Pneumonectomy for Non-Small Cell Lung Cancer: Differences in Complications and Survival Based on the Side of Resection

Background: Pneumonectomy remains a necessary intervention for certain patients with locally advanced non-small cell lung cancer (NSCLC); however, the prognostic significance of surgical side remains controversial. Right-sided resection is traditionally associated with a higher risk.

Objective: To evaluate postoperative outcomes of pneumonectomy based on the side of resection.

Materials and Methods: This multicenter retrospective study included 326 patients who underwent radical pneumonectomy for NSCLC between 2015 and 2024 in three oncology centers. Left-sided resections were performed in 188 patients (57.7%) and rightsided in 138 patients (42.3%). Postoperative complications were classified according to the Thoracic Morbidity and Mortality system. Overall survival (OS) and disease-free survival were evaluated using the Kaplan-Meier method. Predictors of early mortality and bronchopleural fistula were analyzed by multivariate logistic regression.

Results: The overall complication rate was 42.9%, but significantly higher after right-sided pneumonectomy (51.4% vs. 33.0%; p=0.009). The incidence of bronchopleural fistula was markedly higher among patients who underwent right-sided surgery (15.6%) compared to those who underwent left-sided surgery (0.7%; p=0.003). Furthermore, a significant difference was observed in 30-day and 90-day mortality rates: for right-sided resection, the rates were 14.5% and 20.3%, respectively, whereas after left-sided resection they were only 3.2% and 6.4% (p<0.001). Median overall survival was 4.05 years after left-sided pneumonectomy and only 1.99 years after right-sided pneumonectomy (p=0.003); similarly, median disease-free survival differed, being 1.17 years and 0.53 years, respectively (p=0.069). Multivariate analysis identified a single independent factor associated with development of bronchopleural fistula, which was right-sided pneumonectomy (OR=16.2; 95% CI=2.07-126.98; p=0.008).

Conclusions: Right-sided pneumonectomy is associated with higher risk of severe complications, bronchopleural fistula, early mortality, and poorer survival outcomes. This procedure should be considered high-risk, requiring rigorous patient selection and the implementation of preventive strategies.

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