SLEEVE LOBECTOMY FOR NSCLC

April 6, 2010 — Sleeve lobectomy (SL) should be considered as a favorable alternative to pneumonectomy (PN) in patients with nonsmall-cell lung cancer (NSCLC), if the procedure is anatomically feasible, according to a new study from thoracic bronchoplastic surgeons in South Korea.

In a retrospective analysis of 210 patients, 5-year survival was statistically significantly higher in the SL group than in the PN group (58.4% vs. 32.1%; P = .0002).

Despite the fact that SL is now "widely used," there are "some debates" about the effectiveness of the procedure, write the study authors, led by Joon Suk Park, MD, from the Department of Thoracic and Cardiovascular Surgery at the Samsung Medical Center and Sungkyunkwan University School of Medicine in Seoul, South Korea.

But with their new data, published in the April issue of the Journal of Thoracic Oncology, the authors conclude that "sleeve lobectomy is a safe and effective operation in the treatment of NSCLC."

The "main reason" for any hesitation in performing SL has been concern about local recurrence, Dr. Park and colleagues explain.

However, in their study, there was no significant difference in recurrence pattern between the SL group and the PN group. "These results are consistent with other studies that showed a similar local recurrence rate between sleeve lobectomy and pneumonectomy," the authors note.

Another reason that SL might not be performed is the degree of difficulty, suggested a thoracic surgeon approached by Medscape Oncology for comment.

"A sleeve lobectomy is technically more demanding than a pneumonectomy," said Frank Detterbeck, MD, chief of the Division of Thoracic Surgery at the Yale University School of Medicine in New Haven, Connecticut.

Dr. Detterbeck pointed out that, in the United States, thoracic surgery is performed by general surgeons, cardiac surgeons, and thoracic surgeons. However, only dedicated thoracic surgeons are likely to be "comfortable" performing SL, said Dr. Detterbeck.

"Most dedicated thoracic surgeons agree that if you can completely remove the tumor with SL, then it is preferable to a pneumonectomy," he said, explaining that a pneumonectomy involves removing one entire lung, whereas SL removes only a section of the lung.

Dr. Detterbeck also praised the study. "It's a great paper. One of the best papers on the subject," he said, pointing out that its virtues include a "large series" of patients and "a good statistical approach."

Creating the 2 Groups

The authors explain that they "tried to perform sleeve lobectomy whenever it was technically feasible in patients who otherwise were candidates for pneumonectomy" in 1973 consecutive patients with primary NSCLC at their center in Seoul. Candidacy for PN included, most notably, sufficient functional pulmonary reserve.

Dr. Detterbeck explained that whether or not the procedure is "feasible" depends on the airway structures involved, which in turn determine "if you can salvage some part of the lung and do a sleeve."

Generally, SL has been used when there is not sufficient lung function in NSCLC patients, note the study authors. Therefore, they wanted to see whether or not SL was a favorable procedure, "not only in patients with pulmonary dysfunction but also in patients with sufficient pulmonary function."

Of the 1973 patients, lobectomy/bilobectomy was performed in 76.6% (n = 1511), PN in 14.9% (n = 294), and SL in 8.5% (n = 168).

There was a median follow-up period of 30.73 months (mean, 41.8 ± 36.7 months) for these PN and SL patients.

To create 2 comparable groups with common clinicopathologic background, the researchers performed a propensity-score analysis, using the "nearest neighbor matching method" of covariates, which include age, sex, neoadjuvant therapy, cell type, and pathologic tumor stage.

Other variables, such as tumor size, preoperative pulmonary function, and postoperative adjuvant therapy, were compared to verify that these 2 groups were nearly identical for statistical comparison.

In the end, the researchers worked with 2 groups of 105 patients each for their analysis.

Results, Including Operative Mortality

Operative mortality was 1.0% (1 of 105 patients) for the SL group and 8.6% (8 of 105 patients) for the PN group (P < .0001).

Postoperative morbidity was similar in both groups (33.4% for SL and 29.5% for PN; P = .376). "The distributions of morbidities in the 2 groups showed no significant difference, even when all of the morbidities were subdivided into major and minor complications," note the authors.

The overall 3-year survival rates were 71.4% for the SL group and 41.8% for the PN group (P < .0001). The overall 5-year survival rates are noted above.

Although direct comparison of the recurrence pattern of the 2 groups was not possible because of the pair-match design of the analysis, the composition of locoregional and distant recurrence was similar in the 2 groups, the authors report.

In the 12 pairs that had a recurrence, there was no significant difference in the pattern of recurrence (P = .180), even though the number of included subjects was too small to have statistical significance, according to the authors.

The total recurrence in the SL group was 30.5% (n = 32) and in the PN group was 38.1% (n = 40).

The researchers also looked at functional outcomes, namely forced expiratory volume (FEV1).

Both the SL and the PN groups had similar preoperative lung function. The mean preoperative FEV1 for the patients who underwent PN was 2.38 ± 0.67 L, and for patients who underwent SL was 2.45 ± 0.720 L (P = .18).

Additionally, for all of the patients who underwent SL, the mean predicted post-PN FEV1 (had they undergone PN) was 1.90 ± 0.50 L, and the mean actual postoperative FEV1 was 2.05 ± 0.55 L; this was a decrease of 18.5% compared with the preoperative FEV1, and an increase of 7.9% compared with predicted post-PN FEV1.

"Our results showed that the sleeve lobectomy can be performed with low operative risk and may offer superior survival and better postoperative pulmonary function compared with the pneumonectomy in selected patients," conclude the study authors.

The study authors have disclosed no relevant financial relationships.

J Thorac Oncol. 2010;5:517-520. Abstract