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Eur J Cardiothorac Surg 2007;31:95-102. doi:10.1016/j.ejcts.2006.10.031
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Paris-Sud University, Le Plessis Robinson, France
Received 8 September 2006; received in revised form 11 October 2006; accepted 23 October 2006.
* Corresponding author. Address: Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue, Paris-Sud University, 133 Avenue de la Resistance, 92350 Le Plessis Robinson, France. Tel.: +33 140948573; fax: +33 146308562. (Email: byildizeli{at}marmara.edu.tr).
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Abstract |
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 Top Abstract 1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
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Key Words: Sleeve lobectomy • Bronchoplastic resection • Lung cancer • Complications • Survival
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1. Introduction |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
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Bronchoplastic procedures have been reported being performed on 3–13% of the patients diagnosed with a resectable pulmonary malignant tumor [1,4–9]. It has been well documented that rate of pneumonectomies decreased significantly with increasing experience with parenchymal-sparing surgery [10,11].
Although few studies report long-term survival rates after sleeve lobectomy for non-small cell lung carcinoma (NSCLC), in some studies, low-grade malignant tumors were added to the NSCLC group, modifying the results [12–14]. The purpose of this study was to review authors’ experience with sleeve lobectomy and to assess operative morbidity, mortality, and long-term survival of sleeve lobectomy performed for non-small cell lung cancer.
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2. Materials and methods |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
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The preoperative workup included physical examination, chest radiography, computed tomography (CT) of the chest and upper abdomen, CT or magnetic resonance imaging of the brain, pulmonary function testing, arterial blood gas measurement, ventilation-perfusion scanning, and electrocardiography. Patients at high risk for heart disease were screened by echocardiography, thallium stress testing, maximum oxygen uptake, exercise testing, and, in some cases, selective coronary arteriography. Bronchoscopy was performed for endobronchial staging and selection of the potential candidates for sleeve lobectomy. Mediastinoscopy was performed when computed tomography showed mediastinal nodes larger than 1.5 cm in diameter or when positron emission tomography showed mediastinal fixation. Bone scanning is performed in symptomatic patients or in patients with abnormal blood work. A pulmonary angiogram was performed when the tumor was adherent to the main pulmonary artery in a patient whose preoperative functional test results contraindicated pneumonectomy. In patients at high risk, a right heart catheterization was performed before and after balloon occlusion of the relevant pulmonary artery to detect pulmonary hypertension, precluding pneumonectomy.
Authors’ technique of sleeve lobectomy has been reviewed in detail elsewhere [15]. Only some specific points are presented herein. All patients underwent double-lumen endotracheal intubation. A posterolateral thoracotomy was performed. No irreversible procedures were performed until resectability was confirmed. Care was taken to preserve as much as possible of the bronchial vascular supply of the remaining lobes during mediastinal lymph node dissection. Circumferential bronchial resection was performed with a knife to obtain straight margins distant from the tumor. Specimens of the resection margins were taken for frozen-section examination to ensure complete resection. Bronchial anastomosis was started using a short continuous running 4-0 polydioxanone suture (PDS, Ethicon, Inc., Somerville, NJ) lying on one third of the cartilaginous airway wall. The remaining cartilaginous and membranous walls were anastomosed using either interrupted 3-0 or 4-0 polyglactin suture (Vicryl, Ethicon) or interrupted 4-0 polydioxanone suture tied at completion of the anastomosis. The knots were placed outside the lumen. When arterial sleeve resection was performed, heparin was given and the resection was made circumferentially to avoid anastomotic stenosis. The suture was performed using 6-0 polypropylene material (Prolene, Ethicon). A pleural or pericardial flap was used routinely to cover the bronchial anastomosis and to separate it from the pulmonary artery, thus preventing bronchovascular fistula. At the end of the procedure, the anastomosis is controlled with bronchoscopy and secretions are cleaned up from the airways.
Most patients were extubated in the operating room after the procedure. When postoperative mechanical ventilation was necessary, a standard endotracheal tube was substituted for the double-lumen tube. Pain relief is achieved with epidural analgesia or patient-controlled analgesia. Patients were followed-up by routine chest roentgenograms and chest computed tomographic scans. Fiberoptic bronchoscopy was performed routinely before hospital discharge, 1 month after discharge, and when atelectasis or a persistent air leak indicated a need to look for anastomotic complications.
Tumor resection was considered complete when the resection margins were free of disease. Resected specimens were examined histopathologically, and surgicopathologic staging was performed according to the New International Staging System for Lung Cancer (International Union Against Cancer, 1997). The tumor was central in 194 patients (89%) and peripheral with nodal involvement in 24 patients (11%). The decision to perform sleeve lobectomy was based on the preoperative bronchoscopic evaluation in 73 patients (33%) and was made during the operation in 145 patients.
Five patients had a history of lobectomy for contralateral lung cancer. Three had been treated for oropharyngeal cancer and three others had received mediastinal radiation therapy for lymphoma treatment. Mediastinoscopy was performed in 31 patients. A total of 16 patients underwent induction chemotherapy (three cycles) for N2 disease. None of the patients received induction radiation therapy.
In 80 patients (36.6%), pneumonectomy was contraindicated preoperatively because of a predicted postoperative forced expiratory volume in 1 s (FEV1) less than 40%, a high pulmonary artery pressure, or severe coronary artery disease. In 35 of these patients, preoperative bronchoscopy and computed tomographic scan showed that a standard lobectomy could not be performed because the tumor had spread to the adjacent main bronchus. In the other 138 patients (63%), sleeve lobectomy was performed electively.
Operative mortality was defined as death within 30 days of the operation or death directly related to the surgical procedure. In order to predict the possible risk factors for the development of postoperative complications, 12 factors were chosen based on clinical data. With regard to these factors, a statistical analysis was performed regarding 59 patients with postoperative complications and 159 patients without the complications.
Findings from local follow-up investigations were used to categorize recurrences as local (tumor growth within the anastomosed area and in the ipsilateral hemithorax in patients without a positive tumoral resection margin), mediastinal, or distant.
2.1 Statistical analysis
Continuous data are presented as mean ± standard error unless otherwise noted. For univariate analysis, the Student's t-test, a 
2-test, and Fisher's exact test of the potential risk factors for postoperative complications were performed. To identify factors independently related to the development of mortality and morbidity, authors also performed forward multivariate stepwise (conditional) logistic regression. Survival rates were calculated by life-table analysis. Kaplan–Meier curves were plotted and compared using the log-rank test for univariate analysis. The results of the multivariate analysis of independent prognostic factors stage were assessed by using the Cox proportional hazards stepwise model, using StatView V (Abacus Concepts, Berkeley, CA). A p-value of less than or equal to 0.05 was considered significant.
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3. Results |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
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Histology revealed that there were 164 squamous cell cancers (75%), 46 adenocarcinoma (21%), 5 large-cell undifferentiated carcinoma, and 3 adenosquamous carcinoma. Among the 218 patients, 69 patients (32%) were stage I (21 IA and 48 IB), 86 (40%) were stage II (6 IIA and 80 IIB), 62 (28%) were stage III (59 IIIA and 3 stage IIIB), and 1 was stage IV with a synchronous brain metastasis. In this patient, sleeve lobectomy was performed 1 month after removal of the brain metastasis. One of the stage I patients had a synchronous contralateral stage II lung cancer for which lobectomy was performed 6 weeks later. Eighty six patients (39%) had N0, 93 (43%) N1, and 39 (18%) N2 disease. Twenty eight patients (13%) had T1, 142 (65%) T2, 45 (21%) T3, and 3 (1%) T4 disease.
Resection was incomplete in nine (4.1%) patients in whom frozen sections of the bronchial margin were positive but pneumonectomy was contraindicated by the results of preoperative investigations. Postoperative radiation therapy in total doses ranging from 30–60 Gy was used in 25 patients and 2–5 cycles of postoperative chemotherapy in 21 patients. Seventeen additional patients received both chemotherapy and radiation therapy after the operation.
3.2 Type of resection
Table 1
shows the types of lung resection and bronchial reconstruction. Right upper sleeve lobectomy was the most common procedure (45.4%). In 28 patients, the bronchogenic tumor invaded both the main bronchus and the pulmonary artery, and consequently, vascular sleeve resection was performed. This double-sleeve resection procedure was used significantly more often among patients who underwent left upper sleeve lobectomy (p
= 0.0001).
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3.3 Operative morbidity and mortality
Postoperative complications occurred in 59 patients (Table 2
). Overall operative mortality and morbidity rates were 4.1% and 22.9%, respectively. Overall operative morbidity was significantly higher in the compromised patients (p
< 0.001), whereas operative mortality was not. FEV1 was 82.6% in the noncompromised group where as 73.9% in the compromised patients (p
< 0.001). Pneumonia was the most common postoperative complication observed in 15 patients (6.8%).
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Nine patients (4.1%) died postoperatively, including five with preoperative findings contraindicating pneumonectomy. One patient died on postoperative day 7 from a septic shock after he was operated on for completion pneumonectomy due to bronchopleural fistula. One patient died at home on the 30th postoperative day from acute pulmonary emboli. One patient died on postoperative day 10 from an unexpected bronchovascular fistula, one of pneumonia on day 11, one of pulmonary embolism on day 14, two of acute respiratory distress syndrome on day 28 and 60, one of empyema on day 58, and one of myocardial infarctus on day 5. Fifty-nine patients with postoperative complications were compared with 159 patients without complications (Table 3 ). Among the risk factors that were investigated, those showing a significant effect on the development of postoperative complications in the multivariate analysis were compromised patients (i.e. patients with predicted postoperative forced expiratory volume in 1 s (FEV1) is less than 40%, a high pulmonary artery pressure, or severe coronary artery disease) (p = 0.001), history of current smoking (p = 0.01), right sided resections (p = 0.003), bilobectomy (p = 0.03), squamous cell cancer (p = 0.03), and N1 or N2 disease (p = 0.01). Other factors, such as age (mean 62.9 years, range 35–78 vs 63.0 years, range 19–82, complication vs noncomplication), sex, mediastinoscopy, induction therapy, vascular sleeve resection, or positive bronchial margin had no significant effect on the risk of postoperative complications.
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Among the 138 patients without preoperative contraindication to pneumonectomy, 4 died postoperatively. During follow-up, 5 patients were lost to follow-up and 38 of the remaining 129 patients died. Among them, 27 (71%) died of lung cancer (local or distant relapse or a second primary cancer) and 11 patients died of another disease. Among the 91 alive patients, 5 patients were presented with local recurrence, two with mediastinal recurrence, and five with distant recurrence.
Among the nine patients with microscopic invasion of the bronchial stump, three died postoperatively, one of a bronchovascular fistula and one of respiratory failure, and one received adjuvant chemotherapy and died because of liver and bone metastases 35 months after operation. Three patients underwent adjuvant radiation therapy and the other three underwent both adjuvant radiotherapy and chemotherapy. Two died of local and distant relapse 12 and 35 months after operation, and four were alive without recurrence after 25, 16, 8, and 2 months. During follow-up, 81 of the 190 remaining patients died. Among them, 55 (68%) died of recurrent lung cancer. The first site of recurrence was local in 10, mediastinal in 20, and distant in 25. Eleven (13%) other patients died of a second primary cancer; eight of them had a different histology, and in the three remaining patients, lung cancer developed in the contralateral lung more than 5 years after the sleeve lobectomy. The remaining 15 patients died of another disease with no documented lung cancer relapse.
Death by local tumor growth was significantly more common among the patients with incomplete resection (2 of 9 vs 10 of 199; p = 0.03). Among the patients with complete resection, fatal locoregional (both local and mediastinal) recurrence was seen in 11.5% (9 of 78) of patients with N0 disease, 10.2% (9 of 88) of those with N1 disease, and 42.4% (14 of 33) of those with N2 disease. The locoregional recurrence rate was significantly higher in patients with N2 disease (p = 0.0001).
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4. Discussion |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
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It is well known that bronchoplastic resections are technically more challenging than pneumonectomy. There have been many retrospective analyses of the operative mortality and morbidity of sleeve lobectomy and pneumonectomy for NSCLC [1–3,6,9,11,17]. Tedder et al. [1] reported that 30-day mortality was 5.5%; however in a recent meta-analysis, Ferguson and Lehman [3] reported that the weighted mean operative mortality was 4.1% (confidence interval [CI], 2.3–5.9%). On the other hand, the mortality after pneumonectomy was reported as 6.0% (confidence interval, 1–11%), that is significantly higher than sleeve lobectomy [3]. Deslauriers et al. [2] reported an operative mortality four times more important after pneumonectomy (5.3% vs 1.3%, p = 0.036). Thus, authors’ operative mortality of 4.1% was acceptable.
It has been reported that the major complications after performing sleeve resection were the narrowing of the bronchoplasty site and atelectasis, whereas the pneumonectomy group suffered primarily from postpneumonectomy empyema and respiratory failure [8]. Completion pneumonectomy or lobectomy for anastomotic dehiscence or stenosis was common after sleeve lobectomy. It has been reported that the incidence of bronchopleural fistula was 3% and bronchovascular fistula 2.5% following sleeve lobectomy [1]. Overall bronchial anastomotic complications were seen in 6.4% of authors’ patients, which is similar to recent series [16,17]. Five patients with anastomotic complications were treated with completion pneumonectomy (one died), one with carinal pneumonectomy, one with lobectomy, and one resection anastomosis of the stenosis. Three patients with bronchial stenosis required a stent insertion. One patient died due to bronchovascular fistula. Authors believe that all anastomotic complications, especially bronchostenosis and fatal bronchovascular fistula [15], can be prevented by precise dissection, preservation of blood supply, meticulous anastomosis, elimination of anastomotic stenosis, anastomotic buttressing, and interposition of viable tissue between bronchial and vascular structures [18].
Hollaus et al. [19] analyzed the risk factors associated with complications after bronchial sleeve resections and reported 26.8% morbidity and 5.5% mortality rates. Authors’ operative morbidity of 22.9% was acceptable. Authors also found that postoperative complications were significantly lower in noncompromised patients (p = 0.01), as Hollaus et al. [19].
Tedder et al. [1] reported that the incidence of pneumonia was 10% following sleeve lobectomy. Authors considered pneumonia any new infiltrate on chest roentgenogram, fever >38 °C, accompanied by a rise of oxygen consumption and a decline of oxygen saturation. Authors’ pneumonia rate of 6.8% lies in the lower range and may be a result of aggressive bronchoscopic intervention if radiological signs of secretions are suspected. In order to decrease postoperative pulmonary complications, such as pneumonia, early extubation, ambulation, use of epidural analgesia, aggressive pulmonary toilet, and multiple bedside bronchoscopies should be performed [10].
It has been also reported that anastomotic complications have been associated with pathologic N2 status and positive bronchial margins [15,19]. In addition to presence of N disease, authors also found that right sided resections, smoking, and squamous cell carcinoma were the predisposing factors for the development of postoperative complications. Authors observed that patients who underwent sleeve bilobectomy had more complications than that of sleeve lobectomy (p = 0.03). Possible reasons may be inadequate preservation of the right main bronchus for right upper and middle lobe bronchoplasty and mismanaged size discrepancy for right lower and middle lobe bronchoplasty [18]. In addition to these, following sleeve upper bilobectomy, inadequate re-expansion of the right lower lobe may become a contributing factor for development of the postoperative complications. Authors’ findings were similar to Suzuki et al. [20] who reported that heavy and current smoking, metastases to lymph nodes, decreased albumin, and resection of the right lower or middle and lower lobe are the risk factors for the development of bronchopleural fistula following lung cancer surgery.
Many patients in this era are treated with neoadjuvant chemotherapy and radiotherapy when mediastinal nodes are involved. Therefore, these patients will be candidates for bronchoplastic resections after induction therapy. Although Yamamoto et al. [21] reported that preoperative chemoradiotherapy adversely affects mucosal blood flow and healing, recent studies demonstrate that sleeve lobectomy is also safe and efficient after neoadjuvant therapy [10,22]. Importance of protecting anastomoses with well-vascularized flaps to prevent possible bronchial complications has been reported [21]. In the present study, only 16 patients (7.3%) had an induction chemoradiotherapy and authors did not observe any negative impact of neoadjuvant treatment in developing the postoperative complications.
A major concern regarding sleeve lobectomy for lung cancer is the increased incidence of locoregional recurrence. Suture line recurrence may be related to lung preservation at the expense of adequate bronchial margins [1]. The incidence of local recurrence has ranged from 5–51% [15]. In a meta-analysis of Ferguson and Lehman [3], although no difference was observed in 5-year survival between sleeve lobectomy and pneumonectomy (51.4% vs 49.1%, respectively), isolated local/regional recurrence was found higher after sleeve lobectomy (20%) than pneumonectomy (10%). However recently, Deslauriers et al. [2] reported 22% of locoregional recurrence after sleeve lobectomy and 35% after pneumonectomy. This wide variation is probably ascribable to the absence in most studies of a definition of local recurrence. Authors defined local recurrence as tumor relapse after complete resection, located at the bronchial anastomosis or in the ipsilateral lung. Local recurrence occurred in 10 patients (4.5%). In addition, two patients with a positive bronchial stump died of local tumor development. Among the 208 patients, 30 died of local or mediastinal recurrence, resulting in a locoregional recurrence rate of 14.4%, which is similar to that reported by others [2,9].
Long-term survival rates after sleeve lobectomy for NSCLC were comparable with those after conventional resections in the review performed by Tedder et al. [1] and Ferguson and Lehman [3]. Recent studies comparing sleeve lobectomy with pneumonectomy reported similar [4] or significantly longer survival [2,9] in patients treated with sleeve resection. Authors’ survival results were similar with Deslauriers et al. [2] and Okada et al. [9] who report a significant better survival after sleeve lobectomy in stage I and stage II but not in stage III patients.
The relationship between the surgical outcome of sleeve lobectomy and nodal involvement remains controversial. Although Deslauriers et al. [2] did not demonstrate a significant difference in survival for patients N2 disease, many authors have shown that an N2 lesion was the most significant factor related to survival. Van Schil [23] reported that nodal status was the major determinant for long-term survival after sleeve lobectomy with significantly shorter survival in patients with N2 disease as compared with those with N1 or N0 disease. In keeping with a study by Mehran et al. [12], none of the authors’ patients with N2 disease were alive 5 years after the sleeve lobectomy.
It has been shown that N2 disease is highly predictive of distant recurrences [14]. The main cause of death in authors’ patients with N2 disease was distant relapse. This, together with the fact that complete lymph node dissection was performed in all of the authors’ patients, suggests that pneumonectomy may not increase survival as compared with sleeve resection in these patients. It has been reported that patients with extralobar N1 disease have a significantly worse prognosis than patients with intralobar N1 disease [24]. Difference in 5-year survival observed by Riquet et al. [24] between intralobar and extralobar N1 patients was 53.6% versus 38.5%, respectively. In authors’ study and in that reported by Mehran et al. [12], there were no significant differences in survival between N0 and N1 disease. Others, however, have found a significantly lower survival rate in patients with N1 than N0 disease [13], leading to controversy about the use of sleeve resection in noncompromised patients with N1 disease. On the other hand, Bagan et al. [6] demonstrated that the size of the tumor (pathologic T, pT) limits the technical possibility of sleeve lobectomy performance in N0 or intralobar N1 disease. In this report, authors did not study the prognostic role of extralobar and intralobar N1 disease. In the report of Takeda et al. [5], 72.6% of the patients who underwent sleeve lobectomy were stage I or II, whereas those underwent pneumonectomy was 34.5%. Authors’ results were similar that 32% of the authors’ patients were stage I and 39% were N0, thus it can be speculated that lung-saving procedures are performed more commonly for patients with early stage of NSCLC.
It has been reported that incomplete resection is associated with a worse prognosis [15,25]. Tronc et al. [25] found that 5-year and 10-year survival was 58 and 38% for complete resection versus 11% and 6% for incomplete resection, respectively (p < 0.05). However, in the present study, multivariate analysis of the factors for long-term survival did not reveal the negative effect of incomplete resection. Possible explanation of this result may come from authors’ relatively high number of complete resection rate (95.9%) for the patients underwent sleeve lobectomy for NSCLC. In fact, the incomplete resection rate was reported 13% by Tronc et al. [25], resulting in significantly poor prognosis of the patient with incomplete resection.
It is well known that pneumonectomy limits pulmonary reserve, increases pulmonary artery pressure, and leads to greater long-term cardiopulmonary disability and worse quality of life than does lobectomy [9]. Also, pneumonectomy has been reported to increase the risk of cardiopulmonary death [9]. Moreover, development of a second primary lung tumor requiring further operation is not uncommon [12]. Although Kim et al. [4] suggested that sleeve lobectomy should be performed in selective patients without lymph node metastasis due to higher locoregional recurrence, Ferguson and Lehman [3], have reported that sleeve lobectomy is favored over pneumonectomy. Authors agree with others [10,11,16,22] that sleeve resection should be the procedure of choice whenever it is technically feasible, even in patients who could tolerate pneumonectomy.
In conclusion, sleeve lobectomy can be performed for patients who are anatomically appropriate regardless of whether they would tolerate a larger resection. It is an alternative procedure to pneumonectomy and even to sleeve right pneumonectomy in selected patients. Sleeve lobectomy achieves local tumor control and is associated with acceptable rates of mortality and bronchial anastomotic complications. Compromised patients, smoking, presence of N1 or N2 disease, right sided resections, bilobectomy, and squamous cell carcinoma are the predisposing risk factors for postoperative mortality and the morbidity. In patients with non-small cell lung cancer, the main adverse prognostic factors are N2 disease and stage III; the outcome is not affected by the presence of preoperative contraindications to pneumonectomy and incomplete resection.
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Appendix A |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
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Dr M. Dusmet (London, United Kingdom): I think your study shows yet again what a good operation a sleeve lobectomy is. Why do you think that right-sided resections are more at risk for complications than left-sided resections?
Dr Yildizeli: It's always difficult to conclude with retrospective studies that one factor is an independent risk factor compared to others. When we looked at our patients, we have seen that more than 50% of our patients operated had a right resection; right upper lobectomy or bilobectomy or lower lobectomy. It's a matter of statistical analysis that we have found this. Actually we all know that right-sided resection may have complications. Possible reasons may be inadequate preservation of the right main bronchus for right upper and middle lobe bronchoplasty and mismanaged size discrepancy for right lower and middle lobe bronchoplasty and extensive devascularization of the tracheal margins.
Dr P. Van Schil (Antwerp, Belgium): It could have something to do with the number of patients.
Dr Yildizeli: Exactly. Sixty three percent of the patients had a right-sided tumor.
Dr F. Rea (Padua, Italy): Do you have any patients in your series that received neoadjuvant chemotherapy or radiotherapy?
Dr Yildizeli: Yes. Sixty-three of our patients had neoadjuvant chemotherapy. Nearly one-third of them had chemotherapy, one-third of them received both chemo and radiotherapy, and the other ones had received radiotherapy. We could not demonstrate any beneficial effect or any other effect of the adjuvant therapy on the long-term survival of the patients.
Dr Van Schil: Could you comment on the staging and restaging of the patients with N2 disease? I noticed that less than half of your patients had a cervical mediastinoscopy. You’re showing that N2 disease has a dismal prognosis. Would you expand your indications for mediastinoscopy?
Dr Yildizeli: Actually, as your paper has already shown before, the main prognostic factor of N2 disease is obvious. We don’t discuss this. For nearly the last decade, with mediastinoscopy, PET scan has also been used in France. All the patients are admitted with the CT scan and PET scan. If they are negative, we do not perform mediastinoscopy, but if they are positive, we always do mediastinoscopy first before the operation. That's our policy.
Dr O. Kshivets (Siauliai, Lithuania): As I understood, you have zero 5-year survival for lung cancer patients with N2 lymph node metastases. Do you perform mediastinal lymphadenectomy for these patients in total? In other words, do you perform mediastinal systematic lymph node dissection?
Dr Yildizeli: This oncologic concept that all the patients presenting with lung cancer should have mediastinal lymph node dissection is not a matter of concern.
Dr C. Gebitekin (Bursa, Turkey): My question is that 60 of your patients had neoadjuvant chemotherapy. In how many cases were the resection margins completely negative for tumor? And if the tumor requires sleeve resection, it's always T2 tumor. How did you get the T1 tumor?
Dr Yildizeli: Actually it's known that the patients who should undergo sleeve resection are presenting with early stage lung cancer because they have central tumors. Sixty-five percent of our patients had T2 disease whereas only 13% had T1 of whom had more commonly upper lobe tumors.
Those patients who had induction chemotherapy, and we had 16 patients, none of them had a positive resection margin after the operation. Unfortunately those who had a positive resection margin had a contraindication to pneumonectomy.
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Footnotes |
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References |
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TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
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ldzeli B, Chapelier AR, Dicenta I, Mussot S, Dartevelle PG. Sleeve lobectomy for bronchogenic cancers: factors affecting survival. Ann Thorac Surg 2002;74:851-859.This article has been cited by other articles:
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  F. Rea, G. Marulli, M. Schiavon, A. Zuin, A.-M. Hamad, G. Rizzardi, E. Perissinotto, and F. Sartori A quarter of a century experience with sleeve lobectomy for non-small cell lung cancer Eur. J. Cardiothorac. Surg., September 1, 2008; 34(3): 488 - 492. [Abstract] [Full Text] [PDF]
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 S. Benlloch, J. M. Galbis-Caravajal, C. Alenda, F. M. Peiro, M. Sanchez-Ronco, J. M. Rodriguez-Paniagua, B. Baschwitz, E. Rojas, and B. Massuti Expression of molecular markers in mediastinal nodes from resected stage I non-small-cell lung cancer (NSCLC): prognostic impact and potential role as markers of occult micrometastases Ann. Onc., July 29, 2008; (2008) mdn538v1. [Abstract] [Full Text] [PDF]
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 A. M. Ciccone, A. D'Andrilli, F. Venuta, C. Andreetti, and E. A. Rendina Imaging of tumor infiltration of the pulmonary artery amenable to sleeve resection J. Thorac. Cardiovasc. Surg., July 1, 2008; 136(1): 229 - 230. [Full Text] [PDF]
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A. S. Bayram, M. M. Erol, H. Salci, O. Ozyigit, S. Gorgul, and C. Gebitekin Basic interrupted versus continuous suturing techniques in bronchial anastomosis following sleeve lobectomy in dogs Eur. J. Cardiothorac. Surg., December 1, 2007; 32(6): 852 - 854. [Abstract] [Full Text] [PDF]
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M. Ismail Sleeve lobectomy. Is it valid for all cases of lung cancer? Eur. J. Cardiothorac. Surg., July 1, 2007; 32(1): 185 - 185. [Full Text] [PDF]
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