Induction Chemotherapy Before Sleeve Lobectomy for Lung Cancer: Immediate and Long-Term Results

Neoadjuvant therapy does not increase postoperative morbidity of sleeve lobectomy in locally advanced non-small cell lung cancer

OBJECTIVES

To evaluate the feasibility and safety of sleeve lobectomy after neoadjuvant therapy by assessing the postoperative morbidity.

METHODS

Patients who underwent sleeve lobectomy for non-small cell lung cancer (NSCLC) were retrospectively analyzed from January 2018 to December 2021. A total of 613 patients were enrolled, including 124 patients who received previous neoadjuvant therapy and 489 patients who did not. Propensity score matching was adopted to create a balanced cohort consisting of 97 paired cases. Patient demographics and perioperative outcomes were compared between the 2 groups, and logistic regression analysis was used to identify risk factors for postoperative complications.

RESULTS

In the entire cohort, univariable logistic regression analysis showed that smoking history (odds ratio [OR], 1.501; 95% confidence interval [CI], 1.011-2.229, P = .044), open thoracotomy (OR, 1.748; 95% CI, 1.178-2.593, P = .006), and operation time more than 150 minutes (OR, 1.548; 95% CI, 1.029-2.328, P = .036) were risk factors for postoperative complications, and multivariable logistic regression analysis showed open thoracotomy was an independent risk factor (OR, 1.765; 95% CI, 1.178-2.643, P = .006). In the balanced cohort, the neoadjuvant group had a lower proportion of double-sleeve resections (3.1% vs 11.3%, P = .035) and longer postoperative chest tube drainage (6.67 ± 3.81 vs 5.13 ± 3.74 days, P < .001). However, no significant differences were observed in postoperative morbidity between the 2 groups (25.8% vs 24.7%, P = .869). The complete pathologic response of chemoimmunotherapy was significantly superior to chemotherapy alone (28.2% vs 4.1%, P < .001), and no significant differences were noted in postoperative morbidity in different neoadjuvant therapy modalities.

CONCLUSIONS

After neoadjuvant therapy, sleeve lobectomy can be safely performed with no increased postoperative morbidity.

Is sleeve lobectomy safe after induction therapy?-a systematic review and meta-analysis

BACKGROUND

Sleeve lobectomy (SL) is a lung-sparing procedure, which is accepted as a valid operation for centrally-located advanced tumors. These tumors often require induction treatment by chemotherapy and/or radiotherapy to downstage the disease and thus facilitate subsequent surgery. However, induction therapy may potentially increase the risk of bronchial anastomotic complications and related morbidity. This meta-analysis aims to determine the impact of induction therapy on the outcomes of pulmonary SL.

METHODS

We compared studies of patients undergoing SL or bilobectomy for non-small cell lung cancer (NSCLC) with and without induction therapy. Outcomes of interest were in-hospital mortality, morbidity, anastomosis complication and 5-year survival. Odds ratio (OR) were computed following the Mantel-Haenszel method.

RESULTS

Ten studies were included for a total of 1,204 patients. There was no statistical difference for between patients who underwent induction therapy followed by surgery and patients who underwent surgery alone in term of post-operative mortality (OR: 1.80, 95% confidence interval (CI): 0.76-4.25, P value =0.19) and morbidity (OR: 1.17, 95% CI: 0.90-1.52, P value =0.237). Anastomosis related complications rate were 5.2% and appears increased after induction therapy with a statistical difference close to the significance (OR: 1.65, 95% CI: 0.97-2.83, P value =0.06). Patients undergoing surgery alone showed better survival at 5 years (OR: 1.52, 95% CI: 1.15-2.00, P value =0.003).

CONCLUSIONS

SL following induction therapy can be safely performed with no increase of mortality and morbidity. However, the need for induction therapy before surgery is associated with increased anastomotic complications and poorer survival prognosis at 5 years.

Impact of Neoadjuvant Chemoradiation on Adverse Events After Bronchial Sleeve Resection

BACKGROUND

We analyzed the association between neoadjuvant chemoradiation in patients undergoing bronchial sleeve resection with the incidence of postoperative pulmonary and airway complications.

METHODS

After instructional review board approval we performed a retrospective review of a prospectively maintained database of 136 patients who underwent sleeve resection in our institution between January 1998 and December 2016. Administration of neoadjuvant chemoradiation treatment was the studied exposure. Outcomes of interest were rates of postoperative pulmonary and airway complications. Nonparametric testing of demographic, surgical, and pathologic characteristics and morbidity was performed. Logistic regression models evaluated postoperative pulmonary complications and airway complications. Analysis was performed using Stata/IC 15.

RESULTS

We analyzed 136 patients (18 underwent neoadjuvant chemoradiation), 77 (57%) of whom had non-small cell lung cancer. Postoperative pulmonary complications were observed in 44 of 136 patients (32%). Incidences of pulmonary complications were higher in the neoadjuvant chemoradiation group compared with the non-neoadjuvant radiation group (15/18 patients [83%] vs 29/118 patients [25%], respectively; P < .001). Likewise, rates of pneumonia, atelectasis, respiratory insufficiency, bronchial stenosis, prolonged air leak, bronchopleural fistula, and completion pneumonectomy (2/18 [11%]) were higher in the neoadjuvant chemoradiation group, reaching statistical significance in all cases except bronchial stenosis and prolonged air leak. Only neoadjuvant chemoradiation therapy remained significant for postoperative pulmonary and airway complications on logistic regression (both P < .05) CONCLUSIONS: Patients who undergo neoadjuvant chemoradiation before sleeve resection are at an increased risk of pulmonary and airway complications.

Bronchus Anastomosis Healing Depending on Type of Neoadjuvant Therapy

BACKGROUND

Preoperative radiotherapy and/or chemotherapy of lung cancer in patients with locally advanced disease is an option in multimodal treatment. Sleeve lobectomy has an important part in decreasing complications and sparing lung function. We present our experience in a large cohort of patients after sleeve lobectomy with or without neoadjuvant treatment and standardized assessment of bronchial anastomotic healing.

METHODS

The data used for this study were collected in a prospective database in our hospital. Anastomotic healing was documented by bronchoscopy on the seventh postoperative day and thereafter only when necessary, using a standardized scoring system. From 2006 to 2017, we performed 501 sleeve lobectomies representing 19% of all lung cancer resections. A total of 365 of patients had no preoperative treatment (73%), 41 had neoadjuvant chemotherapy (8%), and 95 had radiochemotherapy (19%).

RESULTS

Using our scoring system of the bronchial anastomosis from 1 (excellent) to 5 (insufficient), we found the anastomosis was worse than grade 2 after no treatment, chemotherapy, or radiochemotherapy in 17%, 10%, and 30%, respectively (P = .002). The rate of anastomotic insufficiency was equally low after no pretreatment and chemotherapy (2.7% and 2.4%) and rose to 10.4% after radiotherapy (P = .002). Similarly, the risk for pulmonary complications was higher after radiochemotherapy (39%) compared with no pretreatment (29%) or chemotherapy (27%), respectively (P = .382).

CONCLUSIONS

Neoadjuvant radiotherapy is associated with worse wound healing of the anastomosis after sleeve lobectomy in lung cancer. There seems to be a higher risk for anastomotic insufficiency and complications.

Does Induction Therapy Increase Anastomotic Complications in Bronchial Sleeve Resections?

BACKGROUND

Sleeve lobectomy represents a safe and effective treatment for central NSCLC to avoid the risks of pneumonectomy. Induction therapy (IT) may be indicated in advanced stages; however, the effect of IT on bronchial anastomoses remains uncertain. The purpose of the study was to evaluate the impact of IT on the complications of the anastomoses.

METHODS

Between 2000 and 2012, 159 consecutive patients were submitted to sleeve lobectomy for NSCLC at our Institution. We retrospectively compared the results of patients who underwent IT before operation with those who received upfront surgery.

RESULTS

In the study period, 49 (30.8%) patients received IT (37 chemotherapy, 1 radiotherapy and 11 chemo-radiotherapy) and 110 (69.2%) patients were directly submitted to surgery (S). The two groups were comparable for sex, age, comorbidities, ASA score, pulmonary function, side, type of procedure and histology. Pathological stage was statistically higher for IT group (p = 0.001). No differences between IT and S groups were observed in terms of post-operative mortality (2% vs 0%, p = NS), morbidity (45% vs 38%, p = NS), including early (6% vs 9%, p = NS) and long-term (16% vs 14%, p = NS) bronchial complication rates. Patients undergoing induction mediastinal radiotherapy, however, are at higher risk of bronchial complications.

CONCLUSION

In our experience, the use of induction chemotherapy did not significantly increase mortality and morbidity rates, in particular, neither for early nor for late anastomotic complications. We, therefore, conclude that sleeve lobectomy after induction chemotherapy is safe and reliable procedure for the treatment of locally advanced NSCLC.

Robotic sleeve resection for pulmonary disease

Background

Few studies have described robotic sleeve resection with pulmonary resection. Here, we report the successful implementation of a completely portal robotic sleeve resection with or without pulmonary resection using a modified suture mode.

Methods

In total, 339 patients underwent curative robotic pulmonary surgery at Ruijin Hospital between May 2015 and September 2017. Three of these patients underwent robotic sleeve resection (right upper lobe, one; left upper lobe, one; and lingular segmental bronchus, one). Five port incisions were utilized, and a simple continuous running suture combined with two interrupted sutures of the membranous and cartilaginous junction portion was preferred for the anastomosis.

Results

The postoperative course was uneventful for two patients with squamous cell carcinoma. The lingular segmental bronchus patient without pulmonary resection (a salivary gland tumor) underwent short-term atelectasis. The median operation time was 155 (range 132–230) minutes. The median anastomosis time was 25 (range 23–32) minutes. The median length of postoperative hospital stay was 7 (range 6–10) days. There was no mortality or conversion to thoracotomy for any of the patients. All patients were followed for 3–6 months, and there is no tumour recurrence.

Conclusions

Our limited experience suggested that robotic sleeve resection for pulmonary disease with or without pulmonary resection may be safe and effective. The anastomosis time can be shortened with more robotic surgery experiences and the modified suture mode.

[Progress of Neoadjuvant Therapy Combined with Surgery in Non-small Cell Lung Cancer]

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Bronchial and arterial sleeve resection for centrally-located lung cancers

The use of bronchial and arterial sleeve resections for the treatment of centrally-located lung cancers, when available, has become the option of choice in comparison with pneumonectomy (PN). Technical expertise, in particular in vascular reconstruction, and perioperative management improved over time allowing excellent short-term and long-term results. This is even truer if considering literature data from the main experiences published in the last years. These evidences have given to such lung sparing reconstructive procedures more and more acceptance among the surgical community. This article focuses on the main technical aspects and literature data regarding bronchovascular sleeve resections.

Reconstruction of the bronchus and pulmonary artery

Bronchovascular reconstructive procedures employed in order to avoid pneumonectomy (PN) in patients functionally unsuitable have provided, over time, excellent results, similar or even better than those obtained by PN. In recent years, new successful techniques have been developed that pertain in particular the prevention of major complications and the reconstruction of the pulmonary artery (PA). Encouraging data from increasing number of published experiences support the choice of parenchymal sparing procedures for lung cancer also in patients with good functional reserve. This is even more true if considering trials published in the last 10 years, thus indicating that improved outcome can be achieved with increased experience in reconstructive techniques and perioperative management. This article discusses the main technical aspects and results of literature.

Sleeve Lobectomy Versus Standard Lobectomy for Lung Cancer: Functional and Oncologic Evaluation

BACKGROUND

The purpose of this study was to compare functional and oncologic outcome of sleeve lobectomy (SL) with that of standard lobectomy (STL) in patients with non-small cell lung cancer.

METHODS

Between January 2009 and April 2013, 44 consecutive patients undergoing upper SL (29 right side, 15 left side) were prospectively enrolled to be compared with 44 patients with the same side distribution who were randomly selected from patients undergoing upper STL during the study period. Functional and oncologic results of the two groups were compared.

RESULTS

Pathologic tumor stage ranged between I and IIIa with similar patient distribution between the two groups. Postoperative complication rates were 20.5% in the SL group and 16% in the STL group. There was no postoperative mortality in either group. Mean postoperative decrease in forced expiratory volume in 1 second at 3 months postoperatively was 17.5% ± 6.2% in the SL group and 19% ± 14.8% in the STL group (p = 0.52). There also was no significant difference (p = 0.15) in mean postoperative decrease in 6-minute walk test (64.3 ± 2.5 m versus 69.1 ± 21.4 m) between the two groups. Evaluation of postoperative changes in quality of life at 3 and 6 months based on a standardized questionnaire (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core Questionnaire) did not show significant differences between the SL group and the STL group (p > 0.05) in terms of global health status, physical functioning, and fatigue. Actuarial survival rates at 3 and 5 years, respectively, were 85.3% and 60.1% in the SL group and 88.7% and 58.2% in the STL group, without significant difference (p = 0.68).

CONCLUSIONS

Functional and oncologic results of SL are comparable to those of STL in patients with non-small cell lung cancer.

Bronchial and arterial sleeve resection after induction therapy for lung cancer

Lobectomy with reconstruction of the bronchus and pulmonary artery is a viable therapeutic option for patients with centrally located non-small cell lung cancer. Preoperative chemotherapy or chemoradiotherapy may represent an additional risk factor for postoperative complications because of increased difficulty in surgical dissection and potential impairment of bronchial healing. Although limited data are available in the literature in this setting, a few published studies have reported the possibility of performing even complex bronchovascular reconstructions after neoadjuvant treatment with no increased morbidity and mortality. This article discusses the main technical details and data from the literature.

Sleeve lobectomy compared with pneumonectomy after induction therapy for non-small-cell lung cancer

BACKGROUND

We compared morbidity, mortality, and oncological results of bronchial and/or vascular sleeve lobectomy (SL) with those of pneumonectomy (PN) after induction therapy for lung cancer.

METHODS

Between 1998 and 2011, 82 patients receiving induction therapy (chemo or chemo-radiotherapy) for non-small-cell-lung-cancer underwent sleeve lobectomy (n = 39) or pneumonectomy (n= 43). Only patients undergoing preoperative chemotherapy (39 in the SL group and 39 in the PN group) were included in the study. SL was bronchial in 21, vascular in 12, and broncho-vascular in six cases, respectively. Clinical stage before induction therapy was IIb in seven patients (1 in PN group; 6 in SL group), IIIa in 66 (36 in PN group; 30 in SL group), and IIIb in five patients (2 in PN group; 3 in SL group), respectively. N3 patients were not included in this series.

RESULTS

The rate of downstaged patients (pathological complete response and stage I-II) was 79.5% in the SL group and 53.8% in the PN group (p = 0.01).Postpneumonectomy mortality rate was 2.6 %. There was no postoperative mortality after SL. Complications occurred in 12 patients (30.8%) after PN and in 11 patients (28.2%) after SL (p = 0.6). Three-year and 5-year survival rates were 68 ± 3% and 64 ± 8% in the SL group; and 59.5 ± 5% and 34.5 ± 8% in the PN group (p = 0.02). The difference in terms of recurrence rate (locoregional and distant) between the two groups was not significant (p = 0.2).

CONCLUSIONS

SL represents a valid therapeutic option even after induction chemotherapy, providing better long-term survival than PN, with no increase of postoperative complications or recurrence rate. Pathological downstaging is a favorable prognostic factor.

Sleeve lobectomy after induction chemoradiotherapy

OBJECTIVES

The effect of induction chemoradiotherapy (CRT) on bronchial anastomoses remains uncertain. This prospective study aimed to assess the impact of neoadjuvant CRT on mortality, morbidity and survival following circular sleeve lobectomy (SL).

METHODS

All consecutive patients undergoing SL between June 2005 and December 2010 were prospectively included. Clinico-demographic variables were sex, age, clinical and pathologic TNM staging, comorbidities, pulmonary function, SL type, complications, neoadjuvant CRT and mortality.

RESULTS

Of 79 patients, who underwent SL during this period, 53 (67%) patients were directly assigned to surgery and 26 (33%) patients had pre-induction treatment for N2 pathologically confirmed. Induction treatment (CRT) was based on platinum-based chemotherapy and radiation (range 45-60 Gy). Twenty-one (80%) patients of the CRT group achieved a complete mediastinal pathological response. Mortality occurred in only three cases in the non-CRT [bronchovascular fistula, pulmonary artery thrombosis (reoperation and pneumonectomy and exitus due to pneumonia) and ADRS]. There were no differences with respect to complication rate between the non-CRT and CRT patients (33 versus 37%, P > 0.05), and overall 5-year survival was 69 and 33%, respectively (P = 0.017). Overall survival in the subgroup of CRT patients with mediastinal complete response after induction resulted significantly worse than the non-CRT group (43 versus 69%, P < 0.01). The rate of distant metastases was similar in both groups and only one patient experienced local recurrence.

CONCLUSIONS

Neoadjuvant CRT does not increase surgical morbidity, anastomotic complications or mortality in SL. Complete mediastinal response after induction therapy overcomes a significant independent prognostic factor for better survival. Although SL following induction CRT carries a good prognosis, the long-term results shows significantly lower survival compared with SL without induction CTR. In addition, patients who had complete pathological responses have a better prognosis than non-responders. SL appears to be safe and reliable after neoadjuvant concurrent CRT and can be considered the primary surgical option to save the complications related to pneumonectomy in central tumours.

The role of sleeve resections in advanced nodal disease

OBJECTIVE

The aim of this study was to compare the short-term and long-term results of sleeve resections depending on limited nodal disease (N0/N1, LND) and advanced nodal disease (N2/N3, AND) for non-small cell lung cancer (NSCLC) at a single institution.

METHODS

We retrospectively reviewed our prospective database of all NSCLC patients undergoing sleeve resections between January 1999 and December 2008. Patients' characteristics, morbidity, mortality, locoregional recurrence, distant recurrence, and survival were analyzed corresponding to LND and AND.

RESULTS

The indication was NSCLC for 170 sleeve resections (LND: n=120; AND: n=50) out of 213 consecutive sleeve resections. Both groups were statistically equal with regard to age (LND 61.8±12.4 vs AND 60.8±9.6 years), gender, co-morbidities, type of sleeve resection (bronchial vs bronchovascular), number of dissected lymph nodes (LND 40.0±12.4 vs AND 36.7±14.0), histology and completeness of resection (LND 96.7% vs AND 98.0%), respectively. More patients had induction chemotherapy in AND group (p=0.049). The short-term results were equal on the subject of morbidity rate (LND: 34.2%, AND: 44.0%), secondary pneumonectomy (LND: 1.7%, AND: 4.0%), and mortality rate (LND: 5.0%, AND: 6.0%), respectively. LND was associated with a better 5-year-survival rate (LND: 67%; AND: 42%) and mean survival (LND: 80.8 months; AND: 37.7 months; p=0.014). In the long-term follow-up, more distant metastases were detected in AND group (26.0% vs 14.2%, p=0.079) in contrast to identical locoregional recurrence (LND: 1.7%; AND: 0%). In the event of metastazing, the mean time to the development of distant metastases was similar (LND: 19.1 months; AND: 12.4 months; p=0.2).

CONCLUSIONS

Lymph node involvement is a negative prognostic factor concerning long-term survival. Sleeve resections in AND do not result in higher morbidity and mortality. But even in AND, sleeve resections are associated with promising long-term survival and extraordinary local control of the disease as a result of high complete resection rates. High rate of distant failure warrants further investigation for the systemic control of the disease.