Sleeve lobectomy after induction chemoradiotherapy

• Published in: European journal of cardio-thoracic surgery Vol. 41; no. 5; pp. 1052 - 1058
• Main Authors: Gómez-Caro, Abel, Boada, Marc, Reguart, Noemí, Viñolas, Nuria, Casas, Frances, Molins, Laureano
• Format: Journal Article
• Language: English
• Published: Oxford Oxford University Press 01-05-2012
• Subjects: Adult; Aged; Aged, 80 and over; Anastomosis, Surgical - adverse effects; Biological and medical sciences; Bronchi - surgery; Carcinoma, Non-Small-Cell Lung - pathology; Carcinoma, Non-Small-Cell Lung - surgery; Carcinoma, Non-Small-Cell Lung - therapy; Cardiology. Vascular system; Chemoradiotherapy - adverse effects; Female; Humans; Lung Neoplasms - pathology; Lung Neoplasms - surgery; Lung Neoplasms - therapy; Male; Medical sciences; Middle Aged; Neoadjuvant Therapy - adverse effects; Neoplasm Staging; Pneumology; Pneumonectomy - adverse effects; Pneumonectomy - methods; Postoperative Care - methods; Postoperative Complications; Prognosis; Prospective Studies; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Survival Analysis; Treatment Outcome; Sparing surgery; Chemotherapy; Sleeve lobectomy; Radiotherapy; Induction; Sleeve; Chemoradiotherapy; Treatment; Surgery; Circulatory system; Cardiology; Lobectomy; Pneumology
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1093/ejcts/ezr184

OBJECTIVES
The effect of induction chemoradiotherapy (CRT) on bronchial anastomoses remains uncertain. This prospective study aimed to assess the impact of neoadjuvant CRT on mortality, morbidity and survival following circular sleeve lobectomy (SL).
METHODS
All consecutive patients undergoing SL between June 2005 and December 2010 were prospectively included. Clinico-demographic variables were sex, age, clinical and pathologic TNM staging, comorbidities, pulmonary function, SL type, complications, neoadjuvant CRT and mortality.
RESULTS
Of 79 patients, who underwent SL during this period, 53 (67%) patients were directly assigned to surgery and 26 (33%) patients had pre-induction treatment for N2 pathologically confirmed. Induction treatment (CRT) was based on platinum-based chemotherapy and radiation (range 45-60 Gy). Twenty-one (80%) patients of the CRT group achieved a complete mediastinal pathological response. Mortality occurred in only three cases in the non-CRT [bronchovascular fistula, pulmonary artery thrombosis (reoperation and pneumonectomy and exitus due to pneumonia) and ADRS]. There were no differences with respect to complication rate between the non-CRT and CRT patients (33 versus 37%, P > 0.05), and overall 5-year survival was 69 and 33%, respectively (P = 0.017). Overall survival in the subgroup of CRT patients with mediastinal complete response after induction resulted significantly worse than the non-CRT group (43 versus 69%, P < 0.01). The rate of distant metastases was similar in both groups and only one patient experienced local recurrence.
CONCLUSIONS
Neoadjuvant CRT does not increase surgical morbidity, anastomotic complications or mortality in SL. Complete mediastinal response after induction therapy overcomes a significant independent prognostic factor for better survival. Although SL following induction CRT carries a good prognosis, the long-term results shows significantly lower survival compared with SL without induction CTR. In addition, patients who had complete pathological responses have a better prognosis than non-responders. SL appears to be safe and reliable after neoadjuvant concurrent CRT and can be considered the primary surgical option to save the complications related to pneumonectomy in central tumours.