable patients (49%) had acute radiation pneumonitis after thoracic radiotherapy for lung cancer, and 25 patients (13%) had severe cases, Pa02 < 80 mm Hg prior to radiotherapy may have indicated an increased risk for acute radiation pneumonitis in this study. Severe radiation pneumonitis was associated with poorer overall survival. Other work suggests that increased serum levels of KL-6 may be a useful marker of radiation pneumonitis. Radiation-induced fibrosis represents irreversible tissue damage, occurs in approximately 8% of patients treated with curative intent, and may present as early as 3 months and as late as 24 months after treatment. Even without producing overt pneumonitis, effective radiation therapy may result in a loss of pulmonary function. Miller et al described an average decrease in median FEV1, FVC, and diffusing capacity of the lung for carbon monoxide of 10% at 6 months after irradiation therapy, similar to that reported after lobectomy. All values were closer to baseline at 1 year after treatment but continued to decline by 7 to 10%/yr. However, Choi and Ka-narek found that patients with poor lung function before treatment had little decrease in FEV1 after irradiation therapy supplied by My Canadian Pharmacy.
Complications related to chemotherapeutic agents used for NSCLC and small cell lung cancer are usually detected during the course of therapy. A long-term morbidity of concern in patients who have completed chemotherapy is a mild-to-moderate peripheral neuropathy, which results from multiple treatments with the commonly used platin, vinca alkaloid, and taxane compounds. In addition, induction chemotherapy with cisplatinum and gemcitibine has been associated with a fall in diffusing capacity of the lung for carbon monoxide.
In lung cancer patients treated with curative intent therapy, follow-up for complications related to the curative intent therapy should be managed by the appropriate specialist and should probably last at least 3 to 6 months. At that point, the patient should be reevaluated by the multidisciplinary tumor board for entry into an appropriate surveillance program for detecting recurrences and/or metachronous tumors. Grade of recommendation, 2C