Quality of Life after Lung Cancer Surgery: A Prospective Pilot Study comparing Bronchial Sleeve Lobectomy with Pneumonectomy

The comparison of perioperative outcomes and disease-free survival between pneumonectomy after immunochemotherapy and after isolated chemotherapy: one single center experience

OBJECTIVE

This study aims to compare the perioperative outcomes and disease-free survival (DFS) between pneumonectomy after immunochemotherapy and chemotherapy.

METHODS

We retrospectively identified patients who received neoadjuvant immunotherapy (n = 15) or chemotherapy alone (n = 12) in our single center between 2021 and 2023. The primary end point was 30-day major complications. The secondary end point was major pathologic response.

RESULTS

There was no significant difference in operation time, blood loss and postoperative stay time between ICI (Received immune checkpoint inhibitor treatment including PD-1 and PD-L1 inhibitors) and Chemo cohort. There were also no difference in postoperative complications including complications > grade III, 90-day death and bronchial fistula. The pCR rate was 40.0% (6/15) in the ICI cohort versus 0.0% (0/12) in the chemo cohort (p = 0.020). The MPR or pCR rate was 60.0% (9/15) in the ICI cohort versus 8.3% (1/12) in the chemo cohort (p = 0.014). ICI cohort was associated with an improved overall 1, 2, and 3-year disease-free survival(DFS)compared with chemo cohort. At the same time, both patients received ICI and Chemo were grouped according to whether pCR occurred or not, and it was found that DFS in the pCR group was better than DFS in the non-pCR group.

CONCLUSIONS

Based on our results, we argue that compared with pneumonectomy after isolated chemotherapy, pneumonectomy after immunochemotherapy not added 90-day mortality, postoperative, morbidity, but improved DFS; thus, it should be the induction therapy choice for anatomically eligible centrally located lung cancers.

Case Report: Uniportal robot-assisted thoracoscopic double-sleeve lobectomy after neoadjuvant immunotherapy

Minimally invasive thoracic surgery, including video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery, has been proven to have an advantage over open thoracotomy with less pain, fewer postoperative complications, faster discharge, and better tolerance among elderly patients. We introduce a uniportal robot-assisted thoracoscopic double-sleeve lobectomy performed on a patient following neoadjuvant immunotherapy. Specialized instruments like customized trocars with a reduced diameter, bulldog clamps, and double-needle sutures were utilized to facilitate the maneuverability through the single incision. This technique integrates the merits of multiport robot-assisted thoracic surgery with uniportal video-assisted thoracoscopic surgery.

Timing of recovery of quality of life after robotic anatomic lung resection

Patient-reported outcomes (PROs) are an underreported aspect of surgical recovery. The purpose of our study was to track PROs after robotic anatomic lung to determine the timing to recovery of baseline patient baseline quality of life. This was a prospective cohort study at an academic medical center (4/2021-12/2022). Patients who underwent robotic anatomic lung resection were asked to complete PROMIS-29 surveys at the preoperative clinic visit, postoperative clinic visit, 30 days and 90 days postoperatively via in-person and email-based electronic surveys. The PROPr score, a summary of health-related quality of life, and mental and physical health z-scores were estimated for each patient using published methods and compared by postoperative timing. 75 patients completed the preoperative survey and at least one postoperative survey; 56 completed postoperative clinic surveys, 54 completed 30-day postoperative surveys, and 40 completed 90-day postoperative surveys. All three PROMIS scores decreased between the preoperative and first postoperative visit (all p < 0.05). PROPr scores increased over time but remained significantly worse than baseline by 90 days (-0.08 difference between 90 days and preoperative, p = 0.02). While PROMIS summary z-scores for physical health remained - 0.29 lower at 90 days postoperatively, this did not reach statistical significance (p = 0.06). Mental health scores returned to baseline by 90 days postoperatively (p = 0.41). While some PROs returned to baseline by 90 days postoperatively, overall quality-of-life scores remained significantly below preoperative baselines. These findings are important to share with patients during the informed consent process to achieve patient centered care more effectively.

Pain experience of lung cancer patients during home recovery after surgery: A qualitative descriptive study

BACKGROUND

Patients with lung cancer surgery often suffer pain after discharge. However, there is limited evidence to describe the pain experience from the qualitative investigation. This study was designed to describe the pain experience of lung cancer patients during home recovery after surgery and to provide evidence for developing pain management strategies.

METHODS

This qualitative descriptive study recruited 35 patients who had received lung resection and were discharged by purposive sampling from May to July 2022. Mobile phone interviews were conducted to collect views on patients' pain experience after discharge. The interviews were audio-recorded and converted verbatim into standard text, and the data were iteratively thematic analyzed.

RESULTS

A thematic framework was identified for three themes: perception and impact of pain, coping styles for pain, and unmet needs for pain. Whether short or long-term after discharge, patients complain that they suffer from different degrees and types of pain, causing them a "double burden" physically and mentally. The lack of knowledge about pain may lead them to adopt very different coping styles and desire professional continuous pain management.

CONCLUSIONS

This study may help clarify the status of pain problems that patients face after lung cancer surgery and provides multiple dimensions of pain assessment and management objectives for quantitative research. We call on medical staff to pay attention to patients' perspectives and related needs after discharge and formulate targeted management strategies to reduce pain and improve their quality of life.

Safety of adjuvant atezolizumab after pneumonectomy/bilobectomy in stage II-IIIA non-small cell lung cancer in the randomized phase III IMpower010 trial

OBJECTIVE

Adjuvant atezolizumab is a standard of care after chemotherapy in completely resected stage II-IIIA programmed death ligand-1 tumor cell 1% or greater non-small cell lung cancer based on results from the phase III IMpower010 study. We explored the safety and tolerability of adjuvant atezolizumab by surgery type in IMpower010.

METHODS

Patients had completely resected stage IB-IIIA non-small cell lung cancer (Union Internationale Contre le Cancer/American Joint Committee on Cancer, 7th Ed), received up to four 21-day cycles of cisplatin-based chemotherapy, and were randomized 1:1 to receive atezolizumab 1200 mg every 3 weeks (≤16 cycles or 1 year) or best supportive care. Adverse events and clinical characteristics were investigated by surgery type (pneumonectomy/bilobectomy or lobectomy/sleeve lobectomy) in the randomized stage II-IIIA population who received 1 or more atezolizumab dose or with 1 or more postbaseline assessment (safety evaluable) for best supportive care.

RESULTS

Overall, 871 patients comprised the safety-evaluable randomized stage II-IIIA population. In the atezolizumab arm, 23% (100/433) received pneumonectomy/bilobectomy and 77% (332/433) received lobectomy/sleeve lobectomy. Atezolizumab discontinuation occurred in 32% (n = 32) and 35% (n = 115) of the pneumonectomy/bilobectomy and lobectomy/sleeve lobectomy groups, respectively. Grade 3/4 adverse events were reported in 21% (n = 21) and 23% (n = 76) of patients in the atezolizumab arms in the pneumonectomy/bilobectomy and lobectomy/sleeve lobectomy groups, respectively. In the atezolizumab arms of the surgery groups, 13% (n = 13) and 17% (n = 55) had an adverse event leading to hospitalization. Atezolizumab-related adverse events leading to hospitalization occurred in 5% (n = 5) and 7% (n = 23) of the surgery groups.

CONCLUSIONS

These exploratory findings support use of adjuvant atezolizumab after platinum-based chemotherapy in patients with completely resected stage II-IIIA programmed death ligand-1 tumor cell 1% or more non-small cell lung cancer, regardless of surgery type.

Video-assisted thoracoscopic versus open sleeve lobectomy for non-small cell lung cancer: A systematic review and meta-analysis from six comparative studies

BACKGROUND

Lung sleeve resection is indicated for centrally located lung tumors, especially for patients who cannot tolerate pneumonectomy. With video-assisted thoracoscopic surgery (VATS) being increasingly implemented for a wide variety of thoracic pathologies, this study aims to compare the intraoperative, postoperative, and long-term outcomes of VATS and open bronchial sleeve lobectomy for non-small cell lung cancer (NSCLC).

METHODS

The MEDLINE (via PubMed), Cochrane Library, and Scopus databases were searched. Original clinical studies, comparing VATS and open sleeve lobectomy for NSCLC were included. Evidence was synthesized as odds ratios for categorical and weighted mean difference (WMD) for continuous variables.

RESULTS

Our analysis included six studies with non-overlapping populations reporting on 655 patients undergoing bronchial sleeve lobectomy for NSCLC (229 VATS and 426 open). VATS sleeve lobectomy was associated with significantly longer operative time ((WMD): 45.85 min, 95% confidence interval (CI): 12.06 to 79.65, p  =  0.01) but less intraoperative blood loss ((WMD): -34.57 mL, 95%CI: -58.35 to -10.78, p < 0.001). No significant difference was found between VATS and open bronchial sleeve lobectomy in margin-negative resection rate, number of lymph nodes resected, postoperative outcomes (drainage duration, length of hospital stay, 30-day mortality), postoperative complications (pneumonia, bronchopleural fistula/empyema, prolonged air leakage, chylothorax, pulmonary embolism, and arrhythmia), and long-term outcomes (overall survival, recurrence-free survival).

CONCLUSIONS

The limitation of our study arises mainly due to the heterogeneity of the included studies. Nevertheless, VATS bronchial sleeve lung resection constitutes a feasible and safe alternative to the open sleeve lung resection surgery for the management of centrally located lung tumors.

Postoperative Symptom Burden in Patients Undergoing Lung Cancer Surgery

CONTEXT

Previous studies on quality of life (QOL) after lung cancer surgery have identified a long duration of symptoms postoperatively. We first performed a systematic review of QOL in patients undergoing surgery for lung cancer. A subgroup analysis was conducted focusing on symptom burden and its relationship with QOL.

OBJECTIVE

To perform a qualitative review of articles addressing symptom burden in patients undergoing surgical resection for lung cancer.

METHODS

The parent systematic review utilized search terms for symptoms, functional status, and well-being as well as instruments commonly used to evaluate global QOL and symptom experiences after lung cancer surgery. The articles examining symptom burden (n = 54) were analyzed through thematic analysis of their findings and graded according to the Oxford Centre for Evidence-based Medicine rating scale.

RESULTS

The publication rate of studies assessing symptom burden in patients undergoing surgery for lung cancer have increased over time. The level of evidence quality was 2 or 3 for 14 articles (cohort study or case control) and level of 4 in the remaining 40 articles (case series). The most common QOL instruments used were the Short Form 36 and 12, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire, and the Hospital Anxiety and Depression Score. Thematic analysis revealed several key findings: 1) lung cancer surgery patients have a high symptom burden both before and after surgery; 2) pain, dyspnea, cough, fatigue, depression, and anxiety are the most commonly studied symptoms; 3) the presence of symptoms prior to surgery is an important risk factor for higher acuity of symptoms and persistence after surgery; and 4) symptom burden is a predictor of postoperative QOL.

CONCLUSION

Lung cancer patients undergoing surgery carry a high symptom burden which impacts their QOL. Measurement approaches use myriad and heterogenous instruments. More research is needed to standardize symptom burden measurement and management, with the goal to improve patient experience and overall outcomes.

Longitudinal changes in pulmonary function and patient-reported outcomes after lung cancer surgery

Background

Surgery is the mainstay of treatment for non-small cell lung cancer, but the decline in pulmonary function after surgery is noticeable and requires attention. This study aimed to evaluate longitudinal changes in pulmonary function and integrated patient-reported outcomes (PROs) after lung cancer surgery.

Methods

Data were obtained from a prospective cohort study, the Coordinate Approach to Cancer Patients’ Health for Lung Cancer. Changes in forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV₁) at 2 weeks, 6 months, and 1 year after surgery, and the corresponding modified Medical Research Council (mMRC) dyspnea scale and chronic obstructive lung disease assessment test (CAT) scores were evaluated. Mixed effects model was used to investigate changes in pulmonary function and PROs.

Results

Among 620 patients, 477 (76.9%) underwent lobectomy, whereas 120 (19.4%) and 23 (3.7%) were treated with wedge resection/segmentectomy and bilobectomy/pneumonectomy, respectively. Both FVC and FEV₁ markedly decreased 2 weeks after surgery and improved thereafter; however, they did not recover to baseline values. The corresponding mMRC dyspnea scale and CAT scores worsened immediately after surgery. The dyspnea scale of the mMRC was still higher, while CAT scores returned to baseline one year after surgery, although breathlessness and lack of energy persisted. Compared to the changes from baseline of FVC and FEV₁ in patients who underwent lobectomy, patients who underwent bilobectomy/pneumonectomy showed a greater decrease in FVC and FEV₁, while wedge resection/segmentectomy patients had smaller decreases in FVC and FEV₁ at 2 weeks, 6 months, and 1 year after surgery. Bilobectomy/pneumonectomy patients had the highest mMRC dyspnea grade among the three groups, but the difference was not statistically significant one year after surgery.

Conclusions

After lung cancer surgery, pulmonary function and PROs noticeably decreased in the immediate post-operative period and improved thereafter, except for dyspnea and lack of energy. Proper information on the timeline of changes in lung function and symptoms following lung cancer surgery could guide patient care approaches after surgery.

Trial registration: ClinicalTrials.gov; No.: NCT03705546; URL: www.clinicaltrials.gov

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-022-02149-9.

Factors Affecting Postoperative Lung Functions in Patients Undergoing Lobectomy for Non-Small Cell Lung Cancer

Background and Objectives: The estimation of lung function impairment after pulmonary lobectomy for primary non-small cell lung cancer (NSCLC) has been of great interest since the reduction of respiratory function might severely affect a patient’s quality of life. The perioperative factors that may have an influence on widening the gap between the postoperative measured lung function and predicted postoperative lung function were our greatest concern. We aimed to analyze the perioperative patient factors that may influence postoperative lung function in patients undergoing pulmonary lobectomy. Materials and Methods: A retrospective study was conducted using the medical records of 199 patients who underwent lobectomy for lung cancer between July 2017 and May 2020. After comparing the achieved postoperative forced expiratory volume in 1 s (FEV1) and predicted postoperative (ppo) FEV1, patients were divided into two groups: group A (n = 127), who had preserved pulmonary lung function; and group B (n = 72), who had decreased pulmonary lung function. Primary endpoints included location of pulmonary resection, preoperative performance status, body mass index (BMI) on admission, total muscle area, and muscle index. Results In group A, the proportion of normal weighted patients was significantly higher than that in group B (67.7% vs. 47.2%, p = 0.003). Conversely, the proportion of overweight patients was significantly higher in group B than in group A (47.2% vs. 28.3%, p = 0.003). Group B had a significantly high incidence of upper lobe resection (p = 0.012). The mean total muscle area in group A was higher than that in group B, but the difference was not statistically significant. Conclusions: A greater decrease in postoperative lung function than in ppo FEV1 was associated with BMI and the location of pulmonary resection in patients who underwent lobectomy. Postoperative physiologic changes due to high BMI and the resection of upper lobes need to be discussed to prevent postoperative morbidities.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 2: systematic review of evidence regarding resection extent in generally healthy patients

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, stereotactic body radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in generally healthy patients is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons with at least some adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In healthy patients there is no short-term benefit to sublobar resection vs. lobectomy in randomized and non-randomized comparisons. A detriment in long-term outcomes is demonstrated by adjusted non-randomized comparisons, more marked for wedge than segmentectomy. Quality-of-life data is confounded by the use of video-assisted approaches; evidence suggests the approach has more impact than the resection extent. Differences in pulmonary function tests by resection extent are not clinically meaningful in healthy patients, especially for multi-segmentectomy vs. lobectomy. The margin distance is associated with the risk of recurrence.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in healthy patients with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation on which to build a framework for individualized clinical decision-making.

Evaluating the Content Validity, Clarity, and Relevance of Two Patient-Reported Outcomes for Use With Adults With EGFR-Mutated NSCLC

INTRODUCTION

NSCLCs account for most lung cancers; approximately 30% involve a mutation in the EGFR gene. This study sought to identify one or more patient-reported outcome (PRO) measures relevant for use in clinical trials to assess symptoms and health-related quality of life in this population.

METHODS

Patients with NSCLC from the United States, Europe, and Asia and including those with an exon 20 insertion mutation and other EGFR mutations participated in a combination of concept elicitation and cognitive debriefing interviews to report symptoms and impacts of their NSCLC and provide feedback on the clarity and relevance of several PRO measures.

RESULTS

A total of 30 individuals participated (mean age = 57 years, 87% female, 80% white). The most often reported symptoms included fatigue, shortness of breath, cough, and weight loss. Individuals with the exon 20 insertion mutation (n = 21) more frequently reported negative impacts on daily life, physical functioning, and social functioning but less frequently reported negative impacts to emotional functioning. The PROMIS Short-Form version 2.0-Physical Function 8c and the NSCLC Symptom Assessment Questionnaire were deemed clear, relevant, and easy to complete. The concepts identified during the concept elicitation portion of the interviews were mapped to the content of each PRO, and all items within both PROs were endorsed by at least 20% of the participants.

CONCLUSIONS

These results support the content validity, clarity, and relevance of the PROMIS Short-Form version 2.0-Physical Function 8c and the NSCLC Symptom Assessment Questionnaire in a population with EGFR-mutated NSCLC. Both would be appropriate for inclusion in future studies.

Preoperative predictors of restoration in quality of life after surgery for lung cancer

Background

The preoperative predictors of quality of life (QOL) in patients who undergo lung resection for lung cancer are poorly known. Here, we investigated these predictors in such patients using two QOL measures.

Methods

In this single‐institutional prospective cohort study, we administered the EQ‐5D‐5 levels (EQ‐5D‐5L) from January 2015, and the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire with 30 items from April 2015 to April 2018 preoperatively (Pre) and at one month postoperatively (M1), and one year postoperatively (Y1). General health status was measured by the EQ‐5D visual analogue scale (VAS) and EORTC global health status/QOL (GHS) scores. Multivariable linear regression analyses were used to explore the preoperative predictors of QOL at Y1.

Results

A total of 223 patients were included in the study. The EQ‐5D VAS and EORTC GHS scores, at Pre, M1, and Y1, were 80 ± 15, 77 ± 15, and 84 ± 11; and 74 ± 19, 65 ± 20, and 78 ± 17, respectively. In the multivariable analyses, the albumin level, preoperative VAS score, and preoperative pain/discomfort and anxiety/depression were identified as predictors by the EQ‐5D VAS score. The preoperative EORTC GHS score, absence of diabetes mellitus, preoperative cognitive function score, and preoperative symptom score of pain were identified as predictors by the EORTC GHS score.

Conclusions

The EQ‐5D VAS and EORTC GHS scores traced similar trajectories of QOL. In both QOL measures, preoperative pain was found as a common predictor. These predictors may help improve patient/survivor care in the future.

Health-Related Quality of Life After Lobectomy for Lung Cancer: Conceptual Framework and Measurement

BACKGROUND

Lung cancer surgery has a significant impact on health-related quality of life (HRQOL). In prior studies of HRQOL after lung cancer surgery, researchers selected the HRQOL domains of interest. To increase the patient-centeredness of these studies, we conducted a qualitative study to ascertain which aspects of HRQOL are most relevant to them postoperatively and to identify Patient-Reported Outcome Measurement Information System measures most germane to patients undergoing lobectomy for lung cancer.

METHODS

We conducted in-depth semistructured interviews with 25 patients after lobectomy for lung cancer to solicit input regarding the physical, social, and emotional HRQOL domains relevant after surgery. Interviews were transcribed verbatim, and a thematic content analysis to identify HRQOL themes was performed. Themes were integrated to create a conceptual framework to guide outcome measurement selection.

RESULTS

Qualitative analysis indicated that within the physical health domain, patients were most concerned about general physical function (100% of participants), pain (96%), fatigue (96%), and dyspnea (76%). Neuropathic pain was reported by 28% of participants. Instrumental (100%) and emotional social support (88%) and positive emotions/relief/hope (96%) were also important. Two cross-cutting themes were the desire to maintain independence (32%) and preparing for surgery/expectations (92%).

CONCLUSIONS

Our results indicate that a number of physical, social, and emotional HRQOL domains are relevant after lobectomy for lung cancer. These domains are currently represented by Patient-Reported Outcome Measurement Information System measures and can be readily assessed for clinical or research purposes.

Standard and extended sleeve resections of the tracheobronchial tree

Anatomic resections with bronchial and/or vascular resections and reconstruction, so called sleeve resections were originally performed in patients with impaired cardio-pulmonary reserves. Nowadays, sleeve resections are established surgical procedures of first choice for tracheobronchial pathologies, whenever anatomically and oncologically feasible. Experienced thoracic surgeons have a broad surgical armentarium to avoid a pneumonectomy and the morbidity and mortality associated with it. Sleeve resections are associated with better outcomes in all aspects. Thus, sleeve resection is not an alternative for pneumonectomy and vice versa. In this review article we set out to provide a contemporary overview on this topic.

Combined sleeve lobectomy for centrally located primary lung cancer and lung cancer with hilar lymph node metastasis

BACKGROUND

Centrally located lung cancer or metastatic hilar lymph nodes can invade the airway and other hilar structures, and they must be removed to achieve complete resection.

METHODS

We retrospectively assessed the clinical course of 47 patients with centrally located lung cancer or metastatic hilar lymph nodes who underwent sleeve lobectomy from January 2010 to December 2017.

RESULTS

The invaded structure other than the airway was the pulmonary artery in 21 patients, chest wall in 3, esophageal muscular wall in 2, vagus nerve in 2, pericardium in 2, left atrium in 1, phrenic nerve in 1 and superior vena cava in 1. Twenty-four patients were treated with sleeve lobectomy alone (simple sleeve lobectomy), and 23 patients were treated with sleeve lobectomy with additional methods (combined sleeve lobectomy). Adverse events occurred in 10 patients (48%) in the simple sleeve lobectomy group and 7 patients (30%) in the combined sleeve lobectomy group. During the follow-up period, 15 patients developed recurrent disease and 12 patients died. Patients in the combined sleeve lobectomy group had significantly shorter overall survival (P = 0.004) and disease-free survival periods (P = 0.013). Combined sleeve lobectomy was a significantly poor prognostic factor in the univariate and multivariate analyses. Patients who underwent sleeve lobectomy with an additional method other than angioplasty had a significantly poorer prognosis. However, no patient developed recurrent disease in the hilar area.

CONCLUSIONS

Combined sleeve lobectomy has acceptable adverse events and good local controllability. However, combined sleeve lobectomy is associated with a significantly poorer prognosis than simple sleeve lobectomy in terms of overall survival and disease-free survival.

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.

The Initial Experience on Thoracoscopic Sleeve Lobectomy: Continuous Suturing Technique of the Bronchial Anastomosis in 12 Cases

BACKGROUND

Sleeve resection is a widely performed type of operation in the surgical treatment of non-small cell lung cancer. Video-assisted thoracoscopic surgery (VATS) is now used even in central tumor surgeries of the lung with the increasing technology and experience. Sleeve resection cases performed through VATS in our clinic in recent years were presented with demographic, surgical, pathologic, and survey characteristics.

MATERIALS AND METHODS

Twelve patients who underwent sleeve resection with VATS in our clinic between November 2015 and August 2019 were included in the study. Operative, pathologic, and postoperative characteristics of the patients were examined.

RESULTS

A total of 12 patients, 3 female and 9 male individuals, were included in the study. The mean age of the patients was 61.7±12.9 years. According to the localization of the tumors, left upper lobectomy was performed in 4 patients and 8 patients underwent right upper lobectomy. During the sleeve anastomosis of the patients, 3/0 prolene sutures were used in 5 patients (36%) and 4/0 prolene sutures in 4 patients (36%), whereas 3/0 polydioxanone suture (PDS) was used in 3 patients (28%). The mean operation time was 288.2±77.1 (205 to 460) minutes and the mean anastomosis time was 70±18.5 (55 to 110) minutes. In the postoperative period, 1 patient who had acute myocardial infarction died on the fourth postoperative day. The mean postoperative drainage duration of the patients was 5.5±1.9 (3 to 10) days and the mean length of hospital stay was 6.4±1.9 (4 to 11) days. When the pathologic features were examined, the mean tumor diameter was found to be 2.5±1.2 (1 to 5.5) cm. The mean follow-up period was calculated as 26.1±15.6 months (2 to 47). Other than 1 patient who died, the follow-up of 11 patients still proceeds.

CONCLUSIONS

VATS approach of sleeve resections, which is performed cautiously even by thoracotomy, is becoming more common. These operations, which could be performed in experienced centers, offer a postoperative period of less morbidity to the patients with the advantage of reduced postoperative pain, drainage time, and hospital stay.

N-Methyl-D-Aspartate Antagonists and Steroids for the Prevention of Persisting Post-Surgical Pain After Thoracoscopic Surgeries: A Randomized Controlled, Factorial Design, International, Multicenter Pilot Trial

Purpose

We conducted a feasibility 2×2 factorial trial comparing N-methyl-D-aspartate (NMDA) antagonists (intravenous ketamine and oral memantine) versus placebo and intravenous steroids versus placebo, in patients having elective video-assisted thoracic surgery lobectomies, at St. Joseph's Hamilton, Canada, and Cleveland Clinic, Cleveland, USA. Our feasibility objectives were: 1) recruitment rate/week; 2) recruitment of ≥90% of eligible patients; and 3) >90% follow-up. Secondary objectives were incidence and intensity of persistent post-surgical pain (PPSP) and other clinical and safety outcomes.

Methods

Using computerized randomization, patients were allocated to one of four groups: NMDA active with steroid placebo; NMDA placebo with steroid active; both NMDA and steroid active; both NMDA and steroid placebo. Patients, health providers, and data analysts were blinded to allocation. Patients were followed for 3 months after randomization.

Results

The trial was initiated in May 2017 at Hamilton and, after subsequent regulatory and ethics approval, in April 2018 at Cleveland. The trial had to be stopped after only 1 month of recruitment in Cleveland because the packaged study medications (memantine) expired and we were unable to procure the dosage required. Among 41 eligible patients, 27 (66%) were randomized. The recruitment rate/week was 0.63, 95% confidence interval (CI): 0.47-0.79 in Hamilton; and 1, 95% CI: 0.83-1.17 in Cleveland. Follow-up was complete for all 24 patients (100%) in Hamilton, and 3 of 4 patients in Cleveland. In total, only 4 patients (15%), and 2 patients (7%) had persistent pain at rest and with movement, respectively. There were no significant differences between groups for other outcomes.

Conclusion

The trial had to be stopped prematurely due to non-availability of study medications. Trial feasibility objectives of recruiting 90% of eligible patients and recruiting at least one patient/week per site were not met. Consideration for protocol changes will be necessary for the full trial.

Trial Registration

NCT02950233.

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.

Patient-Reported Outcomes in Cardiothoracic Surgery

BACKGROUND

Current studies in cardiothoracic clinical research frequently fail to use end points that are most meaningful to patients, including measures associated with quality of life. Patient-reported outcomes (PROs) represent an underused but important component of high-quality patient-centered care. Our objective was to highlight important principles of PRO measurement, describe current use in cardiothoracic operations, and discuss the potential for and challenges associated with integration of PROs into large clinical databases.

METHODS

We performed a literature review by using the PubMed/EMBASE databases. Clinical articles that focused on the use of PROs in cardiothoracic surgical outcomes measurement or clinical research were included in this review.

RESULTS

PROs measure the outcomes that matter most to patients and facilitate the delivery of patient-centered care. When effectively used, PRO measures have provided detailed and nuanced quality-of-life data for comparative effectiveness research. However, further steps are needed to better integrate PROs into routine clinical care.

CONCLUSIONS

Incorporation of PROs into routine clinical practice is essential for delivering high-quality patient-centered care. Future integration of PROs into prospectively collected registries and databases, including that The Society of Thoracic Surgeons National Database, has the potential to enrich comparative effectiveness research in cardiothoracic surgery.

Using patient-reported outcomes to manage postoperative symptoms in patients with lung cancer: protocol for a multicentre, randomised controlled trial

INTRODUCTION

Surgery is one of the primary treatments for lung cancer. The postoperative symptom burden experienced by patients with lung cancer is substantial, seriously delaying their recovery from surgery and impairing their quality of life. Patient-reported outcome (PRO)-based symptom management is increasingly regarded as an optimal model for patient-centred care. Currently, clinical trial-based evidence involving early-phase (immediately after surgery for up to 1 month) symptom management of lung cancer is lacking. We propose a randomised trial to evaluate the effect of a PRO-based symptom-monitoring programme with overthreshold alerts and responses for postoperative recovery in patients with lung cancer.

METHODS AND ANALYSIS

The study will recruit 160 patients with lung cancer from six hospitals. The patients will be randomly allocated to the intervention group or control group in a ratio of 1:1. Patients in the intervention group will receive PRO-based symptom management from the specialists when their reported target symptom (pain, coughing, fatigue, disturbed sleep and shortness of breath) scores reach the preset threshold (score ≥4). Patients in the control group will not generate alerts and will follow the standard procedures for symptom management. All patients will receive symptom assessments via the MD Anderson Symptom Inventory-lung cancer module on the day before surgery, daily after surgery and twice a week after discharge until 4 weeks or the start of postoperative oncological treatment. The primary outcome-mean symptom threshold events-will be compared between the intervention and control group via independent sample Student's t-test.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of Sichuan Cancer Hospital on 22 November 2018 (No. SCCHEC-02-2018-045). This manuscript is based on V.2.0, 9 May 2019 of the protocol. The study results will be disseminated in publications in peer-reviewed journals and presentations at academic conferences.

TRIALS REGISTRATION NUMBER

ChiCTR1900020846.

Endobronchial and surgical treatment of pulmonary carcinoid tumors: A systematic literature review

The treatment of pulmonary carcinoid has changed over the last decades. Although surgical resection is still the gold standard, minimally invasive endobronchial procedures have emerged as a parenchyma sparing alternative for tumors located in the central airways. This review was performed to identify the optimal treatment strategy for pulmonary carcinoid, with a particular focus on the feasibility and outcome of parenchyma sparing techniques versus surgical resection. A systematic review of the literature was carried out using MEDLINE, Embase and the Cochrane databases, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Two separate searches of publications in endobronchial and surgical treatment in patients with pulmonary carcinoid, were performed. Outcomes were overall survival, disease free survival, recurrence rate, complications, quality of life, and healthcare costs. Combining the two main searches for endobronchial therapy and surgical therapy yielded 3111 records. Finally, 43 studies concerning surgical treatment and 9 studies related to endobronchial treatment for pulmonary carcinoid were included. Assessment of included studies showed that lymph node involvement, histological grade, tumor location and tumor diameter were identified as poor prognostic factors and seem to be important for patients with pulmonary carcinoid. For patients with a more favorable prognosis, tumor location and tumor diameter are important factors that can help decide on the optimal treatment strategy. Centrally located small intraluminal pulmonary carcinoids, without signs of metastasis can be treated with minimally invasive alternatives such as endobronchial treatment or parenchyma sparing surgical resection. Patients with parenchyma sparing resections should be followed with long term follow up to exclude recurrence of disease. In a multidisciplinary setting, it should be determined whether individual patients are eligible for parenchyma sparing procedures or anatomical resection. Overall evidence is of low quality and future studies should focus on prospective trials in the treatment of pulmonary carcinoid.

Pneumonectomy - permanent injury or still effective method of treatment? Early and long-term results and quality of life after pneumonectomy due to non-small cell lung cancer

INTRODUCTION

Despite the constant decrease of performed pneumonectomies (PN) in recent years, it is still necessary for 15-20% of patients with non-small cell lung cancer (NSCLC) to undergo total lung resection due to the local progression of the disease.

AIM

To assess the frequency and type of postoperative complications, quality of life, and the early and long-term results after PN performed due to NSCLC.

MATERIAL AND METHODS

In the total group of 1160 patients, operated on in 2008-2011 due to NSCLC, 192 of them underwent PN (16.6%). The quality of life was analysed using EORTC-QLQ-C30 questionnaire.

RESULTS

Perioperative mortality after PN was 4%. Five-year survival reached 45%. The factors that significantly affected the 5-year survival in multivariate analysis were: pTNM stage, pN stage, intrapericardial resection, and additional extrapulmonary structures resection. The mean Global Quality of Life was 50.8. The Symptom Scale ranged from 7 to 54.3, the Functional Scale from 58.2 to 76.3 and the rate for NSCLC symptoms ranged from 2.2 to 48.1.

CONCLUSIONS

Pneumonectomies in patients with NSCLC is associated with higher risk of postoperative complications but it does not significantly increase the perioperative mortality. Long-term results in this group of patients are encouraging. According to the questionnaire, the quality of life is favourable. Low intensity of typical NSCLC symptoms was observed. The appropriate qualification for right-sided PN and exclusion of metastasis in N2 nodes are crucial.

Patient-reported outcomes in lung and esophageal cancer

Carcinomas of the lung and esophagus are associated with significant disease and treatment related morbidity. Measuring patients' self-perceived notion of their health-related quality of life (HRQOL), throughout the course of illness, is central to the delivery of comprehensive, patient-centered care. This article reviews commonly used HRQOL instruments in thoracic surgery and discusses the integral role of patient-reported outcomes (PROs) in comparative effectiveness research and prognostication in the realm of lung and esophageal cancer. We also highlight challenges and future directions for widespread implementation of PROs into clinical and research practice.

Pneumonectomy after induction chemoradiotherapy for locally advanced non-small cell lung cancer: should curative intent pulmonary resection be avoided?

PURPOSE

We conducted a retrospective analysis to assess the practicality of pneumonectomy, especially after concurrent induction chemoradiotherapy (i-CRT), for locally advanced non-small cell lung cancer (LA-NSCLC). The operative risks vs. the survival benefit of this procedure for such patients is a subject of controversy.

METHODS

The subjects of this retrospective study were 71 consecutive LA-NSCLC patients with cStage IIIA-C NSCLC, who underwent i-CRT followed by curative intent pulmonary resection between February, 2001 and March, 2013.

RESULTS

Thirty-two patients underwent pneumonectomy (group P) and 39 patients underwent lobectomy (group L). In group P, 17 (54.8%) patients underwent right pneumonectomy. There was no 30-day postoperative mortality in either group and no significant difference in 90-day postoperative mortality between the groups (3.1% vs. 2.6% in groups P and L, respectively). The 5-year overall survival (OS) rate was 58.7% (95% CI: 41.5-75.9%) in group P and 57.3% (95% CI 41.2-73.4%) in group L, without a significant difference between the groups.

CONCLUSION

Our findings suggest that i-CRT followed by pneumonectomy is feasible, with a similar survival benefit to lobectomy. Thus, pneumonectomy after i-CRT should not be avoided as it is a potentially curative intent strategy for carefully selected patients.

Demographics, Safety and Quality, and Prognostic Information in Both the Seventh and Eighth Editions of the TNM Classification in 18,973 Surgical Cases of the Japanese Joint Committee of Lung Cancer Registry Database in 2010

INTRODUCTION

The Japanese Joint Committee of Lung Cancer Registry performed the fourth nationwide registry study of surgical cases. Demographics, safety and quality, prognostic information, and correlations between the seventh and the eighth editions of the TNM classification were investigated. The principal results were compared with those of previous Japanese Joint Committee of Lung Cancer Registry studies.

METHODS

The clinicopathologic profiles, staging, and prognosis of patients who had an operation for primary lung cancer in 2010 were retrospectively collected in 2016 and analyzed.

RESULTS

The cohort consisted of 18,973 patients from 297 hospitals (11,771 males, mean age 68.3 years). Tumor smaller than 2.0 cm was seen in 39.0% of patients, and limited resection was performed in 22.7%. The 30- and 90-day mortality rates were 0.43 and 1.26%, respectively. The overall and disease-free survival rates at 5 years were 74.7 and 67.8%, respectively. The respective 5-year survival rates by pathological stage in the seventh edition in the present study (2010) and in the previous study (2004) were 88.9% and 86.8% for stage IA, 76.7% and 73.9% for stage IB, 64.1% and 61.6% for stage IIA, 56.1% and 49.8% for stage IIB, 47.9% and 40.9% for stage IIIA, 30.2% and 27.8% for stage IIIB, and 36.1% and 27.9% for stage IV. The 5-year survival rates by clinical stage in the eighth edition in the present study were 97.0% for stage 0, 91.6% for stage IA1, 81.4% for stage IA2, 74.8% for stage IA3, 71.5% for stage IB, 60.2% for stage IIA, 58.1% for stage IIB, 50.6% for stage IIIA, 40.5% for stage IIIB, 37.5% for stage IIIC, and 36.0% for IVA/B. With restaging, the overall survival rates of clinical stage IA and IB in the seventh edition were stratified into stages 0 to IA3 and stages IA1 to IIA in the eighth edition, respectively.

CONCLUSIONS

This study demonstrates improved surgical results for lung cancer in Japan. The TNM revision for the eighth edition was supported by the assessment of stage migration from the previous edition and the prognostic stratification.

Preparing Cancer Patients and Family Caregivers for Lung Surgery: Development of a Multimedia Self-Management Intervention

The surgical treatment of lung malignancies often results in persistent symptoms, psychosocial distress, and decrements in quality of life (QOL) for cancer patients and their family caregivers (FCGs). The potential benefits of providing patients and FCGs with preparatory education that begins in the preoperative setting have been explored in multiple medical conditions, with positive impact observed on postoperative recovery, psychological distress, and QOL. However, few studies have explored the benefits of preparatory educational interventions to promote self-management in cancer surgery, including lung surgery. This paper describes the systematic approach used in the development of a multimedia self-management intervention to prepare cancer patients and their FCGs for lung surgery. Intervention development was informed by (1) contemporary published evidence on the impact of lung surgery on patients and FCG, (2) our previous research that explored QOL, symptoms, and caregiver burden after lung surgery, (3) the use of the chronic care self-management model (CCM) to guide intervention design, and (4) written comments and feedback from patients and FCGs that informed intervention development and refinement. Pilot-testing of the intervention is in process, and a future randomized trial will determine the efficacy of the intervention to improve patient, FCG, and system outcomes.

Patient-Reported Outcomes in Thoracic Surgery

The existing thoracic surgical literature contains several retrospective and observational studies that include patient-reported outcomes. To deliver true patient-centered care, it will be necessary to universally gather patient-reported outcomes prospectively, including them in routine patient care, clinical registries, and clinical trials.

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.

For non-small cell lung cancer with T3 (central) disease, sleeve lobectomy or pneumonectomy?

BACKGROUND

Pneumonectomy (PN) has traditionally been the treatment of choice for central lung tumors for which the alternative is sleeve lobectomy (SL). The aim of this study was to compare early and long-term results after SL and PN in focusing on T3 central non-small cell lung cancer (NSCLC).

METHODS

Patients who underwent SL (n=58) or PN (n=42) were retrospectively analyzed. For bias reduction, these 100 patients had been selected according to the following criteria: (I) tumor located in the main bronchus less than 2 cm distal to the carina; (II) there were no N2 disease; (III) no induction therapy was applied; (IV) complete resection (R0) was achieved.

RESULTS

SL and PN patients had comparable mean ages, gender distribution, mean forced expiratory volume in 1 second (FEV1), stage and tumor grade. Postoperative mortality (3.4% vs. 4.8%, P=1.0) and morbidity (41% vs. 38%, P=0.74) were similar between the two groups. Recurrences occurred in 48% of patients after SL and in 31% of those after PN (P=0.08). The 5-year survival after SL (64.8%) and PN (61.4%) was not significantly different (P=0.20). Multivariable survival analysis showed that there were no independent prognostic factors.

CONCLUSIONS

SL does not compromise survival for NSCLC with T3 central disease compared with PN. It is an adequate oncologic resection and should be treated as the first line intervention whenever complete resection can be achieved.

Bronchial sleeve resection or pneumonectomy for non-small cell lung cancer: a propensity-matched analysis of long-term results, survival and quality of life

BACKGROUND

No randomized studies exist comparing pneumonectomy (PN) and sleeve lobectomy (SL). We evaluated surgical results and long-term quality of life in patients operated on for central non-small cell lung cancer (NSCLC) using either SL or PN.

METHODS

A total of 641 NSCLC patients underwent surgery 2000-2010. SL was performed in 40 (6.2%) and PN in 67 (10.5%). In 2011, all surviving patients were sent a 15D Quality of Life Questionnaire which 83% replied. Propensity-score-matching analysis was utilized to compare the groups.

RESULTS

Thirty-two bronchial (18 right/14 left), seven vasculobronchial (3 right/4 left), one right wedge SL, and 18 right and 22 left PN were performed. Preoperatively, the Charlson Comorbidity Index (CCI) score, forced expiratory volume in 1 s (FEV1) and diffusion capacity did not differ between groups. The perioperative complication rate and pattern were similar, but SL group had less major complications (P<0.027). One perioperative death (2.5%) occurred in SL group and four (6%) in PN. The 90-day mortality rate was 5% (n=2) for SL and 7.5% (n=5) for PN. In the follow-up total cancer recurrence did not differ (P=0.187). Quality of life measured by 15D showed no significant difference in separate dimensions or total score, except tendency to favor SL in moving or breathing. The 5-year survival did not differ between groups (P=0.458), but no deaths were observed in SL group after 5 years.

CONCLUSIONS

Due to less major operative complications and better long-term survival, we would advocate using SL when feasible, but in patients tolerating PN it should be considered if SL seems not to be oncologically sufficiently radical.

Use of the lung cancer-specific Quality of Life Questionnaire EORTC QLQ-LC13 in clinical trials: A systematic review of the literature 20 years after its development

The European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Lung Cancer 13 (QLQ-LC13) covers 13 typical symptoms of lung cancer patients and was the first module developed in conjunction with the EORTC core quality-of-life (QL) questionnaire. This review investigates how the module has been used and reported in cancer clinical trials in the 20 years since its publication. Thirty-six databases were searched with a prespecified algorithm. This search plus an additional hand search generated 770 hits, 240 of which were clinical studies. Two raters extracted data using a coding scheme. Analyses focused on the randomized controlled trials (RCTs). Of the 240 clinical studies that were identified using the LC13, 109 (45%) were RCTs. More than half of the RCTs were phase 3 trials (n = 58). Twenty RCTs considered QL as the primary endpoint, and 68 considered it as a secondary endpoint. QL results were addressed in the results section of the article (n = 89) or in the abstract (n = 92); and, in half of the articles, QL results were presented in the form of tables (n = 53) or figures (n = 43). Furthermore, QL results had an impact on the evaluation of the therapy that could be clearly demonstrated in the 47 RCTs that yielded QL differences between treatment and control groups. The EORTC QLQ-LC13 fulfilled its mission to be used as a standard instrument in lung cancer clinical trials. An update of the LC13 is underway to keep up with new therapeutic trends and to ensure optimized and relevant QL assessment in future trials.

The effect of gender on health-related quality of life and related factors in post-lobectomy lung-cancer patients

PURPOSE

While studies have documented gender differences by histologic type among lung cancer patients, the effect of these differences on the health-related quality of life (HRQoL) of post-lobectomy lungcancer patients and related factors remain uncertain. This study examines gender-specific HRQoL and related factors in post-lobectomy lung-cancer patients.

METHODS

A cross-sectional study design was applied. A convenience sample of 231 post-lobectomy lungcancer patients was recruited from the thoracic surgery outpatient departments of two teaching hospitals in Taipei, Taiwan from March to December 2012. Patients performed a spirometry test and completed instruments that included a Beck Depression Inventory-II, an Interpersonal Support Evaluation List, and the symptom and function scales of the Quality of Life Questionnaire. Data analysis used descriptive statistics, including mean and standard deviations, frequency, and percentage values. Independent-sample Student's t-tests and multivariate analyses were used for comparative purposes.

RESULTS

This study confirmed a significant gender effect on HRQoL and HRQoL-related factors such as marital status, religious affiliation, smoking status, histologic type, symptoms, pulmonary function, depression, and family support. Moreover, multivariate analysis found gender to be a significant determinant of the HRQoL aspects of physical functioning, emotional functioning, and cognitive functioning. Finally, results indicated that factors other than gender were also significant determinants of HRQoL.

CONCLUSION

Gender impacts the HRQoL and related factors of postoperative lung-cancer patients. Therefore, gender should be considered in assessing and addressing the individual care needs of these patients in order to attain optimal treatment outcomes.

Moving beyond the boundary: the emerging role of video-assisted thoracic surgery for bronchoplastic resections

Sleeve resections with parenchymal sparing should be attempted whenever possible when operating a central lung cancer rather than performing a pneumonectomy. Long-term results conclusively favored sleeve procedures in improved survival, quality of life, reduced loss in lung function, and improved operative mortality. Therefore, all surgeons should own this technique in their surgical armamentarium. In the last two decades, the minimally invasive surgical approach has slowly gained positions in Thoracic Surgery and now more and more patients ask for a minimally invasive procedure when surgery is required. This technical revolution in thoracic surgery advocates that almost every open procedure could be done in video-assisted thoracic surgery (VATS). Nevertheless, like all other minimally invasive procedures, VATS sleeve lobectomy has a long learning curve. With the skills and the experience derived from major VATS procedures, these demanding surgical operations may also be performed with a minimally invasive approach.

[Pneumonectomy: an alternative to sleeve resection in lung cancer patients?]

Lung cancer is localized in the upper lobes in more than half of the cases. The risk of tumor infiltration of centrally located structures, such as bronchi and vessels are enhanced due to the anatomic topography. Pneumonectomy competes with sleeve resection for the surgical resection of centrally located tumors. The present review deals with the question if pneumonectomy should be considered as an alternative to sleeve resection for the treatment of lung cancer. Primary pneumonectomy does not provide any advantage even in advanced nodal disease. Extended lymph node dissection is not a contraindication for sleeve resections. Local recurrence rate is lower after sleeve resections despite the same radicality for both surgical treatment options. Mortality and morbidity rates are significantly lower for sleeve resections. Sleeve resections are associated with prolonged survival and better quality of life even in elderly patients.

Sleeve lobectomy for non-small cell lung cancer with N1 nodal disease does not compromise survival

BACKGROUND

We evaluated if sleeve lobectomy had worse survival compared with pneumonectomy for non-small cell lung cancer (NSCLC) with N1 disease, which may be a risk factor for locoregional recurrence.

METHODS

Patients who underwent pneumonectomy or sleeve lobectomy without induction treatment for T2-3 N1 M0 NSCLC at a single institution from 1999 to 2011 were reviewed. Survival distribution was estimated with the Kaplan-Meier method, and multivariable Cox proportional hazards regression was used to evaluate the effect of resection extent on survival.

RESULTS

During the study period, 87 patients underwent pneumonectomy (52 [60%]) or sleeve lobectomy (35 [40%]) for T2-3 N1 M0 NSCLC. Pneumonectomy and sleeve lobectomy patients had similar mean ages (60.9 ± 10.7 vs 63.5 ± 12.7 years, p = 0.30), gender distribution (69.2% [36 of 52] vs 60.0% [21 of 35] male, p = 0.37), mean forced expiratory volume in 1 second (66.3 ± 15.9 vs 63.5 ± 17.6, p = 0.47), stage (61.5% [32 of 52] vs 62.9% [22 of 35] stage II, p = 0.90), and tumor grade (51.9% [27 of 52] vs 31.4% [11 of 35] well/moderately differentiated, p = 0.17). Postoperative mortality (3.8% [2 of 52] vs 5.7% [2 of 35], p = 0.68) and median (interquartile range) length of stay (5 [4 to 7] vs 5 [4 to 7] days, p = 0.68) were similar between the two groups. The 3-year survival after pneumonectomy (46.8% [95% CI, 31.8% to 60.4%]) and sleeve lobectomy (65.2% [95% CI, 45.5% to 79.3%]) was not significantly different (p = 0.23). In multivariable survival analysis that included resection extent, age, stage, and grade, only increasing age predicted worse survival (hazard ratio, 1.03/year; p = 0.03).

CONCLUSIONS

Performing sleeve lobectomy instead of pneumonectomy for NSCLC with N1 nodal disease does not compromise long-term survival.

Pulmonary sleeve resection in locally advanced lung cancer using cryopreserved allograft for pulmonary artery replacement

BACKGROUND

During lobectomy, resection of pulmonary artery, followed by reconstruction or replacement with or without concomitant sleeve bronchial resection, is feasible in selected cases. We report morbidity, mortality, and technical issues in pulmonary artery replacement using a cryopreserved arterial allograft after sleeve resection for centrally located non-small cell lung carcinoma (NSCLC).

METHODS

We reviewed clinical and pathologic data of patients who underwent arterial sleeve lobectomy with pulmonary artery replacement in our institution from 2007 to 2012.

RESULTS

Of 178 centrally located NSCLCs, sleeve resections were performed in 92 (51%), pneumonectomies in 33 (18%), and lobectomies in 53 (31%). Of the 32 (34.7%) pulmonary) reconstructions (excluding tangential suture), 20 (21.7%) were end-to-end anastomosis, 2 (2.1%) were pericardial patch reconstructions, and 10 (11%) were PA replacements. Clinical T staging was cT2a in 4 patients, cT2b in 3, cT3 in 2, and cT4 in 1. Four patients received concurrent induction chemoradiotherapy. Three patients underwent a double-sleeve right lobectomy. Cryopreserved allografts used were descending thoracic aorta (n = 3) and pulmonary arteries (n = 7). Complete resection (R0) was achieved in all patients. Final N staging was pN0 (n = 4), pN1 (n = 5), and pN2 (n = 1). There was no operative mortality. Four patients had major morbidity, including 1 early conduit thrombosis treated by pneumonectomy completion. Graft patency, assessed by contrast-enhanced computed tomography scan, was 90%. Mean follow-up was 25 ± 14 (range, 8-47) months (30% for >36 months). Overall 5-year survival was 66.7%, and the estimated median disease-free survival was 42 months.

CONCLUSIONS

In central NSCLCs, conservative surgery using a cryopreserved arterial allograft to replace the pulmonary artery after extended segmental resection could avoid pneumonectomy in selected patients.

Hybrid video-assisted thoracic surgery with segmental-main bronchial sleeve resection for non-small cell lung cancer

BACKGROUND

The purpose of the current study is to present the clinical and surgical results in patients who underwent hybrid video-assisted thoracic surgery with segmental-main bronchial sleeve resection.

METHODS

Thirty-one patients, 27 men and 4 women, underwent segmental-main bronchial sleeve anastomoses for non-small cell lung cancer between May 2004 and May 2011.

RESULTS

Twenty-six (83.9%) patients had squamous cell carcinoma, and 5 patients had adenocarcinoma. Six patients were at stage IIB, 24 patients at stage IIIA, and 1 patient at stage IIIB. Secondary sleeve anastomosis was performed in 18 patients, and Y-shaped multiple sleeve anastomosis was performed in 8 patients. Single segmental bronchiole anastomosis was performed in 5 cases. The average time for chest tube removal was 5.6 days. The average length of hospital stay was 11.8 days. No anastomosis fistula developed in any of the patients. The 1-, 2-, and 3-year survival rates were 83.9%, 71.0%, and 41.9%, respectively.

CONCLUSION

Hybrid video-assisted thoracic surgery with segmental-main bronchial sleeve resection is a complex technique that requires training and experience, but it is an effective and safe operation for selected patients.