Sleeve Lobectomy Versus Standard Lobectomy for Lung Cancer: Functional and Oncologic Evaluation

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

Outcomes and pulmonary function after sleeve lobectomy compared with pneumonectomy in patients with non-small cell lung cancer

BACKGROUND

Sleeve lobectomy is recommended to avoid pneumonectomy and preserve pulmonary function in patients with central lung cancer. However, the relationship between postoperative pulmonary functional loss and resected lung parenchyma volume has not been fully characterized. The aim of this study was to evaluate the relationship between pulmonary function and lung volume in patients undergoing sleeve lobectomy or pneumonectomy.

METHODS

A total of 61 lung cancer patients who had undergone pneumonectomy or sleeve lobectomy were analyzed retrospectively. Among them, 20 patients performed pulmonary function tests, including vital capacity (VC) and forced expiratory volume in 1 s (FEV1) tests, preoperatively and then about 6 months after surgery. VC and FEV1 ratios were calculated (measured postoperative respiratory function/predicted postoperative respiratory function) as the standardized pulmonary functional loss ratio.

RESULTS

Thirty-day operation-related mortality was significantly lower after sleeve lobectomy (3.2%) than pneumonectomy (9.6%). The 5-year relapse-free survival rate was 46.67% versus 29.03%, and the 5-year overall survival rate was 63.33% versus 38.71% in patients receiving sleeve lobectomy versus pneumonectomy. The VC ratio in the pneumonectomy group was better than in the sleeve lobectomy group (1.003 ± 0.117 vs. 0.779 ± 0.12; p = 0.0008), as was the FEV1 ratio (1.132 ± 0.226 vs. 0.851 ± 0.063; p = 0.0038).

CONCLUSIONS

Both short-term and long-term outcomes were better with sleeve lobectomy than pneumonectomy. However, actual postoperative pulmonary function after pneumonectomy may be better than clinicians expect, and pneumonectomy should still be considered a treatment option for patients with sufficient pulmonary reserve and in whom sleeve lobectomy is less likely to be curative.

Parenchymal Sparing Surgery for Lung Cancer: Focus on Pulmonary Artery Reconstruction

Reconstruction of the pulmonary artery (PA) associated with lobectomy for the radical resection of lung cancer has been progressively gaining diffusion in lung cancer surgery as a safe and effective therapeutic option that may allow radical resection when lobectomy is not technically feasible, avoiding pneumonectomy. There are some controversial aspects concerning the intraoperative and perioperative management of a sleeve resection with PA reconstruction that may influence the outcome. In the present article, the authors have analyzed some of the main technical and oncological aspects to take stock of what they have learned from their lung-sparing operations experience over time. PA reconstruction may require prosthetic materials including different options with variable cost. A main concern in vascular reconstructive procedures is avoiding tension on the anastomosis. When PA reconstruction is required, appropriate anticoagulation management is crucial. Results from the main literature data confirm the reliability of lobectomy associated with PA reconstruction in terms of perioperative morbidity and long-term survival. Sleeve lobectomy and PA reconstruction can be performed safely and effectively even after induction therapy.

Complex sleeve lobectomy has the same surgical outcome when compared with conventional lobectomy in patients with lung cancer

OBJECTIVES

No significant data are available to assess whether complex sleeve lobectomy (complex-SL) can be considered comparable to conventional lobectomy (CL) in terms of surgical outcome. The purpose of this study was to compare surgical and oncological outcomes of complex-SL with CL in patients with lung cancer.

METHODS

Between 2000 and 2015, a total of 568 patients who underwent open CL (defined as resection of only 1 lobe) and 187 patients who underwent SL were analysed. The SL group was divided into 2 subgroups: standard-SL (bronchial SL, n = 106) and complex-SL (n = 81) (defined as bronchial sleeve resection together with another surgical intervention: bronchovascular SL, n = 40; vascular SL, n = 26; atypical bronchoplasty with resection of more than 1 lobe, n = 12; bronchial SL + chest wall resection, n = 3).

RESULTS

The complex-SL group had more patients with chronic obstructive pulmonary disease (COPD) (25.9% vs 12.5%, P = 0.001), neoadjuvant treatment (39.5% vs 12.0%, P < 0.001), advanced-stage non-small-cell lung cancer (53.2% vs 33.1%, P = 0.001) and low preoperative forced expiratory volume in 1 s (77.2% vs 84.3%, P = 0.004) than the CL group. The overall surgical mortality (in-hospital or 30-day) was 2.6% (n = 20); it was 2.8% for CL and 2.8% for complex-SL. Postoperative complications occurred in 34.9% of the CL group and 39.5% of the complex-SL group (P = 0.413). The pulmonary complication rate was similar between the groups (24.1% for CL, 27.2% for complex-SL, P = 0.552). The 5-year survival in the CL group was 57.1%, and in the complex-SL group it was 56.2% (P = 0.888). Multivariate analysis showed that TNM stage (P < 0.001) and N status (P < 0.001) were significant and independent negative prognostic factors for survival.

CONCLUSIONS

Complex-SL had a comparable outcome to CL, although the complex-SL group had more patients with advanced-stage NSCLC, low preoperative forced expiratory volume in 1 s and COPD.

Specific techniques for right sleeve lower lobectomy: four case reports

Background

Right sleeve lower lobectomy is rarely performed because pulmonary function of the middle lobe is not spared to the extent of the other lobes and achieving a proper bronchial anastomosis is technically more difficult than other sleeve lobectomies.

Case presentation

We performed four right sleeve lower lobectomies and had good clinical outcomes using specific technical options, such as telescope anastomosing, pericardiotomy, interlobar dissection between the upper and middle lobes, and angioplasty of the lower pulmonary artery, if needed.

Conclusions

The cases presented herein demonstrated that a right sleeve lower lobectomy is one option by which to preserve the middle lobe using specific techniques and is thus recommended in select patients.

Sleeve lobectomy versus lobectomy for primary treatment of non-small-cell lung cancer: A single-center retrospective analysis

BACKGROUND AND OBJECTIVES

It is unclear how much additional perioperative risk a sleeve lobectomy could pose in comparison to lobectomy. The objective of this analysis was to compare the complication rate, 30-day mortality, and overall survival between lobectomy and sleeve lobectomy without prior neoadjuvant treatment in non-small-cell lung cancer (NSCLC).

METHODS

This is a retrospective study using our prospective database for quality assurance in our hospital. Inclusion criteria for our study was a completed lobectomy or sleeve lobectomy for primary treatment of NSCLC.

RESULTS

In 506 patients, the tumor was treated by means of standard lobectomy. In 252 patients with central tumor localization, sleeve lobectomy was performed. Postoperative complications occurred in n:148 (29.24%) patients of the lobectomy group and in n = 76 (30.15%) of the sleeve group. The mortality rate difference between the two groups was statistically significant and favored the lobectomy group (0.78% vs. 4.76%, p = .007). Five year survival was 69.97% for the lobectomy and 65.59% for the sleeve group (p = .829).

CONCLUSION

Sleeve lobectomy for primary surgical treatment of NSCLC has comparable perioperative complications with lobectomy. Sleeve lobectomy does not seem to negatively influence survival. Postoperative mortality was higher in the sleeve group.

Comparison study of computed tomography-guided radiofrequency and microwave ablation for pulmonary tumors: A retrospective, case-controlled observational study

BACKGROUND

The aim of this study was to compare the safety, efficacy, and prognostic value of radiofrequency ablation (RFA) and microwave ablation (MWA) for lung tumors.

METHODS

Between March 2012 and January 2018, 238 patients with lung cancer were treated with MWA (139, 58.4%) or RFA (99, 41.6%) in our center. Patient and tumor characteristics, complications, complete ablation (CA) rate, and prognosis were compared between the groups. Meta-analysis was used to systematically compare the outcomes of RFA and MWA for the treatment of lung tumors.

RESULTS

Ablation was successfully completed in all patients and no procedure-related death occurred. The total complication rates in the RFA and MWA groups were 24.2% (24/99) and 16.5% (23/139), respectively, and there was no statistically significant difference (P = 0.142). The initial and total CA rates were similar at P > 0.05 (RFA vs. MWA: initial CA, 97.0% vs. 96.4%; total CA, 99.0% vs. 98.6%, respectively). During follow-up, there was no significant difference in median progression-free (RFA vs. MWA: 12.5 months, 95% confidence interval [CI] 5.002-19.998 vs. 9.5 months, 95% CI 6.623-12.377; P = 0.673) or overall survival (RFA vs. MWA: 33 months, 95% CI 27.070-38.930 vs. 30 months, 95% CI, 18.482-41.518; P = 0.410) between the groups. Combined with the results of published comparison studies, meta-analysis further confirmed that the outcomes of these two treatments were similar.

CONCLUSION

Both RFA and MWA are safe and effective treatments with a survival benefit for selected patients with primary and metastatic lung tumors.

CT-guided percutaneous laser ablation of metastatic lung cancer: three cases report and literature review

Objective

To report the efficacy and safety of CT-guided percutaneous laser ablation (PLA) for metastatic lung tumors.

Methods

Three cases of metastatic lung cancer underwent CT-guided PLA, and we searched for previously published articles on the minimally invasive CT-guided RFA or MWA for lung tumors in recent five years.

Results

With the guidance of CT, all lesions had good prognosis under laser ablation. Case 1 suffering from severe pulmonary dysfunction and diffuse pulmonary bullae, had small pneumothorax. CT scan obtained four months following the ablation showed two lesions had complete responses and one partial response. Case 2 had successful complete response with absent lung mass, and also had a good postoperative condition without any discomfort in the two-month follow-up. Case 3 showed partial response and improved greatly after five months. 962 cases (mean age of 45.7 years, 62.2% male) of 1297 lung tumors with detailed information were identified from 27 articles. Of these cases, the minority manifested complications such as pneumothorax, hemoptysis, hemothorax, pneumonia, pain and fever.

Conclusions

Percutaneous CT-guided PLA could be a safe and promising minimally invasive treatment for patients with primary lung cancer or unresectable pulmonary metastases, especially multineedle PLA in large tumors, which still needs more large-scale prospective studies to convince this method in the future.

Lung cancer in elderly patients

There is a worldwide-accepted evidence of a population shift toward older ages. This shift favors an increased risk of developing lung cancer that is primarily a disease of older populations. Decision making is extremely difficult in elderly patients, since this group is under-represented in clinical trials with only 25% of them historically opening to patients older than 65 years. For all these reasons, a "customized" preoperative assessment to identify physiological or pathological frailty should be encouraged since standard tools may be less reliable. The work already done to improve patient selection for lung surgery in the elderly population clearly shows that surgical resection seems the treatment of choice for early stage lung cancer. Further studies are required to improve outcome by reducing postoperative morbidity and mortality.

Bronchial and arterial sleeve resection for centrally-located lung cancers

The use of bronchial and arterial sleeve resections for the treatment of centrally-located lung cancers, when available, has become the option of choice in comparison with pneumonectomy (PN). Technical expertise, in particular in vascular reconstruction, and perioperative management improved over time allowing excellent short-term and long-term results. This is even truer if considering literature data from the main experiences published in the last years. These evidences have given to such lung sparing reconstructive procedures more and more acceptance among the surgical community. This article focuses on the main technical aspects and literature data regarding bronchovascular sleeve resections.