M07-02: Pneumonectomy Versus Sleeve Resection

Abstract

The indication for a sleeve resection for lung cancer is well established: a tumor arising at the origin of a lobar bronchus but not infiltrating as far as to require pneumonectomy. In addition, a sleeve resection may be indicated when N1 nodes infiltrate the bronchus from the outside, as is often the case in the left upper lobe tumors requiring a combined reconstruction of the bronchus and the pulmonary artery. From a functional point of view, sleeve lobectomy is strictly indicated in patients who cannot withstand pneumonectomy, but recent experiences have shown that the advantages of sparing lung parenchyma are evident also in patients without cardio-pulmonary impairment. Oncologically, the primary goal is in every case the complete resection of the tumor with free resection margins. When analyzing survival data reported in literature in the last 15 years, most of the studies show similar or better results for parenchymal sparing resections if compared with pneumonectomy. Moreover, in the analysis of 5-year survival according to stage (Table-1) and nodal status, sleeve lobectomy results in higher survival rates for stages I, II and III, although the survival advantage in stage III appears to be limited. In a recent report (Ludwig’05), sleeve lobectomy results a statistically significant favourable prognostic factor for long-term survival with a survival advantage in patients with N0, N1 and N2 disease. However, this prognostic advantage for stage III-N2 patients is not always confirmed, and there are other studies reporting a more evident adverse effect on survival for patients with N2 involvement who have undergone sleeve lobectomy. Therefore the role of parenchymal sparing operations in patients with N2 disease still remains not completely defined (Fadel’02).Table 1Author (year)Stage I patientsStage II patientsStage III patientsStage I 5-yr survival (%)Stage II 5-yr survival (%)Stage III 5-yr survival (%)Sleeve LobectomyVan Schil (‘91)6157−5921−Gaissert (‘96)293112425343Icard (‘99)325716603027Tronc (‘00)83732663488Fadel (‘02)544736556221Mezzetti (‘02)34321761399Terzi (‘02)485250603222Deslauriers (‘04)837229665019Kim (‘05)14181588528Ludwig (‘05)314144574022PneumonectomyGaissert (‘96)92521−43−Mizushima (‘97)81584584213Deslauririers (‘04)164361471503422Kim (‘05)281110753638Ludwig (‘05)3152111454213 Open table in a new tab These results justify the increasing use of parenchymal sparing procedures for lung cancer also in patients with good cardio-pulmonary function, as observed in the last years. Postoperative morbidity and mortality data reveal overall better results for patients undergoing sleeve lobectomy with respect to pneumonectomy (Table-2). Looking at literature data, when morbidity is evaluated according to the type of complication, pneumonectomy patients appear to experience a higher rate of cardiac complications, while sleeve lobectomy patients show increased pulmonary and airway complications incidence.Table 2Author (year)Complications (%)Postoperative mortality (%)Local recurrence (%)Distant recurrence (%)Sleeve LobectomyGaissert (‘96)11414−Icard (‘99)442.81724Okada (‘00)138−Tronc (‘00)161.62211Fadel (‘02)162.91511Mezzetti (‘02)10.83.620−Terzi (‘02)14.512518Kim (‘05)74.96.12222Ludwig (‘05)384.3−−PneumonectomyGaissert (‘96)169−−Okada (‘99)22210−Deslauriers (‘04)−5.335−Kim (‘05)444.1620Ludwig (‘05)264.6−− Open table in a new tab The incidence of microscopic infiltration of the bronchial margins has strong significance when analyzing the anastomotic complication and local recurrence rate. Authors (Kim’05) who have observed a significantly higher incidence of anastomotic leak in their sleeve lobectomy series, report an increased rate of positive margins on frozen section. In our experience (since 1989) of 192 bronchial sleeve resections and 100 resections and reconstructions of the pulmonary artery no increased overall and pulmonary morbidity and mortality rate has been observed. The preservation of lung parenchyma has been indicated by some authors as the possible cause of a theoretical increased risk for loco-regional recurrence after sleeve lobectomy. However, although in some experiences (Fadel’02) a higher local recurrence rate is reported for sleeve resection with advancing nodal status (N2), the few studies (Fadel’02,Terzi’02,Kim’05) analyzing risk factors for recurrence, show that the tumor stage and the nodal status are the only negative predictive factors, rather than the type of operation performed. Postoperative quality of life has been advocated as one of the strongest indicators that should influence the decision to perform a sleeve lobectomy rather than a pneumonectomy. A number of studies indicate that lung parenchyma sparing improves postoperative quality of life determining a greater cardio-pulmonary reserve, less pulmonary edema and less right ventricular dysfunction due to a lower pulmonary vascular resistance (Terzi’02,Martin-Ucar’02). Special concern has been expressed by many thoracic surgeons when considering broncho-vascular reconstructive procedures after induction therapy, due to the significantly higher risk of perioperative complications and mortality. Although only a few authors (Rendina’97,Ohta’03,Stamatis’02) use sleeve resection routinely after neoadjuvant therapy, it has been proven in our experience (2,3), that also complex parenchymal sparing operations can be performed after oncological treatment without increased morbidity and mortality rates observing long-term results comparable to those of the standard procedures (5-year survival: 31%; local recurrence rate:15%).