M07-01: Pneumonectomy versus sleeve resection for the management of resectable lung cancer

Abstract

Sleeve lobectomy for lung cancer was first described as a compromise operation for patients whose pulmonary reserve was considered inadequate to permit pneumonectomy. Since then, several authors have suggested that sleeve resection may provide as good if not better results than pneumonectomy in selected cases of primary lung cancer involving the proximal bronchial tree. Whether sleeve resection is radical enough and indicated for patients who could tolerate pneumonectomy continues to be debated among thoracic surgeons and indeed there are only a handful of reports of clinical series comparing operative mortality, survival, and sites of recurrences between these procedures (Table 1).Table 1- Comparison of survival between sleeve resection and pneumonectomyAuthors (yr)No pts5 year survival (%)Sleeve resectionPneumonectomyGaissert (1996)12842 %44 %Yoshino (1997)5866 %59 %Suen (1999)20038 %36 %Ludwig (2005)31039 %27 %Takeda (2006)17254 %33 % Open table in a new tab Operative mortality, survival, and sites of recurrences were compared in 1,346 consecutive patients who underwent pneumonectomy (N: 1,046) or sleeve resection in our institution over a 25-year interval (Table 2).Table 2- Sleeve lobectomy versus pneumonectomy for lung cancerSleeve lobectomyPneumonectomyNo of patients300(1976-2005)1,046 (1980-2000)Mean age61.2 ± 11 years60.7 ± 9.4 yearsOperative mortality2.7 % (8 / 300)5.3 % (55 / 1,046)Overall 5 year survival54 %31 %Locoregional recurrences16 %35 % Open table in a new tab During that period, sleeve resection was always done whenever technically possible while pneumonectomy was reserved for lesions that could not be removed by a bronchoplastic procedure. While lesions in the hilum of the right upper lobe were the commonest indication for sleeve resection, all lobes of either lung could be involved with tumors amenable to some form of lung-sparing bronchoplastic procedure. All patients included in the analysis were staged by nodal sampling and according to the 1997 revised TNM nomenclature. There were 8 operative deaths out of 300 patients who underwent sleeve resection (2.7 %) and 55 operative deaths out of the 1,046 patients who underwent pneumonectomy (5.3 %, p < 0.05) and most causes of death in either group were related to respiratory events. Of note, four patients (1.3 %) had anastomotic complications after sleeve resection but none of these complications lead to mortality. Follow-up was complete for the entire cohort and the overall 5-year survival was significantly better after sleeve resection (54 %) than after pneumonectomy (31 %, p < 0.0001) (see Table 2). For patients with N1 disease, there was also a significant difference in survival favoring sleeve lobectomy (sleeve resection (N: 72): 50 %; pneumonectomy (N: 361): 34 %; p 0.015). When recurrences occurred, the site of first recurrence was locoregional in 16 % after sleeve resection and in 35 % of patients after pneumonectomy. In summary, this analysis demonstrates that sleeve resection is an effective procedure for patients who could tolerate a pneumonectomy but in whom the surgeon judges that a complete resection is possible through a bronchoplastic procedure with conservation of pulmonary function. As a general statement, sleeve lobectomy should be considered in any case of lung cancer which can be completely resected by this technique.