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Eur J Cardiothorac Surg 2007;31:486-490. doi:10.1016/j.ejcts.2006.11.052
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Is there a role for therapeutic lobectomy for emphysema?

Department of Thoracic Surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, United Kingdom

Received 15 September 2006; received in revised form 23 November 2006; accepted 27 November 2006.

^_* Corresponding author. Tel.: +44 116 2563959; fax: +44 116 2502662. (Email: david.waller{at}uhl-tr.nhs.uk).

Objective: The feasibility of performing a standard lobectomy in patients with non-small cell lung cancer (NSCLC) and severe heterogeneous emphysema whose respiratory reserve is outside standard operability guidelines has been described [Edwards JG, Duthie DJR, Waller DA. Lobar volume reduction surgery: a method of increasing the lung cancer resection rate in patients with emphysema. Thorax 2001;56:791–5; Korst RJ, Ginsberg RJ, Ailawadi M, Bains MS, Downey RJ, Rusch V, Stover D. Lobectomy improves ventilatory function in selected patients with severe COPD. Ann Thorac Surg 1998;66:898–902; Carretta A, Zannini P, Puglisi A, Chiesa G, Vanzulli A, Bianchi A, Fumagalli A, Bianco S. Improvement in pulmonary function after lobectomy for non-small cell lung cancer in emphysematous patients. Eur J Cardiothorac Surg 1999;15(5):602–7]. Postoperative lung function was better than predicted, attributable to the therapeutic benefit of deflation of the hemithorax. Our aim was to determine whether the physiological benefits of this approach were superior to conventional non-anatomical lung volume reduction surgery (LVRS) in similar patients. Methods: A retrospective review of a single surgeon's experience identified 34 consecutive patients who underwent upper lobectomy for completely resected stage I–II NSCLC, and who had severe heterogeneous emphysema of apical distribution with a predicted postoperative FEV₁ of less than 40%. Their perioperative characteristics, postoperative spirometry and survival of these cases were compared to 46 similar patients who underwent unilateral upper lobe LVRS during the same period. Results: Data expressed as median (range). LVRS patients were significantly younger (59 years [39–70] vs 67 years [48–79] p < 0.001), with more severe airflow obstruction (FEV₁ %pred 24 [12–60] vs 44 [17–54] p < 0.001) and more heterogenous disease (‘Q’ score 4 [0.5–11.5] vs 7 [1–13] p = 0.001) than the lobectomy group. No significant difference was found in median survival (88 vs 53 months, p = 0.06). Lobectomy patients had a shorter air leak duration (5 days [2–36] vs 9 days [1–40], p = 0.02) and hospital stay (8 days [3–63] vs 13 days [6–90] p = 0.01). A significant correlation was found between pre-operative Q score and percentage improvement in FEV₁ (r = –0.33, p = 0.02). Conclusions: Lobectomy for lung cancer in patients in severe heterogenous chronic obstructive pulmonary disease is associated with similar improvement in airflow obstruction as conventional LVRS, but is associated with a shorter postoperative course. Lobectomy may therefore offer a therapeutic alternative to conventional LVRS in a selected population.

Abbreviations: NSCLC = non-small cell lung cancer • LVRS = lung volume reduction surgery • COPD = chronic obstructive pulmonary disease • FEV₁ = forced expiratory volume in 1 s • PpoFEV₁ = percent predicted post operative FEV₁ • CT = computed tomography • PET = positron emission tomography

Key Words: Lung volume reduction surgery • Non-small cell lung cancer • Thoracic surgery