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.

pneumonectomy - sleeve resection - NSCLC - elderly

References

• 1 Parkin D M. Global cancer statistics in the year 2000.  Lancet Oncol. 2001;  2 533-543
• 2 Reis L A G, Eisner M P, Kosary C L. SEER cancer statistics review, 1973 – 1998.. Bethesda, MD: National Cancer Institute; 2001
• 3 Melloul E, Egger B, Krueger T et al. Mortality, complications and loss of pulmonary function after pneumonectomy versus sleeve lobectomy in patients younger and older than 70 years.  Interact Cardiovasc Thorac Surg. 2008;  7 986-989
• 4 Bölükbas S, Bergmann T, Fisseler-Eckhoff A, Schirren J. Short- and long-term outcome of sleeve resections in the elderly.  Eur J Cardiothorac Surg. 2010;  37 30-35
• 5 Miller Jr J I. Complications of pulmonary surgery: preoperative evaluation.  Chest Surg Clin N Am. 1992;  2 701-711
• 6 Travis W D, Brambilla E, Müller-Hermelink H, Harris C eds.. Pathology and Genetics of Tumors of the Lung, Pleura, Thymus, and Heart: WHO Classification of Tumors.. New York: Oxford University Press USA; 2004: 59-62
• 7 Mountain C F. Revisions in the international systems for staging lung cancer.  Chest. 1997;  111 1710-1717
• 8 Okada M, Yamagishi H, Satake S et al. Survival related to lymph node involvement in lung cancer after sleeve lobectomy compared with pneumonectomy.  J Thorac Cardiovasc Surg. 2000;  119 814-819
• 9 Deslauriers J, Gregoire J, Jacques L F. Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites of recurrences.  Ann Thorac Surg. 2004;  77 1152-1156
• 10 Castillo M D, Heerdt P M. Pulmonary resection in the elderly.  Curr Opin Anaesthesiol. 2007;  20 4-9
• 11 Leo F, Scanagatta P, Baglio P et al. The risk of pneumonectomy over the age of 70: a case-control study.  Eur J Cardiothorac Surg. 2007;  31 779-782
• 12 Schirren J, Bölükbas S, Bergmann T, Fisseler-Eckhoff A, Trainer S, Beqiri S. Prospective study on perioperative risks and functional results in bronchial and bronchovascular sleeve resections.  Thorac Cardiovasc Surg. 2009;  57 35-41
• 13 Ferguson M K, Lehman A G. Sleeve lobectomy or pneumonectomy: optimal management strategy using decision analysis techniques.  Ann Thorac Surg. 2003;  76 1782-1788
• 14 Au J, el-Oakley R, Cameron E W. Pneumonectomy for bronchogenic carcinoma in the elderly.  Eur J Cardiothorac Surg. 1994;  8 247-250
• 15 Dominguez-Ventura A, Allen M S, Cassivi S D, Nichols III F C, Deschamps C, Pairolero P C. Lung cancer in octogenarians: factors affecting morbidity and mortality after pulmonary resection.  Ann Thorac Surg. 2006;  82 1175-1179
• 16 Aoki T, Yamato Y, Tsuchida M, Watanabe T, Hayashi J, Hirino T. Pulmonary complications after surgical treatment of lung cancer in octogenarians.  Eur J Cardiothorac Surg. 2000;  18 662-665
• 17 Pagni S, Federico J A, Ponn R B. Pulmonary resection for lung cancer in octogenarians.  Ann Thorac Surg. 1997;  63 785-789
• 18 Spiguel L, Ferguson K. Sleeve lobectomy versus pneumonectomy for lung cancer in patients with good pulmonary function.. In: Ferguson M K, ed. Difficult decisions in Thoracic surgery.. London: Springer; 2007: 103-109
• 19 Ma Z, Dong A, Fan J, Cheng H. Does sleeve lobectomy concomitant with or without pulmonary artery reconstruction (double sleeve) have favorable results for non-small cell lung cancer compared with pneumonectomy? A meta-analysis.  Eur J Cardiothorac Surg. 2007;  32 20-28
• 20 Fadel E, Yildizeli B, Chapelier A R, Dicenta I, Mussot S, Dartevelle P G. Sleeve lobectomy for bronchogenic cancers: factors affecting survival.  Ann Thorac Surg. 2002;  74 (3) 851-858
• 21 Icard P, Regnard J F, Guibert L, Magdeleinat P, Jauffret B, Levasseur P. Survival and prognostic factors in patients undergoing parenchymal saving bronchoplastic operation for primary lung cancer: a series of 110 consecutive cases.  Eur J Cardiothorac Surg. 1999;  15 (4) 426-432
• 22 Parissis H, Leotsinidis M, Hughes A, McGovern E, Luke D, Young V. Comparative analysis and outcomes of sleeve resection versus pneumonectomy.  Asian Cardiovasc Thorac Ann. 2009;  17 175-182
• 23 Fentiman I S, Tirelli U, Monfardini S et al. Cancer in the elderly: why so badly treated?.  Lancet. 1990;  335 1020-1022
• 24 Chen Y M, Perng R P, Tsai C M, Whang-Peng J. A phase II randomized study of paclitaxel plus carboplatin or cisplatin against chemo-naïve inoperable non-small cell lung cancer in the elderly.  J Thorac Oncol. 2006;  1 141-145
• 25 Hayakawa K, Mitsuhashi N, Katano S et al. High-dose radiation therapy for elderly patients with inoperable or unresectable non-small cell lung cancer.  Lung Cancer. 2001;  32 81-88
• 26 Ardizzoni A, Scolaro T, Mereu C et al. Induction chemotherapy with carboplatin-paclitaxel followed by standard radiotherapy with concurrent daily low-dose cisplatin plus weekly paclitaxel for inoperable non-small-cell lung cancer.  Am J Clin Oncol. 2005;  28 58-64
• 27 Federal Statistical Office of Germany .Resident population estimates of the Federal Republic of Germany by age and sex. Available at: http://www.destatis.de accessed March 4, 2010
• 28 Balduyck B, Hendriks J, Lauwers P, Nia P S, Van Schil P. Quality of life evolution after lung cancer surgery in septuagenarians: a prospective study.  Eur J Cardiothorac Surg. 2009;  35 1070-1075
• 29 Sarna L, Padilla G, Holmes C, Tashkin D, Brecht M L, Evangelista L. Quality of life of long-term survivors of non-small-cell lung cancer.  J Clin Oncol. 2002;  20 2920-2929

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
Phone: [phone]
Fax: [phone]
Email: [e-mail]