ABSTRACT
Lung cancer involving the carina can be treated by surgery, but patients must be carefully selected before the operation. Because pneumonectomy is required in addition to carinal resection, patients must be able to withstand the procedure, and they must be told that the operative mortality is 2 to 4 times higher than what is expected after standard pneumonectomy. Patients who have mediastinal nodal disease documented preoperatively by mediastinoscopy should not have this operation. In general, it is possible to perform a safe operation if the surgeon adheres to the principles of healthy bronchial suturing and restricts airway resection to a maximum distance of 4 cm. Surgeons must always remember, however, that it is better and safer to accept a positive resection margin than to have to deal with a bronchopleural fistula caused by anastomotic separation. Finally, reported long-term survival rates of 25% to 40% justify the use of this procedure.
Subject(s)
Carcinoma, Bronchogenic/surgery , Carcinoma, Non-Small-Cell Lung/surgery , Lung Neoplasms/surgery , Pneumonectomy/methods , Carcinoma, Bronchogenic/mortality , Carcinoma, Bronchogenic/pathology , Carcinoma, Non-Small-Cell Lung/mortality , Carcinoma, Non-Small-Cell Lung/pathology , Female , Follow-Up Studies , Humans , Lung Neoplasms/mortality , Lung Neoplasms/pathology , Male , Mediastinoscopy/methods , Minimally Invasive Surgical Procedures/methods , Neoplasm Staging , Patient Selection , Preoperative Care/methods , Risk Assessment , Survival Analysis , Treatment OutcomeABSTRACT
BACKGROUND: Sleeve lobectomy (SL) in a lung-saving procedure indicated for central tumors for which the alternative is pneumonectomy (PN). Although it has been suggested that it may provide as good if not better survival results than pneumonectomy in the treatment of lung cancer, there are very few reports of clinical series comparing operative mortality, survival, and sites of recurrences between these procedures. METHODS: Survival and sites of recurrences were analyzed and compared in 1,230 consecutive patients who underwent PN (n = 1,046) or SL (n = 184) in a single institution. Sleeve lobectomy was always done when technically possible. Thus PN was reserved for lesions that could not be removed by a bronchoplastic procedure. Pathologic staging was accomplished by nodal sampling except for N2 and selected N1 patients who underwent mediastinal lymphadenectomy. Ultimately, all patients were staged according to the 1997 TNM nomenclature. RESULTS: There were 3 operative deaths of the 184 SL patients (operative mortality of 1.6%) and 55 operative deaths of the 1,046 PN patients (operative mortality of 5.3%, p = 0.036). Follow-up was complete for all 1,230 patients. For the entire group, survival at 5 years was 52% after SL and 31% after PN (p < 0.0001). These rates for patients with complete resection were 58% for SL and 33% for PN (p = 0.021). There was also a significant difference in survival favoring SL for patients with pathologic stage I (p = 0.018) and stage II (p = 0.005) disease. When recurrences occurred (n = 577), the site of first recurrence was local in 22% of patients with SL and in 35% of patients with PN. CONCLUSIONS: Sleeve lobectomy can be done with a much lower risk of operative mortality than PN. Although it is recognized that stage for stage, PN patients likely have more advanced disease, long-term survival and local control are significantly better when complete resection can be achieved by SL.
