Eur J Cardiothorac Surg 2006;30:168-171
© 2006 Elsevier Science NL
Bronchoplastic lobectomy: do early results depend on the underlying pathology?
A comparison between typical carcinoids and primary lung cancer
Jean Lemaitre
a
,
Ziad Mansour
a
,
Evgenia A. Kochetkova
a
,
Chawki Koriche
a
,
Xavier Ducrocq
a
,
Jean-Marie Wihlm
a
,
Elisabeth Quoix
b
,
Gilbert Massard
a
,
*
a Service de Chirurgie thoracique, Hôpitaux universitaires de Strasbourg, 67091 Strasbourg, France
b Departement de pneumologie, Hôpitaux universitaires de Strasbourg, 67091 Strasbourg, France
Received 27 February 2006;
received in revised form 23 March 2006;
accepted 30 March 2006.
* Corresponding author. Tel.: +33 3 88 11 62 02; fax: +33 388 11 60 77. (Email: Gilbert.Massard{at}chru-strasbourg.fr).
 |
Abstract
|
|---|
Background: This study evaluates the impact of the underlying disease upon the surgical outcome of bronchoplastic lobectomy, comparing typical carcinoid tumours with primary lung carcinoma. Patients and methods: This retrospective study includes 98 consecutive patients (78 males, 20 females). Eighteen patients had a typical carcinoid tumour (group 1), and 80 had a primary bronchial carcinoma (group2). Fifty-six patients underwent bronchoplasty with full sleeve resection (10 patients from group 1, 46 from group 2) and 42 patients had a bronchoplasty with bronchial wedge resection (8 from group 1 and 34 from group 2). Right upper lobectomy was the most common procedure. We compared demographic data, surgical indications, the type of bronchoplasty and postoperative complications. Results: The average age in group 1 (38.5 ± 16.3 years; range 15–77) was significantly lower than in group 2 (61.4 ± 9.5 years; range 14–75) (p
< 0.001). There were no postoperative deaths. Procedure-specific complications (anastomotic dehiscence and atelectasis) were found in 7 patients (8.75%) in group 2 (of which, three had a combination of two of the above-mentioned complications) but none (0%) in group 1 (p
= 0.23). Seven patients from group 2 (8.75%) required treatment for a residual pneumothorax for none (0%) in group 1 (p
= 0.23). The mean duration for air leak was comparable in both groups (p
= 0.366). Three patients (16.67%) from group 1 had non-surgical complications compared to 17 (21.25%) in group 2 (of which, one had a combination of two non-surgical complications) (p
= 0.35). Conclusion: Bronchoplastic resection is a safe operation in patients with carcinoid tumours and should be the reference for treatment.
Key Words: Carcinoid tumour • Lung cancer • Sleeve lobectomy
|
1. Introduction
|
|---|
Bronchoplastic lobectomy is defined as a lobectomy extended to a segment of the adjacent main bronchus, followed by a reimplantation of the remaining lobar bronchus into the main stem bronchus [1]. From a technical point of view, we may differentiate tubular bronchoplasty involving the resection of a complete circumferential bronchial sleeve to the wedge bronchoplasty, which leaves a bridge of bronchus opposite to the resection [2]. Bronchoplastic lobectomies were first used in patients with centrally located bronchial tumours who were too frail to undergo a pneumonectomy. Since then, several authors have supported its routine use for all patients in whom a complete resection of the tumour may be achieved with this conservative technique. In the event of tumours invading the lobar bronchus, or lymph nodes close to the lobar takeoff, the bronchoplastic lobectomy allows the resection of both the primary tumour and the draining lymph nodes with the same effectiveness as a pneumonectomy. However, short-term mortality and complications, long-term survival, and quality of life are substantially improved following bronchoplastic lobectomy [2,3].
Bronchial carcinoid tumours are rare and represent only 2–5% of all bronchial tumours. Depending on the pathological characteristics (number of mitoses, pleiomorphism and disorganisation of the nucleus) they are classified into ‘typical’ and ‘atypical’ tumours. Ninety per cent of carcinoid tumours are situated near the midline; in at least 10% of them, there is evidence of regional lymph node involvement [4]. Due to the relatively benign course of typical carcinoid tumours, it is not surprising that the first bronchoplastic lobectomy was performed in a patient with a carcinoid tumour of the right main bronchus [5]. The central location of typical carcinoid tumours may be considered as the ideal indication for bronchoplastic lobectomy: as patients have a favourable prognosis, they will take a maximal benefit from a conservative resection when compared to pneumonectomy. However, most studies devoted to the outcome of bronchoplastic resections pool together patients with low grade malignancies, such as typical carcinoid tumour, and those with more aggressive carcinomas such as non-small cell carcinomas and atypical carcinoid tumours.
Carcinoid tumours tend to affect patients at a younger age than primary bronchial carcinoma [6]. Therefore, the expected mortality and morbidity rates should be lower in this particular group. The aim of this study was to specifically compare postoperative complication rate of bronchoplastic lobectomy according to the underlying disease, i.e., carcinoid tumour or non-small cell lung cancer.
|
2. Patients and methods
|
|---|
Ninety-eight consecutive patients (78 males and 20 females) who had undergone a bronchoplastic lobectomy between January 1990 and December 2001 were reviewed retrospectively. Group 1 included 18 patients with typical carcinoid tumour. Group 2 was composed of 80 patients with non-small cell lung cancer. The latter included 22 patients with stage IA, 25 with stage IB, 4 with stage IIA, 17 with stage IIB and 12 with stage IIIA.
We compared demographic data and indications for surgery. Mortality was defined as any death occurring during the first 30 days or during the initial hospital stay. Procedure-specific surgical complications included anastomotic dehiscence or stenosis, and postoperative atelectasis requiring bronchoscopic clearance; besides, we registered prolonged air leak (>7 days) and redrainage. Non-surgical complications included cardiac or neurologic events, pneumonia and deep vein thrombosis, or any other event prolonging the hospital stay.
Statistics were performed using the SPSS for Windows version 11.0 software. Student's t-test was used for continuous variables, whereas 
2 or Fishers exact test where appropriate were used when analysing qualitative variables. A p value <0.05 was considered statistically significant.
|
3. Results
|
|---|
Patients of group 1 were significantly younger (p
< 0.001): the average age was 38.5 ± 16.3 years in group 1 (range: 15–77) and 61.4 ± 9.5 years in group II (range: 14–75). Pneumonectomy was contra-indicated on functional grounds in 24 patients: 1 in group 1 (5.56%) and 23 in group 2 (28.75%). In 56 cases a tubular sleeve bronchoplasty was performed, and 42 underwent a wedge bronchoplasty; distribution was even in both groups. Right upper lobectomy was the most frequent intervention in both groups (Table 1
).
Perioperative mortality (30 days) was nil in both group. Procedure-specific complications were not observed in group 1; in group 2, 7 patients had a total of 10 procedure-specific complications (8.75%; p
= 0.23). The latter were three cases of partial bronchial dehiscence, one anastomotic stricture, and six atelectases requiring bronchoscopic suction. None of the anastomotic complications required reoperation. The mean duration for air leaks was similar in both groups (Table 2
). Redrainage was needed in seven patients from group 2 but in none in group 1 (p
= 0.23). Non-surgical complications occurred in 3 patients (16.67%) in group 1 (one complication per patient) and 17 patients (21.25%) in group 2 (one of them having two complications) (p
= 0.35). However, all three supraventricular tachycardias observed in group 1 were quickly reversed by appropriate treatment and did not prolong hospital stay.
Type of bronchoplasty, i.e., bronchial wedge compared to full sleeve, did not influence morbidity.
|
4. Discussion
|
|---|
Although there was no operative mortality, the present study demonstrated an apparently different incidence of procedure-specific complications following bronchoplastic lobectomy according to the underlying disease: virtually all complications were observed in the group of patients with carcinoma in opposition to the group with carcinoid tumours. Unfortunately, disproportionate sample sizes took away any statistical power, and the differences though obvious are not statistically significant. The observed differences in surgical complications cannot be related to surgical technique because the distribution of both types of bronchoplasty was similar. Without any doubt, patients with carcinoid tumours were more fit for surgery: their younger age certainly has positively influenced bronchial healing and postoperative recovery. Besides, absence of smoking or COPD, or other smoking-related comorbidity is expected to improve early postoperative outcome. Parenchymal dystrophy observed in COPD may explain prolonged air leaks and secondary pneumothorax; alteration of mucous secretions in COPD explains the increased incidence of atelectasis. On the contrary, in patients with normal bronchial secretions such as patients with carcinoids, atelectasis was not observed despite bronchial denervation owing to bronchoplasty.
Most studies report complications independently from the type of tumours [3,6–9]. Only two studies looked into the influence of the underlying pathology on the rate of complications. Fadel et al. [1] reported a surgical complication rate of 6.5% and 11% for carcinoid tumours and NSCLC, respectively, whereas mortality rates were 0% and 2.9%, respectively. These results match with ours except for the incidence of non-surgical complications, which was similar in both groups in our study; this may be due either to the small sample size, or to the fact that we registered any minor incident. Suen et al. [10] grouped together low grade malignancies (typical and atypical carcinoid tumours, mucoepidermoid carcinoma, pleiomorphic adenoma and papilloma) and compared them to NSCLC. The sample sizes were comparable to the present study. Surgical complications were observed in 10.6% of low grade malignancies, and in 15.5% of patients with non small cell lung cancer; the rate of non-surgical complications were 5.3% and 42.3%, respectively. The higher complication rate in patients with NSCLC was mostly due to the high incidence of supraventricular tachycardia (38.9%) [10].
Several studies have shown that bronchoplastic lobectomy lowers considerably the operative risk when compared to pneumonectomy, while offering comparable oncologic results in terms of survival and local control of disease [8,10–12]. It further warrants a better preservation of postoperative respiratory function. This is particularly relevant in the younger age group, in whom respiratory function might allow an improved tolerance of pneumonectomy, but for whom the more conservative technique will better preserve lung function and quality of life, and allow for further resections in case of relapse of the initial pathology or appearance of a new primary tumour [2]. Several groups have shown excellent survival rates and low rates of recurrence with bronchoplastic lobectomy in patients with carcinoid tumours [13–15]. On the opposite, pneumonectomy does not only implicate an increased operative risk, but has been identified as an independent factor of poor long-term prognosis in patients with stage I NSCLC [15,16].
While there is no doubt that bronchoplasty is preferable to pneumonectomy, there is an increasing debate about the value of endoscopic treatments for intrabronchial carcinoid tumours [17,18]. However, the few published reports include few patients, and suffer from a short duration of follow-up. We further argument that the depth of invasion cannot always be reliably assessed by endoscopic methods. At least 10% of patients have lymph node involvement which is ignored when no node dissection is performed. Finally, only thorough pathologic examination of the whole specimen can ascertain the diagnosis of a typical carcinoid tumour; this is no longer possible following laser vaporisation [19]. The confirmed uncomplicated course of bronchoplastic operations in patients with typical carcinoids should set an end to this debate.
We conclude that bronchoplastic lobectomy may guarantee a complete resection with neglectable mortality and low morbidity in patients with centrally located carcinoid tumours, and should be regarded as the gold standard of treatment for such patients.
|
References
|
|---|
- Fadel E, Yildizeli B, Chapelier AR, Dicenta I, Mussot S, Dartevelle PG. Sleeve lobectomy for bronchogenic cancers: factors affecting survival. Ann Thorac Surg 2002;74:851-859.[Abstract/Free Full Text]
- Massard G, Kessler R, Gasser B, Ducrocq X, Elia S, Gouzou S, Wihlm JM. Local control of disease and survival following bronchoplastic lobectomy. Eur J Cardiothorac Surg 1999;16:276-282.[Abstract/Free Full Text]
- Tronc F, Grégoire J, Rouleau J, Deslauriers J. Long-term results of sleeve lobectomy for lung cancer. Eur J Cardiothorac Surg 2000;17:550-556.[Abstract/Free Full Text]
- Filosso P, Rena O, Donati G, Casadio C, Ruffini E, Papalia E, Oliaro A, Maggi G. Bronchial carcinoïd tumors: surgical management and long-term outcome. J Thorac Cardiovasc Surg 2002;123:303-309.[Abstract/Free Full Text]
- Price-Thomas C. Conservative resection of the bronchial tree. J R Coll Surg Edimb 1956;1:169.
- Ducrocq X, Thomas P, Massard G, Barsotti P, Giudicelli R, Fuentes P, Wihlm JM. Operative risk and pronostic factors of typical bronchial carcinoïd tumors. Ann Thorac Surg 1998;65:1410-1414.[Abstract/Free Full Text]
- End A, Hollaus P, Pentsch A, Brannath W, Janakiev D, Mueller MR, Pridun N, Wolner E. Bronchoplastic procedures in malignant and nonmalignant disease: multivariable analysis of 144 cases. J Thorac Cardiovasc Surg 2000;120:119-127.[Abstract/Free Full Text]
- Gaissert HA, Mathisen DJ, Moncure AC, Hilgenberg AD, Grillo HC, Wain JC. Survival and function after sleeve lobectomy for lung cancer. J Thorac Cardiovasc Surg 1996;111:948-953.[Abstract/Free Full Text]
- Mehran RJ, Deslaurers 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]
- Suen HC, Meyers BF, Guthrie T, Pohl MS, Sundaresan S, Roper CL, Cooper JD, Patterson GA. Favorable results after sleeve lobectomy or bronchoplasty for bronchial malignancies. Ann Thorac Surg 1999;67:1557-1562.[Abstract/Free Full Text]
- Martin-Ucar AE, Chaudhuri N, Edwards JG, Waller DA. Can pneumonectomy for non-small cell lung cancer be avoided? An audit of parenchymal sparing lung surgery. Eur J Cardiothorac Surg 2002;21:601-605.[Abstract/Free Full Text]
- Van Schil PE, Brutel de la Rivière A, Knaepen PJ, van Swieten HA, Reher SW, Goossens DJ, Vanderschueren RG, van den Bosch JM. Long-term survival after bronchial sleeve resection: univariate and multivariate analyses. Ann Thorac Surg 1996;61:1087-1091.[Abstract/Free Full Text]
- Fink G, Krelbaum T, Yellin A, Bendayan D, Saute M, Glazer M, Kramer MR. Pulmonary carcinoïd: presentation, diagnosis, and outcome in 142 cases in Israël and review of 640 cases from the literature. Chest 2001;119:1647-1651.[Abstract/Free Full Text]
- Filosso P, Rena O, Donati G, Casadio C, Ruffini E, Papalia E, Oliaro A, Maggi G. Bronchial carcinoïd tumors: surgical management and long-term outcome. J Thorac Cardiovasc Surg 2002;123:303-309.[Abstract/Free Full Text]
- Ferguson MK, Karrison T. Does pneumonectomy for lung cancer adversely influence long-term survival?. J Thorac Cardiovasc Surg 2000;119:440-448.[Abstract/Free Full Text]
- Thomas P, Doddoli C, Thirion X, Ghez O, Payan-Defaix MJ, Giudicelli R, Fuentes P. Stage I non-small cell lung cancer: a pragmatic approach to prognosis after complete resection. Ann Thorac Surg 2002;73:1065-1070.[Abstract/Free Full Text]
- Sutedja TG, Schreurs AJ, Vanderschueren RG, Kwa B, Werf TS, Postmus PE. Bronchoscopic therapy in patients with intraluminal bronchial carcinoid. Chest 1995;107:556-558.[Abstract/Free Full Text]
- Van Boxem TJ, Venmans BJ, van Mourik JC, Postmus PE, Sutedja TG. Bronchoscopic treatment of intraluminal typical carcinoid: a pilot study. J Thorac Cardiovasc Surg 1998;116:402-406.[Abstract/Free Full Text]
- Massard G, Thomas P, Fuentes P, Wihlm JM. Is resection the only effective treatment for bronchial carcinoids?. Ann Thorac Surg 1998;66:1870-1872.[Free Full Text]
Top
Abstract
1. Introduction
