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Ann Thorac Surg 2002;73:1736-1739
© 2002 The Society of Thoracic Surgeons

Original article: general thoracic

Personal experience in lung cancer sleeve lobectomy and sleeve pneumonectomy

Maurizio Mezzetti, MD*a, Tiziana Panigalli, MDa, Luigi Giuliani, MDa, Federico Raveglia, MDa, Fabio Lo Giudice, MDa, Stefano Meda, MDa

a San Paolo Hospital, and School of Specialization of Thoracic Surgery, Milan, Italy

Accepted for publication February 6, 2002.

* Address reprint requests to Dr Mezzetti, Via Boccaccio 27, 20123 Milan, Italy
e-mail: maurizio.mezzetti{at}unimi.it


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. Sleeve lobectomy (SL) and tracheal sleeve pneumonectomy (TSP) represent valuable alternative techniques to standard resections in the treatment of benign and malignant conditions of the airway and allow preservation of lung parenchyma.

Methods. Eighty-three sleeve lobectomies and 27 tracheal sleeve pneumonectomies have been performed for nonsmall cell lung cancer in the thoracic department of the University of Milan from 1979 to 1999. There were 46 upper right lobectomies, 11 upper and middle lobectomies, 18 upper left lobectomies, 8 lower left lobectomies, and 27 right pneumonectomies.

Results. Mortality rate was 3.6% in SL and 7.4% in TSP. Complications were 10.8% of all SLs and 15% of all TSPs. The overall 5-year survival rate was 43% for SL and 20% for TSP; the 10-year survival rate was 34% and 14%, respectively. There was a highly significant difference in survival between patients with N0 and N1-N2 disease.

Conclusions. Sleeve lobectomy is an appropriate surgical procedure and an alternative to pneumonectomy in patients with limited respiratory reserve whenever the situation permits. Trachael sleeve pneumonectomy is associated with more complications and poor survival.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Lung cancer represents the leading cause of cancer death in the world, independently by sex. In 2000 in Italy, 35,000 new cases of lung cancer were diagnosed according to the Italian Ministry of Health. The overall 5-year survival rate approaches 20% when diagnosed; this rate increases to 40% after complete surgical resection. Currently only 50% of patients with lung cancer are considered for primary resection.

Bronchoplastic procedures include sleeve lobectomy (SL) and tracheal sleeve pneumonectomy (TSP). They were described in literature for the first time in the 1950s [1]. In bronchial sleeve resections part of the bronchial structure, usually in continuity with adjacent lung parenchyma, is removed followed by the creation of a bronchial end-to-end anastomosis. The cylindrical bronchial wall part that is resected is called a "sleeve" because of its shape. Sleeve procedures conserve lung tissue because an SL avoids a pneumonectomy.

SL is appropriate when the cancer is located at the lobar orifice and when a standard lobectomy is precluded in patients with compromised cardiopulmonary function. With the use of this technique pneumonectomy can be avoided and a complete resection can be obtained. TSP is considered when a central malignant tumor is close to or involves either the right or the left tracheobronchial carena. The cancer can also have its origin in the carena or invade the lower carena from the main stem bronchus. TSP permits complete surgical resection in an otherwise inoperable patient. Bronchoplastic procedures are also valuable for carefully selected elderly patients [2].

Our experience began with an upper right sleeve lobectomy in 1979. Our series concerns only malignant airways disease.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
From 1997 to 1999, 110 patients underwent sleeve resection for nonsmall cell lung cancer in the thoracic department of the University of Milan (Table 1). They represent 3.7% of 2,913 pulmonary resections we performed for cancer. There were 83 SL and 27 TSP. The mean age was 60 ± 10 years. Histologic type was always determined before resection and we never considered small cell lung cancer.


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  		Table 1. Experience With Sleeve Resection

 
The preoperative evaluation included lung cancer staging and histologic type determination to exclude small cell lung cancer, complete pulmonary function study, and cardiac evaluation for both SL and TSP (Table 2). We used contrast-enhanced computed tomography (CT) for noninvasive intrathoracic staging. In addition cervical mediastinoscopy was performed to analyze superior mediastinal lymph nodes in patients with dubious mediastinal lymphadenopathy at CT scan and confirm their involvement. Mediastinoscopy was always performed before TSP [3]. Fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (FDG-PET) imaging has supported mediastinoscopy in mediastinal nodal staging in the last 20 months [4]. Patients with mediastinal node involvement at CT scan confirmed by subsequent mediastinoscopy or FDG-PET imaging were not considered for primary TSP.


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  		Table 2. Preoperative and Postoperative Staging

 
Detection of metastatic disease was obtained by brain CT, abdominal CT, and bone scan. FDG-PET imaging was performed to detect metastatic disease in case of doubts at CT scan. Patients with metastatic disease were excluded.

Bronchoscopy was carried out in all cases to define the airways involvement and the extent of pathologic tissue in the bronchus [3]. Biopsy and brushing specimens of suspected tumor involvement were always obtained.

Preoperative radiation therapy (RT) was given to 15 of 27 patients considered for TSP with mediastinal node disease (N2). These patients received a total dose of 40 to 42 Gray. A successive CT scan showed good sterilization of mediastinal nodes (Table 3) and we accepted these data for surgery.


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  		Table 3. Thirty-Day Mortality

 
Anesthesiologic procedures were as routine for all major thoracic surgery. Ventilation was by double-lumen tube. The incision was in all cases a standard posterolateral thoracotomy that allowed thorough evaluation of the anterior and posterior hilar structures, permitting complete mediastinal node dissection.

For the past 16 years the anastomosis was performed using interrupted sutures of adsorbable filament to reestablish bronchial continuity. In the last 12 years a pleural flap, and in 1 case an intercostal muscle flap, was created circumferentially around the anastomosis when it was necessary to avoid tension on the bronchial suture and to reduce the complication of bronchial disruption [5].

For the last 16 years frozen-section examination of the divided edges has been performed during the operation to ensure radicality in patients with bronchogenic carcinoma. We enlarged the edges resection after the intraoperative response in 9 patients (8 SL and 1 TSP). According to definitive histologic results for all SL patients, there were 50 squamous cell carcinomas, 30 adenocarcinomas, and 3 undifferentiated large cell carcinomas. For all TSP patients, there were 22 squamous cell carcinomas and 5 adenocarcinomas.

Both bronchial sleeve resection and pulmonary arterial sleeve resection were performed in 16 of 83 SL patients, 13 on the left side and 3 on the right side. These were all upper sleeve lobectomies. Artery resection was necessitated by direct tumor invasion or by involved nodes.

Postoperative pathologic TNM staging classified TSP tumors as follows: 8 stage IIB (T3N0) and 19 IIIA (11 T3N1, 8 T3N2). SL tumors were classified as follows: 34 stage I (2 IA, 32 IB), 32 stage II (3 IIA, 29 IIB), and 17 stage III (16 IIIA, 1 IIIB).

Patients whose tumor was N1 or N2 at the definitive examination underwent postoperative mediastinal radiotherapy; and in cases of preoperative RT (15 of 19 patients) it was completed until the patient had been given a total dose of 60 Gray. Adjuvant CT treatment was considered for the whole group except in case of N0 disease.

Follow-up in SL was obtained with periodic clinical and radiographic controls (included standard chest x-ray film and CT scanning). Fibrobronchoscopy was performed in patients who presented with symptoms or signs of possible anastomosis complications or bronchial recurrence. Patients who underwent TSP were always evaluated with periodic fibrobronchoscopy as well.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
In our series the 30-day mortality rate was 4.5% of all sleeve resections (Table 3). This rate according to the literature [6–8] is 3.6% of all SL and 7.4% of all TSP. In our study there were 13 (11.8%) postoperative complications: 5 bronchopleural fistulas, 3 respiratory failures, 2 cases of atelectasis, 2 cases of pneumonia, and 1 thoracotomy suppuration. These represent 10.8% of all SL and 15% of all TSP (Table 4) [9]. Three of 83 SL patients and 2 of 27 TSP patients had bronchopleural fistulas. Patients affected by bronchopleural fistula did not undergo preoperative radiation. None of our patients required completion of pneumonectomy due to complications of the anastomosis.


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  		Table 4. Postoperative Complications

 
Survival rates were analyzed at 5 and 10 years (Table 5). The 5-year survival rates were 43% for SL patients and 20% for TSP patients. The 10-year survival rates were 34% and 14%, respectively. SL patient survival rates according to nodal status at 5 years and 10 years were, respectively, as follows: 61% and 50% for N0 disease, 39% and 26% for N1, and 9% and 0% for N2 (Table 6). TSP patient survival rates at 5 and 10 years were, respectively, 50% and 40% for N0 and 12% and 0% for N1.


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  		Table 5. Five-Year and 10-Year Survival Rates

 

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  		Table 6. Five-Year and 10-Year Survival Rates Related to Nodal Status

 
Local relapse occurred in the area of the anastomosis in 20% of SL patients. There were no local recurrences among TSP patients.

Thirty-eight patients died 5 to 10 years after SL: 34 patients died of neoplastic recurrence, 2 of myocardial infarction; 1 of stroke; and 1 of intestinal infarction. Twenty-nine patients are alive 5 to 10 years postoperatively, and 23 (79.3%) of these are actually free of disease. Sixteen patients died 5 to 10 years after TSP: 13 patients died of neoplastic recurrence, 1 of heart failure, 1 of myocardial infarction, and 1 of pneumonia. Four patients are alive, all without recurrence. Survival rate related to hystologic type was better for squamous cell carcinoma but the difference did not reach statistical significance.


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
Data related to SL and TSP should be considered separately despite the similar surgical technique because of different outcomes.

The most recent review of the literature [6, 10–13] coupled with our experience in bronchoplastic procedures indicates that the fewer postoperative deaths after SL (3.6% at 30 days) and similar long-term mortality and morbidity rates are similar when compared with the alternative procedure of pneumonectomy. SL is a valuable procedure for treating lung cancer in selected patients who cannot tolerate pneumonectomy because of limited cardiopulmonary function. In these patients SL preserves parenchyma and avoids serious postoperative pulmonary dysfunction.

The criteria for selecting patients include the possibility of complete tumor resection both in the bronchial wall and in the resected lung portion [14]. According to our results we conclude that SL is the operation of choice when feasible as an alternative to pneumonectomy in these selected conditions.

TSP is a demanding procedure. Various reports [15, 16] in the last 10 years indicate more favorable outcomes due to surgical and anesthesia techniques advances and to restricted criteria in selection patients. In our series the TSP mortality rate (7.4%) and morbidity rate (15%) are significant, with a long-term survival rate lower than that with standard pneumonectomy as shown in the recent literature [7, 17–19]. In our series the prognosis depends mainly on lymph node involvement.

We recommend accurate mediastinal lymph node staging. We always included mediastinoscopy in TSP preoperative staging to assess the upper mediastinal nodes involvement. In the last 20 months we used FDG-PET scanning in conjunction with CT scanning to provide the most accurate staging without aggressive procedures and it is still under evaluation. From our results we conclude that TSP provides a satisfactory survival rate in patients with N0 disease, but N2 disease is a contraindication to surgery.

Many authors [8, 15] recommend low dosage preoperative radiation therapy to reduce cancer size and for sterilization of mediastinal nodes involved. On the others hand some authors [20] underline that the risk of complication in the anastomosis area increases after preoperative radiation. We believe that low dosage local preoperative irradiation should be considered when a few mediastinal nodes are involved (N2) to sterilize these locations and reduce the cancer mass volume and the cancer stage. We did not note a relation to postoperative bronchopleural fistula insurgence.

We conclude that TSP should be employed when strictly indicated for patients with adequate cardiopulmory function, N0 staging, and no metastatic disease.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Allison P.R. Course of thoracic surgery in Gronningen. Ann R Coll Surg Engl 1959;25:20-38.
  2. Jaklitsch M.T., Bueno R., Swanson S.J., Mentzer S.J., Lukanich J.M., Sugarbaker D.J. New surgical options for elderly lung cancer patients. Chest 1999;116:480S-485S.[Abstract/Free Full Text]
  3. Deslauriers J., Jacques J. Sleeve pneumonectomy. Chest Surg Clin North Am 1995;5:297.[Medline]
  4. Vansteenkiste J.F., et al. Mediastinal lymph node staging with FDG-PET scan in patients with potentially operable non small cell lung cancer. Chest 1997;112:1480.[Abstract/Free Full Text]
  5. Deslauriers J., et al. Long-term clinical and functional results of sleeve lobectomy for primary lung cancer. J Thorac Cardiovasc Surg 1986;92:871.[Abstract]
  6. Mehran R.J., Deslauriers J., Piraux M., Beaulieu M., Guimont C., Brisson J. Survival related to nodal status after sleeve resection for lung cancer. J Thorac Cardiovasc Surg 1994;107:576-583.[Abstract/Free Full Text]
  7. Dartevelle P., Macchiarini P. Carinal resection for bronchogenic carcinoma. Semin Thorac Cardiovasc Surg 1996;8:414.[Medline]
  8. Roviaro G.C., Varoli F., Rebuffat C., et al. Tracheal sleeve pneumonectomy for bronchogenic carcinoma. J Thorac Cardiovasc Surg 1994;107:13-18.[Abstract/Free Full Text]
  9. Tedder M., Anstadt M.P., Tedder S.D., et al. Current morbidity, mortality and survival after bronchoplastic procedures for malignancy. Ann Thorac Surg 1992;54:387-391.[Abstract]
  10. Van Schil P.E., de la Riviere A.B., Knaepe P.J., et al. Long-term survival after bronchial sleeve resection. Univariate and multivariate analyses. Ann Thorac Surg 1996;61:1087-1091.[Abstract/Free Full Text]
  11. Rea F., Loy M., Bortolotti L., Feltracco P., Fiore D., Sartori F. Morbidity, mortality and survival after bronchoplastic procedures for lung cancer. Eur J Cardiothorac Surg 1997;11:201-205.[Abstract]
  12. Watanabe Y., Shinizu J., Oda M., et al. Results in 104 patients undergoing bronchoplastic procedures for bronchial lesion. Ann Thorac Surg 1990;50:607-614.[Abstract]
  13. Tronc F., Gregoire J., et al. Long term results of sleeve lobectomy for lung cancer. Eur J Cardiothorac Surg 2000;17:550-556.[Abstract/Free Full Text]
  14. Massard G., Kessler R., et al. Local control of disease and survival following bronchoplastic lobectomy for non small cell lung cancer. Eur J Cardiothorac Surg 1999;16:276-282.[Abstract/Free Full Text]
  15. Roviaro G., Varoli F., Romanelli A., et al. Complications of tracheal sleeve pneumonectomy: personal experience and overview of the literature. J Thorac Cardiovasc Surg 2001;121:234-240.
  16. Mitchell J.D., Mathisen D.J., Wright C.D., et al. Resection for bronchogenic carcinoma involving the carina: long-term results and effect of nodal status on outcome. J Thorac Cardiovasc Surg 2001;121:465-471.[Abstract/Free Full Text]
  17. Mathisen D.J., Grillo H.C. Carinal resection for bronchogenic carcinoma. J Thorac Cardiovasc Surg 1991;102:16.[Abstract]
  18. End A., Hollans P., et al. Bronchoplastic procedures in malignant and non malignant disease: multivariable analysis of 144 cases. J Thorac Cardiovasc Surg 2000;120:119-127.[Abstract/Free Full Text]
  19. Mitchell J.D., Mathisen D.J., Wright C.D., et al. Clinical experience with carinal resection. J Thorac Cardiovasc Surg 1999;117:39-53.[Abstract/Free Full Text]
  20. Dartevelle P.G., et al. Tracheal sleeve pneumonectomy for bronchogenic carcinoma: report of 55 cases. Ann Thorac Surg 1988;46:48.



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