Is sleeve lobectomy comparable in terms of short- and long-term results with pneumonectomy after induction therapy? A multicenter analysis

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.

The Role of Surgery in Lung Cancer Treatment: Present Indications and Future Perspectives-State of the Art

Non-small cell lung cancers (NSCLC) are different today, due to the increased use of screening programs and of innovative systemic therapies, leading to the diagnosis of earlier and pre-invasive tumors, and of more advanced and controlled metastatic tumors. Surgery for NSCLC remains the cornerstone treatment when it can be performed. The role of surgery and surgeons has also evolved because surgeons not only perform the initial curative lung cancer resection but they also accompany and follow-up patients from pre-operative rehabilitation, to treatment for recurrences. Surgery is personalized, according to cancer characteristics, including cancer extensions, from pre-invasive and local tumors to locally advanced, metastatic disease, or residual disease after medical treatment, anticipating recurrences, and patients' characteristics. Surgical management is constantly evolving to offer the best oncologic resection adapted to each NSCLC stage. Today, NSCLC can be considered as a chronic disease and surgery is a valuable tool for the diagnosis and treatment of recurrences, and in palliative conditions to relieve dyspnea and improve patients' comfort.

Sleeve lobectomy after neoadjuvant chemoimmunotherapy/chemotherapy for local advanced non-small cell lung cancer

Background

Sleeve lobectomy has been reported to be a safe procedure after neoadjuvant chemotherapy. We aim to evaluate the oncological and surgical outcomes of neoadjuvant chemoimmunotherapy (IO+C) for local advanced non-small cell lung cancer (NSCLC) patients who underwent sleeve lobectomy.

Methods

NSCLC patients that underwent sleeve lobectomy between December 2016 and December 2019 were retrospectively included. Patients were divided into two groups: neoadjuvant IO+C and chemotherapy. Oncological, intraoperative and postoperative variables were compared.

Results

In total, 20 patients underwent sleeve lobectomy after neoadjuvant IO+C (n=10) or chemotherapy (n=10). In the neoadjuvant IO+C group, 8/10 (80%) patients achieved a partial response (PR), 1/10 (10%) patients had a complete pathological response (CPR), and 5/10 (50%) patients achieved a major pathological response (MPR). In the neoadjuvant chemotherapy group, only 3/10 (30%) patients had PR, and 3/10 (30%) patients achieved MPR. No complications were found in the neoadjuvant IO+C group, 1 chylothorax occurred in the neoadjuvant chemotherapy group. Other peri- and postoperative outcomes were similar: bleeding volume (365.00 vs. 347.50 mL; P=0.267), operation time (291.88 vs. 287.50 min; P=0.886), chest tube duration (5.40 vs. 5.00 day; P=0.829), total drainage volume (815.50 vs. 842.50 mL; P=0.931) and the length of hospital-stay (7.00 vs. 6.56 day; P=0.915). In addition, less N1 (average number 4.70 vs. 7.40) and N2 (average number 9.80 vs. 20.10) lymph nodes were acquired in the neoadjuvant IO+C group than the neoadjuvant chemotherapy group. The number of lymph nodes positive for tumor cells was also less in the neoadjuvant IO+C group than the neoadjuvant chemotherapy group, both in N1 (0.40 vs. 1.60) and N2 (0.10 vs. 1.30). The positive lymph node ratio (LNR) was lower in the neoadjuvant IO+C group, both in N1 (0.05 vs. 0.15) and N2 (0.01 vs. 0.09). A greater destruction on elastic fiber of the blood vessels, vascular wall degeneration, fibrinoid necrosis and fibrosis, and greater pulmonary interstitial exudation were found in neoadjuvant IO+C patients compared to the neoadjuvant chemotherapy patients.

Conclusions

Sleeve lobectomy for advanced NSCLC following IO+C is feasible, although the operations become more complex, neoadjuvant IO+C did not delay postoperative recovery.

Outcomes of sleeve lobectomy versus pneumonectomy: A propensity score-matched study

OBJECTIVES

To compare short- and long-term outcomes between sleeve lobectomy and pneumonectomy for lung cancer in a single center during a 15-year period.

METHODS

One thousand nine hundred eighty-one patients who underwent either a sleeve lobectomy (n = 964; 48.7%) or a pneumonectomy (n = 1017; 51.3%) from January 2003 to December 2017 at the Shanghai Pulmonary Hospital, were matched according to a propensity score to produce 2 groups of 665 patients each. The study period was divided into 3 5-year subperiods.

RESULTS

Sleeve lobectomy was associated with a lower 30- and 90-day mortality (0.60% and 0.90% vs 1.5% and 3.91%; P = .177 and P = .001, respectively, after matching), lower morbidity (4.36% vs 8.16%; P = .005 before matching, 3.61% vs 8.72%; P < .001 after matching), improved 5-year survival (62.7% vs 43.1%; P < .001 before matching and 61% vs 44.7%; P < .001 after matching), and 5-year disease-free survival after matching (56.6% vs 46.2%; P < .001). The sleeve lobectomy to pneumonectomy ratio increased by 78%, whereas 90-day mortality decreased by 66.81% between the first and the last subperiods.

CONCLUSIONS

Sleeve lobectomy is associated with improved short- and long-term outcomes and should be the resection of choice for centrally located lung cancers, when feasible.

PREOPERATIVE ENDOBRONCHIAL SANITATION AS PREPARATION FOR THORACIC INTERVENTIONS

The aim – to study the effectiveness of endoscopic photodynamic therapy as a preoperative preparation of the tracheobronchial tree in patients with lung cancer. Materials and methods. The study included 181 patients with II-III stage of lung’s cancer. Diagnose of lung’s cancer was confirmed with a morphologically and concomitant endobronchitis. During the preoperative preparation, we used a technique developed by us introducing into the tracheobronchial tree an aqueous solution of brilliant green at concentration of 0.04 %, followed by irradiation of this solution with laser radiation with the wavelength of 0.63 μm (AFL-2 helium-neon laser) in an independent form and in combination with traditional anti-inflammatory therapy. Endoscopic endobronchial sanitation therapy was carried out by low-intensity radiation of the red part of the spectrum (λ=0.63–0.66 μm) in a pulsed mode, with a power of 12 mW. Results. After 3–5 days of the start preoperative preparation and 1–2 sessions of endoscopic bronchosanation, the general state of patients was improved, the amount of sputum decreased and was changing from mucopurulent to mucous. To completely stop the clinical phenomena of endobronchitis, it was necessary to conduct 5-6 sessions of endoscopic photodynamic therapy according to our methodology, with the introduction of our method. In patients without pronounced clinical symptoms of concomitant chronic bronchitis, it was enough to complete only 3 sessions of bronchosanation. Conclusion. Endoscopic photodynamic bronchosanation in the preoperative period in patients for correcting accompanying endobronchitis can significantly reduce or completely stop the clinical manifestations of endobronchitis in the shortest time and leads to a significant decrease in the number of endobronchial complications in surgical and combined treatment of lung cancer.

Surgical treatment of lung cancer with adjacent lobe invasion in relation to fissure integrity

BACKGROUND

Tumor with adjacent lobe invasion (T-ALI) is an uncommon condition. Controversy still exists regarding the optimal resection of adjacent lobe invasion, and the prognostic value in relation to fissure integrity at the tumor invasion point. The aims of this paper were to evaluate the prognosis of T-ALI with regard to fissure integrity, and type of resection.

METHODS

This was a retrospective multicenter study which included all consecutive patients with T-ALI undergoing surgical treatment. Based on radiological, intraoperative and histological findings, T-ALI patients were differentiated into two groups based on whether the fissure was complete (T-ALI-A group) or incomplete (T-ALI-D Group) at the level of tumor invasion point. Clinico-pathological features and survival of two study groups were analyzed and compared.

RESULTS

Study population included 135 patients, of these 98 (72%) were included into T-ALI-A group, and 37 (38%) into T-ALI-D Group. T-ALI-D patients had better overall survival than T-ALI-A patients (63.9 ± 7.0 vs. 48.9 ± 3.9; respectively, P = 0.01) who presented with a higher incidence of lymph node involvement (35% vs. 4%; P = 0.004), and recurrence rate (43% vs. 16%; P = 0.01). At multivariable analysis, T-ALI-D (P = 0.01), pN0 stage (P = 0.0002), and pT≤5 cm (P = 0.0001) were favorable survival prognostic factors.

CONCLUSIONS

T-ALI-D presented a better prognosis than T-ALI-A while extent of resection had no effect on survival. Thus, in patients with small T-ALI-D and without lymph node involvement, sublobar resection of adjacent lobe rather than lobectomy could be indicated.

KEY POINTS

The extent of resection of adjacent lobe had no effect on survival while T-ALI-D, pN0 stage, and pT≤5 cm were significant prognostic factors. In patients with small T-ALI-D and without lymph node involvement, sublobar resection of adjacent lobe could be indicated as an alternative to lobectomy.

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.

Sleeve lobectomy compared with pneumonectomy for operable centrally located non-small cell lung cancer: a meta-analysis

Background

The purpose of this meta-analysis was to evaluate evidence comparing sleeve lobectomy (SL) and pneumonectomy (PN) in the treatment of non-small cell lung cancer (NSCLC).

Methods

The English literature search was undertaken in January 2018 and included studies dating back to 1996. Comparative studies were identified, evaluating survival, local recurrence, and distant recurrence rates, operative mortality, 30-day mortality, as well as complications. A pooled odds ratio (OR) and 95% confidence intervals (95% CI) were calculated with either the random or fixed-effect model.

Results

A total of 27 studies were identified, with publication dates between 1996 and 2018. These 27 studies included a total of 14,194 patients: 4,145 treated with SL and 10,049 treated with PN. The overall survival was significantly higher in the SL group compared to the PN one at 1, 3, 5 years. In patients with N0 and N1 disease, 5-year survival rates following SL exceeded those following PN. There was no statistically significant difference in the 3-, 5-year overall survival of N2 patients, according to the extent of surgery. The PN group had a higher rate of operative mortality, 30-day mortality and distant recurrence incidence. However, no statistical difference in complications and local recurrence between SL and PN were observed.

Conclusions

SL is an effective treatment option for hilar NSCLC with improved long-term survival compared to PN, with no increase of recurrence rate or postoperative complications. Furthermore, N2 disease is an important factor related to survival, and lymph node downstaging is a favorable prognostic factor.

Right upper sleeve lobectomy by video-assisted thoracic surgery

With accumulation of experiences in video-assisted thoracic surgery (VATS) lobectomy, complete VATS sleeve lobectomy (SL) has been carried out in more and more medical centers. We here presented a procedure of sleeve right upper lobectomy by complete VATS for a 62-year-old male patient with central squamous cell carcinoma. Traditional three incisions VATS technique was applied and the utility incision located on anterior axillary line of the 4th intercostal space. Continuous sutures were chosen for bronchial anastomosis using 3-0 prolene sutures. The chest drainage was removed on the postoperative fourth day.

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.

Left sleeve lobectomy versus left pneumonectomy for the management of patients with non-small cell lung cancer

BACKGROUND

The study was conducted to compare the outcomes of sleeve lobectomy (SL) and pneumonectomy (PN) for management of the left lung in patients with non-small cell lung cancer (NSCLC).

METHODS

One hundred and thirty-five patients who underwent left SL (n = 87) or left PN (n = 48) for NSCLC from January 2006 to December 2011 were enrolled in this retrospective study. Left SL was performed when technically possible. The clinicopathological features and treatment outcomes in both groups were compared. Survival was evaluated using the Kaplan-Meier method, and significant differences were calculated using the log-rank test. Multivariate analysis was conducted using the Cox proportional hazards model to analyze significant variables associated with the outcomes of left SL.

RESULTS

There were no significant differences in general clinicopathological features (age, gender, lymph node metastasis, pathological stage, and complications of bronchial fistula) between patients who underwent left SL and left PN. The operation duration was markedly longer and the extent of bleeding was greater for left SL than left PN; however patients who underwent left SL achieved significantly longer overall survival than patients who underwent left PN. The outcomes of left SL were only associated with pathological stage.

CONCLUSIONS

Our results indicate that left SL may offer superior survival than left PN in selected patients. If anatomically feasible, left SL may be a preferred alternative to left PN for NSCLC patients. Pathological stage is an important factor to determine the outcome of SL.

Evolution of a Lung-Sparing Strategy with Sleeve Lobectomy and Induction Therapy for Non-small Cell Lung Cancer: 20-Year Experience at a Single Institution

Background

To elucidate the evolution of a lung-sparing strategy with sleeve lobectomy (SL) and induction therapy for non-small cell lung cancer (NSCLC).

Methods

We retrospectively reviewed 205 patients with NSCLC who underwent pneumonectomy (PN, n = 54) or SL (n = 151) from 1994 to 2013. The study period was divided into four 5-year periods, and surgical trends were analyzed, focusing on the PN:SL ratio.

Results

PN was associated with a significantly advanced pathological stage, a larger tumor size and less pulmonary function compared with SL. The PN group had higher 30-day (3.7 vs. 0 %, p = 0.018) and 90-day (13.0 vs. 1.3 %, p = 0.0003) mortality than the SL group. The overall 5-year survival rate was significantly higher with SL (71.5 %) versus PN (42.8 %, p = 0.011) for patients with pN0–1. The ratio of PN among total surgeries decreased significantly over the four periods (1994–1998, 1999–2003, 2004–2008, and 2009–2013) from 5.63 % to 3.17, 1.40, and 1.38 %, respectively (p < 0.0001); in contrast, the PN:SL ratio increased significantly from 1.64 to 2.50, 3.71, and 5.44, respectively (p = 0.041). During the last period, when we introduced induction therapy, 38 of 651 who received surgery underwent induction therapy. The PN:SL ratios of those who did and did not undergo induction therapy were 15 (PN: 1, SL: 15) and 4.25 (PN: 8, SL: 34), respectively.

Conclusions

A lung-sparing strategy with SL for NSCLC can decrease the PN rate to less than 2 % with less mortality. Induction therapy may facilitate SL and increase the PN:SL ratio.