Pneumonectomy vs. Sleeve Resection for Non-Small Cell Lung Carcinoma in the Elderly: Analysis of Short-term and Long-term Results

Abstract

Background: Aim of the study was to assess the short- and long-term results of sleeve resections and pneumonectomies for centrally located non-small cell lung cancer (NSCLC) in a cohort of elderly patients. Methods: We retrospectively reviewed our prospective database of all patients aged ≥ 70 years who underwent sleeve resection (SL group) or pneumonectomy (PN group) for NSCLC between January 1999 and December 2005. Patients' characteristics, morbidity, mortality and survival were analyzed and compared between groups. Results: Sixty patients qualified for the analysis, of whom 31 underwent sleeve resection and 29 had pneumonectomy. Both groups were statistically equivalent with regard to age (73.6 ± 2.4 vs. 74.2 ± 3.6 years), sex, comorbidities, histology, completeness of resection and stage. Presurgical FEV1 was higher in the PN group (p = 0.02). There were no statistical differences in the morbidity rate (SL: 41.9 %, PN: 44.8 %), mortality rate (SL: 6.5 %, PN: 10.3 %), local recurrence (SL: 3.2 %, PN: 0 %) or distant metastases (SL: 19.4 %, PN: 24.1 %). The loss of FEV1 was higher in the PN group (27.3 %) compared to the SL group (12.0 %; p = 0.001). Overall 5-year survival and mean survival for SL patients was 59 % and 51.9 months compared to 0 % and 30.1 months for the PN patients (p = 0.038). In patients with stage N2 disease, the type of surgery showed a trend to prolonged long-term survival favoring sleeve resection (p = 0.096). Conclusion: In specialized centers both pneumonectomy and sleeve resection can be performed with acceptable mortality and morbidity rates in elderly patients with centrally located NSCLC. In elderly patients with anatomically suitable NSCLC, sleeve resections offer better functional results and long-term survival irrespective of nodal status.

Key words

pneumonectomy - sleeve resection - NSCLC - elderly

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Invited Commentary

Bronchial sleeve resections as well as vascular sleeve resections are among the most important techniques used in thoracic surgery. With both techniques, which are used either alone or in combination, healthy lung tissue can be preserved. In 1955, Price-Thomas first described sleeve resection of the right main bronchus. Also in 1955, Paulson and Shaw presented their first results using bronchoplastic procedures in lung cancer. In 1986, Vogt-Moykopf published the then largest series of broncho- and angioplastic procedures in lung cancer. He and others could show that long-term survival in patients treated by sleeve resection is almost the same compared with lobectomy considering the tumor stage. It could also be demonstrated that sleeve resection has considerable advantages related to the pulmonary function, as presumed. It is no longer a matter of choice to perform pneumonectomy or sleeve resection. Whenever possible, a sleeve resection has to be done. Bronchoplastic procedures, most commonly sleeve resection, are underutilized procedures. It could be said that the knowledge, expertise, and technical ability to appropriately apply sleeve resection for benign and malignant disease are the defining characteristics of an expert thoracic surgeon. The number of broncho- and angioplastic procedures is therefore a distinguished mark of expertise in thoracic surgery and is utilized to designate a lung cancer center in Germany.

Bölükbas and Schirren present a very well designed and analyzed study, which compares the results of sleeve lobectomy compared to pneumonectomy in elderly patients. They come to the same results as other authors before them. Therefore the future focus of research and analyses of sleeve resections should be on technique itself. The results considering morbidity and mortality are much better today, for example the authors did not see insufficiency of an anastomosis although no specific covering technique was used. There is a lot of discussion on new techniques using running sutures for the bronchial anastomosis, and telescope anastomosis has still its advocates. We would like to read more about the results of these techniques. How often do stenoses occur as late complications and how are they treated? Hopefully, we will gather new and important information about the percentage of sleeve resections in expert centers such as this to prepare proven recommendations for further quality assurance requirements.

For the future we should consider sleeve resections and pneumonectomy as different procedures for different diseases.

Prof. Dr. med. Godehard Friedel
Chefarzt Thoraxchirurgie
Klinik Schillerhöhe, RBK Stuttgart
Solitudestraße 18
70839 Gerlingen
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