Long-term clinical and functional results of sleeve lobectomy for primary lung cancer

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.

Fundamentals of Standard Sleeve Resection

Standard sleeve resection refers to the circumferential removal of a segment of the main bronchus in continuity with a lobectomy in order to avoid pneumonectomy. By doing so, surgery can be carried out in patients with compromised pulmonary function while also benefiting those with more normal function. It is most often indicated for malignant tumors located at the origin of the right upper lobe bronchus. Operative mortality is low and in the range of 2% to 3%, and quality of life and long-term survival are better than what is observed after pneumonectomy.

Late Results after Sleeve or Wedge Lobectomies for Non-Small-Cell Lung Carcinoma

From January 1971 to June 1983, 35 lobectomies with bronchoplastic procedures for invasive non-small-cell lung carcinoma were performed. Sleeve lobectomy was carried out in 21 cases, wedge lobectomy in 11, and upper sleeve bilobectomy in 3. There were 23 stage I, 10 stage II, and 2 stage IIIa tumors. Completion pneumonectomy was required in 1 case for anastomotic fistula and in 2 for atelectasis of residual lung. One of these patients died later due to empyema. The 5-year probability of death with recurrence was 31.98%. The 5-year disease-free survival was 58.57%. Metastatic relapse was observed in 8 cases and locoregional recurrence in 5. A new primary lung tumor occurred in 2 patients.

Surgical Techniques and Long-Term Results of Pulmonary Artery Reconstruction in Patients With Lung Cancer

BACKGROUND

Pulmonary artery (PA) reconstruction for lung cancer is technically feasible with low morbidity and mortality. We assessed our experience with partial or circumferential resection of the PA during lung resection.

METHODS

Between 1998 and 2013, we performed PA angioplasty in 150 patients with lung cancer. Partial PA resection was performed in 146 patients. PA reconstruction was performed by running suture in 113 patients and by using a pericardial patch in 33. A circumferential PA resection was performed in 4 patients, and reconstruction was made with polytetrafluoroethylene and by a custom-made bovine pericardial conduit. Bronchial sleeve resection was associated in 56 patients. Stage I disease was present in 32 patients, stage II in 43, stage IIIA in 51, and stage IIIB in 17. Seventy-five patients received induction chemotherapy, and 7 patients had a complete response.

RESULTS

Thirty-day mortality was 3.3% (n = 5); two of these patients died of a massive hemoptysis. Pulmonary complications occurred in 33 patients, cardiac in 28, and air leaks in 17. Overall 5-year and 10-year survival was 50% and 39%, respectively. Survival at 5 and 10 years for stages I and II vs stage III was, respectively, 66% vs 32% and 56% vs 20% (p < 0.0001). Five-year survival was 61% for N0 and N1 nodal involvement vs 28% for N2, and the respective 10-year survival was 45% vs 28% (p = 0.001). Induction chemotherapy did not influence survival. Multivariate analysis yielded advanced stage, N2 status, and squamous cell carcinoma as negative prognostic factors.

CONCLUSIONS

PA reconstruction is safe, with excellent long-term survival. Our results support this technique as an effective option to pneumonectomy for patients with lung cancer.

Tracheobronchoplasty in Japan

More than a century has passed since the first tracheoplasty was successfully performed by Eiselsberg in 1896. In that time, tracheobronchoplasty has developed with the extension of operative indications. This review focuses on who contributed to the development of this operation in Japan, and in what ways, with comparisons to results for these operations in the West. The headings include "Pioneers and colleagues", "Symbols and taxonomy", "Surgical anatomy", "Surgical diseases", "Anesthesia", "Surgical techniques", "Results", and "The present state". Although effort has been made to acknowledge various opinions, the convictions expressed herein are my own.

Techniques of Bronchial Sleeve Resection

A bronchial sleeve resection can be considered for lesions arising from a lobar bronchus so as to preclude a standard lobectomy, yet without enough distal involvement as to warrant a pneumonectomy. Limited bronchial resection allows maximal conservation of pulmonary function in patients with benign or malignant disease, without compromising oncologic outcome. This article defines the indications and preoperative management of candidate patients and discusses key anesthetic considerations and surgical techniques for this complex airway reconstruction. The essential component of a successful operation is a tension-free bronchial anastomosis. Open communication and careful discussion of airway management between anesthesiologist and surgeon will help ensure a good outcome.

Bronchovascular reconstruction for lung cancer: does induction chemotherapy influence the outcomes?

BACKGROUND

Bronchoangioplastic interventions (BAIs) for lung cancer are challenging procedures associated with a high risk of postoperative morbidity and mortality. The role of induction chemotherapy (IC) in these patients is debated.

METHODS

We reviewed clinical records of patients who underwent a BAI between 1998 and 2009 using a prospective clinical and operative database.

RESULTS

Among 47 patients (39 men; mean age, 66 years) who underwent BAI, 26 (55.3%) received IC for N2 disease or for locally advanced lung cancer. We performed 35 pulmonary artery (PA) sleeve resections (31 partial and 4 circumferential), 10 PA reconstructions with a pericardial patch (8 autologous, and 2 heterologous), and 2 PA reconstructions using heterologous conduit. The 30-day mortality rate was 4.2% (n=2). Morbidity occurred in 19 (40.4%) patients; 5 patients (10.6%) had major complications (3 [6.4%] patients with fatal bronchovascular fistulas and 1 patient each with cardiac dislocation and acute respiratory distress syndrome) (2.2%). Fourteen patients (29.8%) had minor complications: 6 (12.7%) cardiac, 7 (14.9%) pulmonary, and 1 (2.2%) stroke. IC did not influence the complication rate. Overall 5-year survival and disease-free survival was 39.2% and 36.9%, respectively. Early pathologic stage and the absence of nodal involvement significantly influenced survival (p=0.005 and p=0.002, respectively). Patients receiving IC had a better prognosis (62.7% versus 10.7%; p=0.0003). At multivariate analysis, IC influenced long-term survival (p=0.003 [95% CI, 2.92-8.56]).

CONCLUSIONS

BAIs are feasible and effective surgical procedures with acceptable morbidity and mortality. IC does not influence morbidity and allows good long-term outcomes.

Outcomes of Sleeve Lobectomy versus Pneumonectomy for Lung Cancer

Background

Sleeve lobectomy for lung cancer in close proximity to or involving the carina is widely accepted. Operative morbidity and mortality rates, recurrence, and survival rates have varied considerably across studies.

Materials and Methods

From March of 2005 to July of 2010, sleeve lobectomy was performed in 19 patients and pneumonectomy was performed in 20 patients. In this paper, the results of sleeve lobectomy and pneumonectomy for patients with lung cancer will be compared and evaluated.

Results

There were no postoperative complications in either group, but there was one mortality in the pneumonectomy group. There was better preservation of pulmonary function in the sleeve lobectomy group than the pneumonectomy group (p=0.066 in FVC, p=0.019 in FEV1). The 3-year survival rates were 46.7% in the sleeve lobectomy group and 54.5% in the pneumonectomy group (p=0.505). The 3-year disease-free survival rates were 38% in the sleeve lobectomy group and 45.8% in the pneumonectomy group (p=0.200).

Conclusion

Sleeve lobectomy for lung cancer showed low mortality, low bronchial anastomotic complication rates, and good preservation of pulmonary function.

Preserving middle lobe to improve lung function in non-small-cell lung cancer

When a lung tumor arises in segment 6, the close anatomical relationship to the middle lobe bronchus may make a lower bilobectomy necessary. Sleeve lobectomy may be an alternative. These procedures were compared retrospectively in 36 patients operated on between January 2005 and December 2006 with non-small-cell lung cancer (stage I-IIIB) of the right lower lobe. Sleeve lobectomy was performed in 21 patients and bilobectomy in 15 (41%). Preoperative lung function was comparable in both groups. Radical resection was achieved in 34/36 patients. Operation time was 121 min for sleeve lobectomy and 144 min for bilobectomy. Chest tubes were removed after 5 days in both groups. Postoperative lung function was better after sleeve lobectomy than bilobectomy (forced expiratory volume in 1st sec: 78% vs. 69%). Preservation of the middle lobe by sleeve lobectomy is feasible. There was no evidence that this resection was less radical, and complication rates were similar in both groups.

Comparative Analysis and Outcomes of Sleeve Resection versus Pneumonectomy

To compare the outcome of sleeve resection or complex sleeve resection versus (Vs) pneumonectomy for lung cancer in a single unit. Between 1998 and 2006, 664 lung resections were carried out. There were 129 (19.4%) pneumonectomies and 79 (11.9%) sleeve resections; Twenty one patients (26.5%) underwent a complex sleeve resection. Operative mortality for the sleeve resections (SR) was 2.5% and for the pneumonectomies 8.53%. Overall 5-year survival after SR was 46.8% and after pneumonectomy 37.1%. The survival curves for the 2 procedures after adjusting for risk factors are different. The area under the curve is higher for the SR (Hazard ratio 1.78 C.I.: 0,92-3,46). The 5-year survival for early stages favors SR. The survival for the complex SR was not influenced by the complexity of the procedure but from the TNM stage of each individual case. Multivariate analysis of risk factors affecting survival after surgery showed: male sex Hazard ratio (HR) 1.19, 0.63–2.27(95%CI), Age >63 1.38(HR), 0.78–2.48, Pneumonectomy 1.78(HR), 0.92–3.46 and stage III 4.44(HR), 1.94–10.16(95% CI). For comparative stages survival appears to be better after sleeves, moreover male sex, sleeve resection, age younger that 63 and early TNM stage are positive predictors for survival.

Surgical Techniques and Results for Partial or Circumferential Sleeve Resection of the Pulmonary Artery for Patients with Non-Small Cell Lung Cancer

BACKGROUND

We assessed our experience with partial or circumferential resection of the pulmonary artery during lobectomy.

METHODS

We retrospectively reviewed a prospective electronic database of patients who underwent pulmonary artery resection. The technique used was an R0 resection with end-to-end anastomosis only if needed, distal control of the pulmonary artery by clamping the vein (not the artery), and no postoperative anticoagulation.

RESULTS

Between October 1998 and June 6, 2006, 42 (3.2%) of 1328 patients who underwent lobectomy performed by one surgeon required resection of the pulmonary artery (38 partial, 4 circumferential) to achieve a margin-negative resection and avoid pneumonectomy. Of these, 41 had non-small cell lung cancer, and 23 (55%) had neoadjuvant chemoradiotherapy (median dose of 60 Gy). Right upper lobectomy was performed in 2 patients and a left upper lobectomy in 40. A negative bronchial and vascular margin was achieved in all. Morbidity occurred in 11 patients (atrial fibrillation in 6) and left recurrent laryngeal neurapraxia in 2. Aspiration resulted in one operative death. Follow-up (median, 48 months) showed no local recurrence on the pulmonary artery and normal blood flow through it. Five-year survival was 60%.

CONCLUSIONS

Pulmonary artery resection and reconstruction to avoid pneumonectomy can be performed safely, even in a highly irradiated field. Clamping of the remaining pulmonary vein for distal control is safe and affords more room. Circumferential resection with end-to-end anastomosis of the pulmonary artery is rarely required. Partial resection is safe, does not impede blood flow, and does not compromise local recurrence rates. Postoperative anticoagulation is not needed.

Reconstruction of the Pulmonary Artery

Sleeve resection and prosthetic reconstruction of the pulmonary artery have progressively gained acceptance as an alternative to pneumonectomy in lung cancer surgery. Previous concern was mainly related to technical difficulties, intraoperative and postoperative complications, lack of long-term survival, and impact on cardiopulmonary function. For this reason it was not until very recently that lobectomy associated with resection and reconstruction of the pulmonary artery, associated or not to a sleeve resection of the bronchus, has been demonstrated to be an advantageous alternative. The concern about an increased complication rate has been proven to be excessive; in fact, pulmonary artery reconstruction can be performed safely and effectively with the correct indications and technique. We hereby report our experience, along with a review of the indications, the surgical technique, and outcome of pulmonary artery reconstruction.

Comparison of Morbidity, 30-Day Mortality, and Long-Term Survival After Pneumonectomy and Sleeve Lobectomy For Non–Small Cell Lung Carcinoma

BACKGROUND

The advantage of sleeve lobectomy as an alternative to pneumonectomy for preserving lung function is obvious and among other arguments allows operating on patients with lung cancer who would not tolerate pneumonectomy. The purpose of this retrospective, nonrandomized study is to compare the early (30-day mortality) and late (5-year survival) outcomes of both procedures.

METHODS

The charts of 310 patients who underwent either pneumonectomy or sleeve lobectomy for lung cancer stages I to IIIA from 1987 to 1997 were reviewed. One hundred ninety-four patients underwent pneumonectomy, and 116 patients underwent sleeve lobectomy. Specific operative complications, i.e., anastomotic leakage versus stump dehiscence, perioperative complications, 30-day or in-hospital mortality, and 5-year survival were registered for comparison of the immediate risk of the respective procedures.

RESULTS

In the bronchial sleeve lobectomy group, the incidence of anastomotic leakage was 6.9% (8 of 116 patients) and the operative mortality was 4.3%. The incidence of bronchial stump fistulas after pneumonectomy was 3.6% (7 of 194 patients), and early mortality was 4.6%. All but 6 patients (98%) had a complete resection. Overall 5-year survival after sleeve lobectomy was 39% and after pneumonectomy, 27%. The distribution of 5-year survival stage by stage in either group is presented. Sleeve lobectomy, age younger than 65 years, pN0, and stage I are positive prognostic factors for long-term survival. In the multivariate analysis, pneumonectomy is a negative prognostic factor.

CONCLUSIONS

The indication for pneumonectomy versus sleeve lobectomy depends on the localization of the primary tumor on the one hand, and on cardiorespiratory function, which might be more often distinctly impaired in the sleeve group, on the other hand. This could explain why the mortality in the sleeve lobectomy group was identical with that in the pneumonectomy group. However, both techniques are appropriate treatment modalities of advanced lung cancer or patients with critical functional reserve. Therefore, whenever possible, sleeve lobectomy should be performed.

Lung resection in the pulmonary-compromised patient

Every patient evaluated for lung resection should have preoperative pulmonary function testing. Patients with a significant decrease in FEV1% (approximately 60%-70% or less) should have a quantitative radionuclide perfusion scanning. Patients with a low ppoFEV1% (approximately 40%) should be considered for exercise testing because their risk for developing postoperative complications is higher. A VO2max between 10 to 15 ml/kg/minute or a ppoVO2max of less than 10 ml/kg/minute would usually be considered prohibitive for surgery. Nevertheless, no single criterion should be used to exclude a patient from surgery. Rather, the use of multiple preoperative studies is needed to select patients who will tolerate and benefit from pulmonary resection. Surgical interventions other than standard lobectomies or pneumonectomies can be offered to selected high-risk patients. Experience from lung volume reduction surgery has shown that some patients who would have been considered inoperable can safely undergo resection of their lung cancer.

Bronchoplasty for bronchial stenosis in a neonate: a case report

Bronchial stenosis is an uncommon problem in children. Management can be difficult because of the small luminal diameter and proximity of the lung parenchyma to the bronchial lesion. Bronchoplasty procedures have obvious advantages in children because of their long life expectancy. Long-term functional results are superior compared with pneumonectomy because of preserved lung tissue. A premature neonate weighing only 779 g at birth was born with severe respiratory distress syndrome complicated with hyperbillirubinemia and bronchopulmonary dysplasia. The child underwent bronchoplasty using a costal cartilage graft for a right main bronchus stenosis after 2 failed attempts at bronchoscopic dilatations. In spite of all complications, the child improved sufficiently to be discharged without any oxygen dependency. Our case highlights the successful application of bronchoplasty in a very small baby. Preoperative and intraoperative bronchoscopy was helpful in localization of the endobronchial lesion. Understanding the principle, precise attention to technical detail and meticulous postoperative care contribute toward long-term benefit for pulmonary conservation.

Personal experience in lung cancer sleeve lobectomy and sleeve pneumonectomy

BACKGROUND

Sleeve lobectomy (SL) and tracheal sleeve pneumonectomy (TSP) represent valuable alternative techniques to standard resections in the treatment of benign and malignant conditions of the airway and allow preservation of lung parenchyma.

METHODS

Eighty-three sleeve lobectomies and 27 tracheal sleeve pneumonectomies have been performed for nonsmall cell lung cancer in the thoracic department of the University of Milan from 1979 to 1999. There were 46 upper right lobectomies, 11 upper and middle lobectomies, 18 upper left lobectomies, 8 lower left lobectomies, and 27 right pneumonectomies.

RESULTS

Mortality rate was 3.6% in SL and 7.4% in TSP. Complications were 10.8% of all SLs and 15% of all TSPs. The overall 5-year survival rate was 43% for SL and 20% for TSP; the 10-year survival rate was 34% and 14%, respectively. There was a highly significant difference in survival between patients with N0 and N1-N2 disease.

CONCLUSIONS

Sleeve lobectomy is an appropriate surgical procedure and an alternative to pneumonectomy in patients with limited respiratory reserve whenever the situation permits. Trachael sleeve pneumonectomy is associated with more complications and poor survival.

Parenchymal sparing operations for bronchogenic carcinoma

By the end of the 1950s, the principles of tracheobronchial and pulmonary artery (PA) reconstruction had been established, and their successful clinical application had taken place. It was not until very recently, however, that these techniques aroused widespread interest among thoracic surgeons as a means to achieve complete cancer resection while preserving functioning lung parenchyma. At the present time, sleeve resection of the bronchus and/or PA has a definite role in the surgical management of lung cancer. Growing interest in this field is evidenced by an increasing number of technical variations intended to adapt the basic technique to the different anatomical settings. Also pitfalls, complications, and their prevention and treatment are being extensively described. Last but not least, functional and oncological long-term results, comparing favorably with those of more extended resections, are being reported by many groups. This demonstrates that sleeve lobectomy is no longer reserved only for particularly skillful surgeons. Sleeve lobectomy has achieved its rightful position among the techniques commonly used in thoracic surgery after 40 years of improving understanding and alternating enthusiasm and legitimate doubts.

Low morbidity of bronchoplastic procedures after chemotherapy for lung cancer

OBJECTIVE

To evaluate if induction chemotherapy, with or without irradiation, represents an additional risk factor for early and late morbidity and perioperative mortality in bronchoplastic procedures for lung cancers.

METHODS

From January 1998 to January 2001, 27 patients underwent a bronchial sleeve resection after induction treatment at the European Institute of Oncology in Milan. They represent 7% of lung cancer resections (387) and 27% of those performed after neoadjuvant treatment (100 cases). Histology was: 17 epidermoid carcinoma, 8 adenocarcinoma and 2 SCLC. Twenty-four patients (89%) received a preoperative cisplatin based polichemotherapy, and three cases (11%) a chemo-radiation therapy. A right sleeve lobectomy or bilobectomy was undertaken in 21 patients (78%) and a left lobectomy in 6 (22%). A resection of tracheal carina was associated in three cases and a vascular resection in 10 (five vena cava and five pulmonary artery). Twelve patients (44%) received adjuvant mediastinal irradiation. Perioperative morbidity of the study group (group 1) was compared with that of patients submitted to sleeve resection without neoadjuvant treatment (group 2), or standard pneumonectomy after induction treatment (group 3).

RESULTS

There were no postoperative deaths. A major perioperative complication occurred in two patients (7%) of group 1, one patient of group 2 (3.5%), and four in group 3 (17%). Among patients of the study group, no anastomotic dehiscence or pleural empyema were observed. Only one late anastomotic stricture occurred after postoperative radiation treatment. No significant difference in early and late complication rate was found between the three groups of patients. High rate of complete resection was achieved (93%) in patients of the study group and extent of nodal dissection was similar between sleeve resections and pneumonectomy patients.

CONCLUSIONS

Preoperative chemotherapy or combination of chemo-radio therapy is not associated with an additional risk of anastomotic complications in bronco and angioplastic procedures. Parenchyma sparing resection is a valid option for selected patients with locally advanced lung cancer after induction treatment. A longer follow up is necessary to evaluate efficacy of the procedure in term of survival and local control.

Long-term results of sleeve lobectomy for lung cancer

OBJECTIVE

Sleeve lobectomy is a lung saving procedure indicated for central tumors for which the alternative is a pneumonectomy. Current controversies relate to the safety of the procedure and adequacy as a cancer operation. The aim of the study is to analyze long-term survival after sleeve lobectomy, particularly in relation with nodal status and histological type. The incidence and patterns of recurrences were reviewed.

METHODS

From 1972 to 1998, 184 patients (male 152, female 32) underwent sleeve resection for lung cancer. The mean age was 60+/-10 years (11-78 years), and the indications for operation were a central tumor (79%), peripheral tumor with nodal involvement (13%) and compromised pulmonary function (8%). The histological type was predominantly squamous (n=125, 68%), followed by non-squamous (n=50, 27%) and carcinoid tumors (n=9, 5%). Resection was complete in 161 patients (87%).

RESULTS

The operative mortality was 1.6% (n=3). Follow-up was complete for the remaining 181 patients (mean, 5.7 years; range, 1 month-26 years). The survival at 5 and 10 years of all patients was 52 and 33%, respectively. Theses rates for patients with N0 status (n=97) were 63 and 48%, and 48 and 27% for those with N1 status (n=68; N0 vs. N1, P<0.05). An 8% survival rate was observed with N2 status (n=19) at 5 years, with no survivors after 7 years of follow-up. The 5 and 10 year survival was 56 and 34% for squamous carcinoma vs. 33 and 22% for non-squamous carcinoma (P<0.05). These rates were 58 and 38% for complete resection vs. 11 and 6% for incomplete resection at 5 and 10 years, respectively (P<0.05). Local recurrences occurred in 22% of cases, and the prevalence was statistically different between patients with N0 disease (14%) and N1 disease (23%; P=0.03), but not between N1 and N2 disease (42%; P=0.2). When local and distant recurrence were pooled together, the differences were highly significant between N0 (22%) and N1 (41%) disease (P=0.007), and between N0 and N2 (63%) disease (P=0.0002), but not between N1 and N2 disease (P=0.09).

CONCLUSION

Sleeve lobectomy is a safe and effective therapy for patients with resectable lung cancer. The presence of N1 and N2 disease, or of non-squamous carcinoma significantly worsen the prognosis.

Lung conservation techniques: bronchial sleeve resection and reconstruction of the pulmonary artery

Bronchial and vascular reconstructive procedures are a technically feasible alternative to pneumonectomy and have the advantage of sparing functioning lung parenchyma. Between 1989 and 1999, we performed bronchovascular sleeve resection and reconstruction in 145 patients (109 men, 36 women; age range, 26 to 76 years, mean, 56 years) with non-small-cell lung cancer (NSCLCL). Forty-one patients had induction chemotherapy and 3 had pre-operative radiotherapy. Immediate and long-term postoperative evaluation included bronchoscopy, spirometry, electrocardiogram, Doppler echocardiography, and perfusion lung scans, computed tomography and, only recently, angio-magnetic resonance (MR) imaging. Follow-up ranged between 3 months and 10 years (mean, 3.7 years) and is complete for all patients. We report the results of this series and conclude that morbidity, mortality, and functional data indicate that bronchovascular reconstructions are equal to standard lobectomy in terms of pulmonary function. Long-term survival is comparable with that reported for standard resection (lobectomy-pneumonectomy). These findings suggest that even complex lung-sparing operations can be proposed as adequate procedures in the treatment of lung cancer as long as a complete anatomical resection is obtained.

Does pneumonectomy for lung cancer adversely influence long-term survival?

OBJECTIVE

The increased operative mortality associated with pneumonectomy has stimulated the use of lung-sparing operations such as sleeve lobectomy. Whether pneumonectomy adversely affects long-term outcome after lung resection is unknown.

METHODS

We reviewed the cases of patients who underwent lobectomy/bilobectomy or pneumonectomy because of non-small cell lung cancer between January 1980 and June 1998. Survival curves were compared by the log-rank test. Covariates were determined for operative mortality and survival using logistic regression analysis and Cox proportional hazards estimation, respectively.

RESULTS

There were 259 men and 183 women who underwent lobectomy/bilobectomy (340) or pneumonectomy (102). Operative mortality was 36 (8.1%) patients overall, 24 (7.0%) for lobectomy/bilobectomy and 12 (12%) for pneumonectomy. Mean follow-up was 41 months (range 0-222 months). Median survival was worse for pneumonectomy (stage II: 17.9 vs 36.3 months, log-rank P =. 05; stage III: 11.7 vs 21.3 months, log-rank P =.07). However, important covariates for survival were age, primary tumor status, regional nodal status, and forced expiratory volume in 1 second. After adjusting for these covariates, survival did not differ significantly between the types of operations (hazard ratio for pneumonectomy 1.21; 95% CI 0.88-1.68).

CONCLUSIONS

We did not detect a significant long-term adverse influence of pneumonectomy on survival after adjusting for other prognostic factors, but randomized clinical trials would be needed to definitively address this issue.

Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer

BACKGROUND

Lobectomy associated with reconstruction of the pulmonary artery (PA) is a technically feasible alternative to pneumonectomy in patients with lung cancer. However, concern about postoperative complications and long-term survival limited its acceptance so far.

METHODS

Between 1989 and 1996, we performed a PA reconstruction in 52 patients (41 men, 11 women; age range 35 to 75 years, mean 60 years) with lung cancer. Eleven patients had induction chemotherapy. We performed 15 PA sleeve resections, 34 PA reconstructions by a pericardial patch, and three PA reconstructions by a pericardial conduit, associated with a bronchial sleeve lobectomy or bilobectomy (33), or with standard lobectomy (19). Immediate and long-term postoperative evaluation included spirometry, echocardiography, perfusion lung scans, computed tomography, and PA angiography. The follow-up ranged between 27 and 96 months and is complete for all patients.

RESULTS

We had one specific postoperative complication (PA thrombosis) and no mortality. Perfusion scans and PA angiography were normal in all but the 1 patient having thrombosis. Mean forced expiratory volume (FEV) in 1 s and forced vital capacity (FVC) were, respectively, 72% and 80% preoperatively, 65% and 76% 1 month after surgery, and then they plateaued at 70% and 78% after 6 months. Echocardiography showed patterns in the normal range and normal estimates of PA pressures in all but 2 patients. Five-year survival was 38.3% for the entire group, 18.6% for stages IIIA and B, and 64.4% for stages I and II.

CONCLUSIONS

Morbidity, mortality, and functional data do not differ from what is currently reported for standard lobectomy. Long-term survival is in line with that reported for standard resection. These data support PA reconstruction as a viable option in the treatment of lung cancer.

Survival and prognostic factors in patients undergoing parenchymal saving bronchoplastic operation for primary lung cancer: a series of 110 consecutive cases

OBJECTIVE

The purpose of this study was to report our experience concerning bronchial sleeve lobectomy for treating bronchogenic cancer.

METHOD

From 1980 to 1994, 110 patients underwent bronchial sleeve lobectomy for bronchogenic cancer. In 45 patients, preoperative investigations contraindicated pneumonectomy, whereas in 65 other patients, sleeve resection was performed without functional necessity. The most common procedures were sleeve lobectomy of the right upper lobe (64%), and of the left upper lobe (21%). Sixteen patients (15%) underwent additional arterial vascular resection. Seven patients had microscopic invasion of the bronchial margin without the possibility of further resection in six with regard to their limited respiratory function. Tumors were staged as follow: 32 stage IB (all T2 N0), 57 stage IIB (57T2 N1), and 17 stage IIIA (eight, T3N1; nine, T2N2), whereas four patients had an in situ cancer (four stage 0).

RESULTS

Operative mortality was 2.75%. The 5- and 10-year actuarial survival rates were, respectively, 39 and 22% for the entire group. The 5-year actuarial survival rates were, 60% in stage IB, 30% in stage IIB, and 27% in stage IIIA. Four factors significantly influenced survival (P<0.05): nodal stage, arterial resection, invasion of the bronchial stump and poor functional respiratory status contraindicating pneumonectomy.

CONCLUSIONS

In our experience, sleeve resection for stage I provides comparable survival to that of standard resection at equal stage. However, in patients with pathologically N1 disease, who can tolerate a pneumonectomy, a randomized study is mandatory to confirm that sleeve lobectomy can be performed without the risk of decreasing long-term survival. In our study, patients who required an associated vascular resection demonstrated a poor survival.

Safety and efficacy of bronchovascular reconstruction after induction chemotherapy for lung cancer

OBJECTIVE

The aim of this study was to ascertain the safety and efficacy of bronchial sleeve resection and reconstruction of the pulmonary artery in patients who had undergone induction chemotherapy for lung cancer.

METHODS

Between January 1991 and July 1996, we operated on 68 patients who had received three cycles of cisplatin-based induction chemotherapy. In 27 of these cases, we performed a lobectomy (n = 25) or bilobectomy (n = 2) associated with reconstruction of the bronchus, the pulmonary artery, or both. In only five additional patients, pneumonectomy had to be carried out. Before chemotherapy, 14 patients were in stage IIIA and 13 were in stage IIIB. All patients in stage IIIB had T4 disease; no N3 cases were included. At thoracotomy, one patient had no evidence of tumor, six were in stage I, 13 were in stage II, six were in stage IIIA, and one was in stage IIIB. Sixteen patients had epidermoid carcinoma and 11 had adenocarcinoma.

RESULTS

Sixteen patients underwent bronchial sleeve resection; 11 had various types of pulmonary artery reconstruction, associated with the bronchial sleeve in eight cases. In 26 patients, resection was radical with histologically negative margins. Neither bronchial complications nor deaths occurred. One patient had empyema and two had wound infections. Mean chest tube duration was 6 days. After a postoperative follow-up of 4 to 69 months (mean 25 months), 14 patients are alive and free of disease, one is alive with disease, and 12 have died. There were no local recurrences. The 1- and 4-year survival rates are 78% and 39%, respectively.

CONCLUSIONS

Although it is technically demanding, lobectomy associated with bronchovascular reconstruction is feasible, with good immediate and long-term results, after induction chemotherapy.

Bronchoplasty in the management of low-grade airway neoplasms and benign bronchial stenoses

BACKGROUND

Parenchyma-sparing bronchoplastic procedures have altered the management of benign bronchial stenoses and low-grade neoplasms of the airway. Reliable techniques are available to allow sleeve resection of any lobe or the main bronchus and thus maximize preservation of lung parenchyma.

METHODS

Between 1972 and 1995 we performed 100 bronchoplastic procedures on 99 patients. Seventy-eight patients had low-grade or benign tumors including carcinoid, mucoepidermoid, and fibrous histiocytomas. Seven patients had inflammatory lesions including histoplasmosis and tuberculosis. Two patients had idiopathic stenosis. Thirteen patients had stenoses due to prior trauma or previous operation. Resection involved the bronchus alone in 51 cases. Sleeve lobectomies were done in 49 patients.

RESULTS

There were two postoperative deaths in complicated patients. Major complications occurred in 3 patients. Sixteen patients presented preoperatively with postobstructive pneumonia but had no major postoperative complications. Long-term follow-up (mean, 88 months) reveals only one instance of tumor recurrence (adenoidcystic carcinoma) and progressive stenosis in 1 patient with idiopathic stenosis.

CONCLUSIONS

Lung-sparing bronchoplastic operations are the procedures of choice in anatomically suited patients with low-grade malignant tumors of the airway and benign bronchial stenosis.

Survival and function after sleeve lobectomy for lung cancer

Between 1962 and 1991, 72 patients (mean age 63.4 years) underwent sleeve lobectomy for primary lung cancer. Thirty-seven patients had adequate lung function and 35 were deemed unsuitable for pneumonectomy on the basis of inadequate pulmonary reserve (n = 31) or cardiac risk factors (n = 4). Squamous cell carcinomas (68%) and adenocarcinomas (26%) predominated. Upper lobectomy was performed in 48 patients, lower and middle lobectomy in 13, and right upper and middle bilobectomy in 11. Hospital mortality was 4% (3/72) and compares with a hospital mortality of 9% in 56 consecutive pneumonectomies between 1986 and 1990. Major complications occurred in 11% (bronchopleural fistula 1, persistent atelectasis 4, pneumonia 4). Adjusted actuarial survival after sleeve lobectomy at 1 and 5 years was 84% and 42%, compared with 76% and 44% after pneumonectomy. Five-year survival after lower and middle lobectomy in 13 patients (52%) was similar to that after upper lobectomy (46%), suggesting that in carefully selected patients the concept of sleeve lobectomy can be applied to all pulmonary lobes. N1 disease and compromised lung function were associated with lower survival (N1 38% vs N0 57%; compromised 20% vs adequate 55%). Comparison of preoperative and postoperative lung function and quantitative ventilation-perfusion isotope studies substantiated the preservation of pulmonary function in this group of patients. Sleeve lobectomy is the procedure of choice for anatomically suitable carcinomas or when reduced pulmonary reserve precludes extensive resection.

Are bilobectomies acceptable procedures?

BACKGROUND

Controversy about operative morbidity and oncologic value of bilobectomy has led to a review of our experience over the past 12 years.

METHODS

The charts of 112 patients (100 men and 12 women with a mean age of 63 years) were reviewed for operative mortality and morbidity and long-term survival. Survival of patients with stage I or stage II disease was compared with that of stage-matched and age-matched groups having right pneumonectomy.

RESULTS

Four patients (3.5%) died postoperatively. Nonfatal complications occurred in 55 patients (49%); the most frequent problem was pleural space disease (34%). Survival studies focused on the 96 patients with nonsmall cell bronchogenic cancer (44 in stage I, 32 in stage II, and 20 in stage IIIA). The overall 5-year survival rate was 40%; the 5-year survival rate was similar for stage I and stage II (41% for stage I, 50% for stage II, and 17% for stage IIIA). The incidence of local recurrence was significantly increased after bilobectomy for stage I cancer (chi 2 = 5.066; p < 0.05) compared with pneumonectomy but did not affect 5-year survival. Local recurrence and survival were similar after bilobectomy and pneumonectomy in stage II.

CONCLUSIONS

These data demonstrate an increased morbidity after bilobectomy. Survival studies demonstrate an increased risk of local recurrence in patients with stage I disease, which might be partly explained by understaging.

Pulmonary function after sleeve lobectomy

Preoperative and postoperative pulmonary function of 109 sleeve lobectomy patients (90 right upper lobe, 10 left upper lobe, and 9 left lower lobe) were evaluated over a period of 30 years. Ninety-eight men and 11 women, with a mean age of 60 years, were reviewed. The diagnosis was lung cancer in 97 patients and carcinoid tumors in 12 patients. Indications for operation were anatomic suitability in 103 patients, and impaired pulmonary function (forced expiratory volume in 1 second (FEV1) less than 1,200 mL) in 6 patients. The predicted postoperative FEV1 was calculated and compared with the measured postoperative FEV1. Preoperative spirometry and split pulmonary radionuclide ventilation/perfusion scans were used to calculate the predicted postoperative FEV1. Postoperative spirometry had been performed 125 days after operation (range, 25 to 342 days). Our results showed a gradual improvement in postoperative pulmonary function. A complete and stable condition was reached 4 months after operation. Correlation between the predicted (mean, 2,097 mL) and measured FEV1 (mean, 2,067 mL) was good (linear regression and correlation test; r = 0.72). These values did not differ significantly (Wilcoxon signed rank test; p = 0.81). Our findings indicated a complete recovery of the reimplanted lung lobes after sleeve lobectomy.

Tracheobronchial sleeve resection in children and adolescents

Bronchoplastic techniques preserving lung parenchyma allow resection and reconstruction of the major bronchi and carina and are widely used in adults. The smaller and more delicate airways of children make such operations more demanding, but successful outcome can still be achieved with particular attention to technique. The authors treated 12 patients age 8 to 19 years (mean, 13.8 years) over a 12-year period. Ten patients had tumors of the airway: carcinoid (4), mucoepidermoid (2), malignant fibrous histiocytoma (1), adenocarcinoma (1), granular cell (1), and invasive fibrous tumor (1); and 2 had nonneoplastic strictures. Previous operative treatment included incomplete local excision in 2 and laser ablation in 1. Carinal resection and reconstruction was performed in 6 patients, main-stem bronchial resection in 3, and sleeve lobectomy in 3. There was one death after a complex airway reconstruction for extensive mediastinal fibrosis involving the airway. Postoperative morbidity consisted of prolonged atelectasis in 3 patients. Residual malacia in 1 patient with postpneumonectomy syndrome required further tracheobronchial resection. Follow-up is complete (mean, 64 months; range, 7 to 130). There has been no anastomotic stenosis or tumor recurrence. Preservation of lung function is expected in all patients. In 7 patients, bronchoscopy 4 months to 11 years postoperatively confirmed anastomotic patency and growth. The understanding of bronchoplastic techniques and precise attention to technical detail should allow these procedures to be successfully performed in pediatric patients.

Staging and management of lung cancer: sleeve resection

Sleeve lobectomy is a lung-saving procedure usually indicated for central tumors for which the alternative is a pneumonectomy. It preserves normal lung tissue and may enable pulmonary resection to be done in selected patients with inadequate cardiac or pulmonary reserve. One experience extends from January 1972 to December 1991, during which time 142 patients underwent a variety of sleeve resections for bronchogenic neoplasms. The majority of operations were upper-lobe sleeve resections (N = 110) and most procedures were considered complete and potentially curative (87%). There were three postoperative deaths (surgical mortality of 2.5%) and prolonged atelectasis was the most common major complication (N = 9). Follow-up was complete for the 139 survivors (mean follow-up time of 2,149 days) and overall survival was 46% at 5 years and 33% at 10 years. Five- and 10-year survivals for patients with stage I disease were 63% and 52%, respectively, while only 14% of patients with stage III disease survived 5 years. Local recurrences occurred in 23% of patients but when the resection had been complete, this incidence was 17% (21/124). These results indicate that sleeve resection is an adequate cancer operation for both compromised and uncompromised patients. Operative mortality, survival, and incidence of local recurrence are not different than what is seen after more conventional procedures.

Bronchoplastic and angioplastic techniques in the treatment of bronchogenic carcinoma

From 1979 to 1991, 51 bronchoplasties, 18 angioplasties, and 4 combined broncho-angioplasties were performed for bronchogenic carcinoma. Sixteen patients underwent operation because of compromised pulmonary function; bronchoplasty, angioplasty, or the combined procedure was performed in the remaining 57 patients because of a suitable anatomic location of the neoplasm. Twenty-four patients had stage I disease, 32 stage II, and 17 stage IIIa. Three patients died postoperatively (3.65%). Major postoperative complications occurred in 20 patients (27.3%) (10 early, and 10 late). A completion pneumonectomy was required in 4 patients (5.4%), 2 for anastomotic stricture, 1 because of vascular thrombosis after angioplasty, and 1 for local recurrence after angioplasty. Three-year and 5-year survival rates for the entire group were 55.4% and 40.8%, respectively. One-year and 3-year survival rates after angioplasty were 78.6% and 31.4%. Of the 4 patients who underwent a combined bronchoangioplastic procedure, 1 died after 23 months and 3 are alive and well after 11, 15, and 20 months. Survival was more favorable in the combined N0-N1 group (62% and 43.1%) than in the N2 group (23.4%), but the difference was not significant (p < 0.2). Three-year survival after angioplasty was found to be lower than, although not significantly different from, the overall 3-year survival rate (31.4% versus 55.4%; p = not significant). No statistically significant differences were found among survival rates of patients with compromised and noncompromised pulmonary reserve. We conclude that bronchoplastic and angioplastic procedures are valid techniques as curative operations in carefully selected patients with bronchogenic carcinoma.(ABSTRACT TRUNCATED AT 250 WORDS)

Staging systems of lung cancer

The staging of lung cancer involves assessment of the anatomic extent of disease based on the best available data. Such a definition of neoplastic burden facilitates the systematic analysis and meaningful communication of diagnostic, therapeutic, and prognostic information. Clinical staging involves the best estimate of extent of disease before performance of surgical resection or biopsy procedures (or both). Surgical-pathologic staging is based on the histopathologic analysis of resected specimens, including determining the extent of local and regional disease. During the past 50 years, two major classification schemes for staging of lung cancer have evolved--one for non-small-cell lung cancers (the TNM system, indicating the status of primary tumor [T], regional lymph node [N], and metastatic [M] involvement) and the other for small-cell carcinoma of the lung (based on limited versus extensive disease). In this report, we review the evolution of the current staging systems used for primary lung cancer and their prognostic implications.