Is a sleeve lobectomy significantly better than a pneumonectomy?

Stallard, Joseph; Loberg, Anna; Dunning, Joel; Dark, John

doi:10.1510/icvts.2010.245506

Abstract

A best evidence topic was written according to a structured protocol. The question addressed was ‘whether a sleeve lobectomy results in a better survival rate than a pneumonectomy in suitable patients?’ Altogether, more than 327 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude in the biggest meta-analysis of nearly 3000 patients, the five-year survival was 50% for sleeve lobectomy compared to 30% for pneumonectomy. Operative mortality was 3% vs. 6% for pneumonectomy, and locoregional recurrence was 17% vs. 30%. These results are broadly consistent across all the 13 cohort studies presented here many of which document a 20-year single centre experience or more. There are significant issues in all cohort studies on this subject as, due to their non-randomized nature, the reason for not performing a sleeve resection may well have been more advanced disease, which would necessarily mean that the pneumonectomy patients would have a lower expected survival and higher local recurrence. In addition, there have been many large cohort studies to date and thus no more are required, as future studies are unlikely to resolve this issue. Thus, the only study that would adequately correct for this issue would be a randomized trial, but to prove a 10% increase in five-year survival a 300 patient study would be needed. This is bigger than any study ever done in this area and as some centres took 30 years to collect these numbers of potential sleeve patients an RCT is not a realistic possibility. Therefore, we conclude that no more cohort studies should be performed, as the results will be consistent with the meta-analyses and an RCT to eliminate their bias is unattainable, and thus no more research should be done on this topic and surgeons should use the figures presented above and in more detail in this best evidence topic to govern their management in the future.

Sleeve lobectomy, Pneumonectomy, Non-small cell lung cancer

1. Introduction

A best evidence topic was constructed according to a structured protocol. This is fully described in ICVTS [1].

2. Three-part question

In [patients undergoing lung resection for non-small cell lung cancer] is [sleeve lobectomy] superior to [pneumonectomy] in terms of [survival.]

3. Clinical scenario

In theatre, you are operating on a 57-year-old with the intention of a lobectomy due to a non-small cell carcinoma (NSCLC) in the upper lobe of the right lung. You find that the tumour, however, extends into the right main bronchus. Facing two options, your assistant suggests performing a pneumonectomy as the sleeve lobectomy is quite technically difficult and you could cause a bronchopleural fistula. However, you feel that the patient would benefit from a sleeve lobectomy in terms of lung function and survival but you are not sure of the data for this and thus resolve to check the literature after the operation.

4. Search strategy

Medline 1950 to May 2007 using OVID interface

[Sleeve Lobectomy.mp OR Sleeve resection.mp] and [exp Pneumonectomy OR Pneumonectomy.mp]

5. Search outcome

Three hundred and twenty-seven papers were found using the reported search. From these, 15 papers were identified that provided the best evidence to answer the question. These are presented in Table 1 .

Table 1.

Best evidence papers

Author, date and country,	Patient group	Outcomes	Key results	Comments
Study type
(level of evidence)
Ma et al., 2007,	Twelve studies were	Five-year overall	Extracted from 10 studies:	This meta-analysis
Eur J Cardiothorac	identified with a combined	survival	SL group – 50.3%	showed that SL can be
Surg, China, [2]	total of 2984 subjects. 876		PN group – 30.6%	carried out instead of a
	underwent SL and 2108			PN without increasing
Level 2a	underwent PN	One-year survival	Extracted from 10 studies:	the morbidity and
			reported as a risk difference	mortality in appropriate
			of 0.10 (95% CI: 0.07–0.18)	patients
			in favour of a SL	SL has been shown to
				offer better long-term
		Postoperative	Reported in 12 studies:	survival
		mortality	SL 3.5% (31/876), PN 5.7%
			(121/2108).
			(OR: 0.65; 95% CI:
			0.42–1.01)

		Postoperative	Reported in eight studies:
		complications	SL – 31.3% (154/492)
			PN – 31.6% (245/776)
			(OR: 1.01; 95% CI:
			0.70–1.44)

		Locoregional	SL – 16.1% (72/447)
		recurrence	PN – 27.8% (402/1443)
			(OR: 0.91; 95% CI:
			0.45–1.82)

Ferguson and	Twelve studies were	Five-year	SL – 52.4%	The meta-analysis
Lehman, 2003,	identified: 860 underwent	survival	PN – 48.7%	showed that SL has a
Ann Thorac Surg,	SL and 746 underwent PN			better long-term survival
USA, [3]		Operative	SL – 4.1% (CI: 2.3–5.9%)	and quality of life than
		mortality	PN – 6.0% (CI: 1–11%)	PN in patients with early
Level 2a			(P=0.3)	stage lung cancer. SL has
				also been shown to be
		Local/regional	The likelihood of isolated	more cost effective than
		recurrence	local/regional recurrence:	PN
			SL – 20%
			PN – 10%

		QALYS	SL – 4.37
			PN – 2.48

Melloul et al., 2008,	Retrospective single	30-day	Patients <70 years of age:	This study also showed
Interact	institution analysis of	mortality	SL – 0%, PN – 3% (P=0.5)	that PN resulted in a
CardioVasc Thorac	patients undergoing SL or			higher postoperative loss
Surg, Switzerland,	PN between 2000 and		Patients >70 years of age:	of FEV₁ than SL. The
[4]	2005. 78 patients		SL – 0%, PN – 15%	study, therefore,
	underwent PN (65 patients		(P=0.2)	suggests that SL has a
Level 2b	<70 years of age in PN			therapeutic advantage
	group) and 69 underwent	Overall	Patients aged <70 years of	over PN
	SL. (50 patients <70 years	complication	age: SL – 44%, PN – 26%
	of age in SL group)	rate	(P=0.05)

			Patients >70 years of age:
			SL – 32%, PN – 23%
			(P=0.7)

Okada et al., 2000,	The study compared the	Ten-year	SL – 36%	This study shows SL to
J Thorac	outcomes of SL to PN in	survival	PN – 21%	be more beneficial than
Cardiovasc Surg,	patients with NSCLC.			PN in all areas studied.
Japan, [5]	151 patients underwent SL	Five-year	SL – 48%	The study, therefore,
	and 50 underwent PN. For	survival	PN – 29%	suggests that SL should
Level 2b	bias reduction in			be performed in all
	comparison with a	Three-year	SL – 61%	patients with NSCLC
	non-randomized control	survival	PN – 36%	regardless of their nodal
	group, they generated the			status as long as total
	results by pairing 60 SL	30-day	SL – 0%	resection is achievable
	patients with 60 PN	mortality	PN – 2%
	patients


		Postoperative	SL – 13%
		complication	PN – 22%

		Local	SL – 8%
		recurrence	PN – 10%

Martin-Ucar et al.,	This was a prospective	One-year survival	SL – 73% (±8%)	As the study progressed
2002, Eur J	study looking at a 119		PN – 64% (±5%)	the number of PN being
Cardiothorac Surg,	consecutive patients			done decreased. The
UK, [6]	operated on by a single	30-day	SL – 10.5% (4/38)	study shows that SL can
	surgeon. 81 patients	mortality	PN – 9.9% (8/81)	be carried out in a large
Level 2b	underwent PN and			number of patients with
	38 underwent	FEV₁	Mean perioperative loss of	NSCLC of a main stem
	bronchoplastic∓angioplastic		FEV₁:	bronchus allowing for
	procedure (SL)		SL – 170 (range=0–500) ml	better long-term
			PN – 620	outcomes, while
			(range=200–1400) ml	preserving more lung
			(P=0.0003)	function

Kim et al., 2005,	This retrospective study	Ten-year	SL – 45.5%	This study suggests that
Ann Thorac Surg,	reviewed all the patients	survival	PN – 45.3%	SL should only be carried
Korea, [7]	with primary NSCLC who			out in selected patients,
	were operated on at Seoul	Five-year	SL – 59.5%	such as those that do not
Level 2b	National University Hospital	survival	PN – 53.7%	have positive lymph
	between January 1989 and			nodes, as SL has a higher
	December 1998. 200 PN	Three-year	SL – 63.8%	recurrence rate. For this
	were carried out and	survival	PN – 63.0%	patient group they
	49 SL			recommend using SL
		Early	SL – 51%	over PN as SL does not
		postoperative	PN – 35%	effect survival outcomes
		complications

		Operative	SL – 6.1%
		mortality	PN – 4.1%

		Recurrence	SL – 57%
			PN – 30%

Ludwig et al.,	This retrospective study	Overall five-year	SL – 39%	The study concluded that
2005, Ann Thorac	analysed the outcome of	survival	PN – 27%	SL should be performed
Surg, Germany, [8]	310 patients who		(P=0.0129)	whenever possible over
	underwent SL or PN for			PN due to its superior
Level 2b	NSCLC (stages I–IIIA)	Three-year	SL – 47.4%	outcomes in all areas
	between 1987 and 1997.	survival	PN – 37.1%
	116 patients had a SL and
	194 patients had a PN	One-year survival	SL – 72.4%
			PN – 62.9%

		30-day	SL – 4.3%
		mortality	PN – 4.6%

		Postoperative	SL – 44 complications
		complications	PN – 50 complications

Takeda et al., 2006,	This was a retrospective	Overall five-year	SL – 53.4%	Based on their results,
Eur J Cardiothorac	study, comparing surgical	survival	PN – 32.9%	this study concluded
Surg, Japan, [9]	results after SL and PN for		(P=0.0028)	there was no difference
	NSCLC over 20 years in			in morbidity, mortality
Level 2b	one institution. Results	Five-year	No statistical difference:	and overall survival
	generated from analysing	Survival in	SL – n=45	between each procedure
	outcomes of	stage I and II	PN – n=38
	62 consecutive SLs to	patients
	110 consecutive PNs
		30-day	SL – 1.6%
		postoperative	PN – 1.8%
		mortality

		Hospital deaths	SL – 4.8%
			PN – 3.6%

		Local	SL – 9.7%
		recurrence	PN – 10.9%

		Distant	SL – 29.0%
		recurrence	PN – 42.7%

Gaissert et al.,	The study analysed the	Actuarial	SL – 42±6.5%	The study confirmed that
1996, J Thorac	outcomes of SLs and PNs	survival at	PN – 44±7.3%	SL is the first choice
Cardiovasc Surg,	carried out at	Five-year		procedure where the lung
USA, [10]	Massachusetts General			cancer is anatomically
	Hospital. The study	Actuarial	SL – 80±4.8%	suited for this procedure.
Level 2b	compared 72 patients	survival at	PN – 76±5.9%	They concluded survival
	undergoing SL between	One-year		is acceptable and is
	1962 and 1991 with			comparable with PN. The
	56 patients that	Hospital	SL – 4%	study suggests a better
	underwent PN between	mortality	PN – 9%	quality of life is expected
	1986 and 1990			with a SL due to the
		Major	SL – 11%	preservation of
		complications	PN – 16%	functioning lung

Yoshino et al.,	Retrospective study	Three-year	SL – 65.7%	The study concluded that
1997, J Surg	comparing 29 SL patients	disease-free	PN – 58.8%	an SL should be
Oncol, Japan, [11]	between 1977 and 1993, to	survival		performed whenever
	29 PN patients selected			feasible for centrally
Level 2b	according to set criteria	Operation-	SL – 0%	located lung cancer. This
	from 129 PNs performed.	related	PN – 6.9%	was due to the operation
	There was no differences	mortality	(P<0.05)	being safer and just as
	observed between the two			curable as a PN for lung
	groups regarding stage,	Postoperative	SL – 13.7%	cancer as no statistical
	histological population, or	complications	PN – 24.1%	significance was seen
	age. Operations were		(P<0.05)	between recurrence
	carried out at the			rates
	Department of Chest	Local	SL – n=3
	Surgery, National Kyushu	recurrence	PN – n=6
	Cancer Center
		Distant	SL – n=6
		metastases	PN – n=7

Suen et al., 1999,	Department retrospective	Overall five-year	SL for NSCLC – 37.5%	This study suggests SL
Ann Thorac Surg,	review of their experience	actuarial	SL for low grade – 100%	should be standard
USA, [12]	of SL and PN for NSCLC,	survival	PN for NSCLC – 35.8%	procedure for patients
	and SL for low grade			with low grade malignant
Level 2b	malignancy between	Operative	SL for NSCLC – 5.2%	tumour involving the
	January 1988 and	mortality	SL for low grade – 0%	main bronchus, as SL
	September 1998. 77 SL: 58		PN for NSCLC – 4.9%	conserves lung
	for NSCLC and 19 for low			parenchyma and have
	grade malignancies. 142			excellent short- and
	PN for NSCLC			long-term outcomes.
				They also conclude SL is
				a good alternative for PN
				for patients with NSCLC
				involving the main
				bronchus, as the
				outcomes are similar

Ghiribelli et al.,	This retrospective study	Overall five-year	SL – 38%	This study confirms SL,
2002, J Cardiovasc	analyses the outcomes of	survival	PN – 25%	when performed in
Surg (Torino),	patients with NSCLC		(P=0.03)	selected patients with
Italy, [13]	which underwent SL or			NSCLC, provides at least
	PN at The University	30-day	SL – 5.2%	similar long-term
Level 2b	Hospital of Siena. (January	postoperative	PN – 3.9%	outcomes as PN. As lung
	1990–December 1995.)	mortality		parenchyma is reserved
	38 patients underwent SL,			SL should be first choice
	127 patients underwent	Postoperative	SL – 23.6%
	PN	complications	PN – 23.2%

		Local	SL – 5.2%
		recurrence	PN – 4.8%


Deslauriers et al.,	A single institution analysed	Five-year	SL – 52%	This study concluded
2004, Ann Thorac	the survival and recurrence	actuarial	PN – 31%	that SL is effective and
Surg, Canada, [14]	rates in 1230 consecutive	survival	(P<0.0001)	can be accomplished
	patients with NSCLC who			safely in patients with
Level 2b	underwent PN (n=1046)	Five-year	SL – 58%	resectable NSCLC. They
	or SL (n=184). From	actuarial	PN – 33%	showed that SL has
	January 1972 to	survival	(P=0.021)	better outcomes for
	December 2000	(patients		survival, lower mortality
		with complete		rates and lower
		resection)		locoregional recurrence

		Operative	SL – 1.3%
		mortality	PN – 5.3%
			(P=0.036)

		Locoregional	SL – 22%
		recurrence	PN – 35%

Bagan et al., 2005,	This retrospective study	Five-year	SL – 72.5%	This study concludes that
Ann Thorac Surg,	analysed the outcomes of	actuarial	PN – 53.2%	SL where possible is a
France, [15]	surgery carried out on	survival	(P=0.0025)	safer option than PN for
	patients between 1984 and			patients with NSCLC
Level 2b	2002 who underwent lung	Operative	SL – 4.5%	affecting the right lobe,
	resection for NSCLC of	mortality	PN – 12.6%	as SL has better long- and
	involving the right upper		(P=0.07)	short-term results
	lobe. SL – n=66,
	PN – n=151	Postoperative	SL – 28.8%
		complications	PN – 29.9%
			(P=0.88)

		Locoregional	SL – 4.5%
		recurrence	PN – 7.6%
			(P=0.15)


Lausberg et al.,	This paper is a	Two-year	SL – 61.9%	This study shows that SL
2005, Ann Thorac	retrospective review of one	survival	PN – 56.1%	is a good option in
Surg, Germany,	department's experience		(P=NS)	treating centrally located
[16]	of lung resections for			lung tumours, as you get
	bronchogenic carcinoma	Operative	SL – 1.2%	similar outcomes as PN
Level 2b	from October 1995 to June	mortality	PN – 7.5%	without the
	1999. 422 lung resections		(P<0.03)	complications. They
	where performed, with			currently state that local
	regards to this best	Bronchial	SL – 0%	recurrence rates are
	evidence topic there 81 SLs	complications	PN – 7.5%	similar between the two
	and 40 PNs performed		(P<0.001)	procedures, however,
				they have only followed
		Local disease	SL – 4.3%	their study group up for
		recurrence	PN – 9.1%	two years, so further
			(P=NS)	follow-up will be needed
				for a definitive answer

Author, date and country,	Patient group	Outcomes	Key results	Comments
Study type
(level of evidence)
Ma et al., 2007,	Twelve studies were	Five-year overall	Extracted from 10 studies:	This meta-analysis
Eur J Cardiothorac	identified with a combined	survival	SL group – 50.3%	showed that SL can be
Surg, China, [2]	total of 2984 subjects. 876		PN group – 30.6%	carried out instead of a
	underwent SL and 2108			PN without increasing
Level 2a	underwent PN	One-year survival	Extracted from 10 studies:	the morbidity and
			reported as a risk difference	mortality in appropriate
			of 0.10 (95% CI: 0.07–0.18)	patients
			in favour of a SL	SL has been shown to
				offer better long-term
		Postoperative	Reported in 12 studies:	survival
		mortality	SL 3.5% (31/876), PN 5.7%
			(121/2108).
			(OR: 0.65; 95% CI:
			0.42–1.01)

		Postoperative	Reported in eight studies:
		complications	SL – 31.3% (154/492)
			PN – 31.6% (245/776)
			(OR: 1.01; 95% CI:
			0.70–1.44)

		Locoregional	SL – 16.1% (72/447)
		recurrence	PN – 27.8% (402/1443)
			(OR: 0.91; 95% CI:
			0.45–1.82)

Ferguson and	Twelve studies were	Five-year	SL – 52.4%	The meta-analysis
Lehman, 2003,	identified: 860 underwent	survival	PN – 48.7%	showed that SL has a
Ann Thorac Surg,	SL and 746 underwent PN			better long-term survival
USA, [3]		Operative	SL – 4.1% (CI: 2.3–5.9%)	and quality of life than
		mortality	PN – 6.0% (CI: 1–11%)	PN in patients with early
Level 2a			(P=0.3)	stage lung cancer. SL has
				also been shown to be
		Local/regional	The likelihood of isolated	more cost effective than
		recurrence	local/regional recurrence:	PN
			SL – 20%
			PN – 10%

		QALYS	SL – 4.37
			PN – 2.48

Melloul et al., 2008,	Retrospective single	30-day	Patients <70 years of age:	This study also showed
Interact	institution analysis of	mortality	SL – 0%, PN – 3% (P=0.5)	that PN resulted in a
CardioVasc Thorac	patients undergoing SL or			higher postoperative loss
Surg, Switzerland,	PN between 2000 and		Patients >70 years of age:	of FEV₁ than SL. The
[4]	2005. 78 patients		SL – 0%, PN – 15%	study, therefore,
	underwent PN (65 patients		(P=0.2)	suggests that SL has a
Level 2b	<70 years of age in PN			therapeutic advantage
	group) and 69 underwent	Overall	Patients aged <70 years of	over PN
	SL. (50 patients <70 years	complication	age: SL – 44%, PN – 26%
	of age in SL group)	rate	(P=0.05)

			Patients >70 years of age:
			SL – 32%, PN – 23%
			(P=0.7)

Okada et al., 2000,	The study compared the	Ten-year	SL – 36%	This study shows SL to
J Thorac	outcomes of SL to PN in	survival	PN – 21%	be more beneficial than
Cardiovasc Surg,	patients with NSCLC.			PN in all areas studied.
Japan, [5]	151 patients underwent SL	Five-year	SL – 48%	The study, therefore,
	and 50 underwent PN. For	survival	PN – 29%	suggests that SL should
Level 2b	bias reduction in			be performed in all
	comparison with a	Three-year	SL – 61%	patients with NSCLC
	non-randomized control	survival	PN – 36%	regardless of their nodal
	group, they generated the			status as long as total
	results by pairing 60 SL	30-day	SL – 0%	resection is achievable
	patients with 60 PN	mortality	PN – 2%
	patients


		Postoperative	SL – 13%
		complication	PN – 22%

		Local	SL – 8%
		recurrence	PN – 10%

Martin-Ucar et al.,	This was a prospective	One-year survival	SL – 73% (±8%)	As the study progressed
2002, Eur J	study looking at a 119		PN – 64% (±5%)	the number of PN being
Cardiothorac Surg,	consecutive patients			done decreased. The
UK, [6]	operated on by a single	30-day	SL – 10.5% (4/38)	study shows that SL can
	surgeon. 81 patients	mortality	PN – 9.9% (8/81)	be carried out in a large
Level 2b	underwent PN and			number of patients with
	38 underwent	FEV₁	Mean perioperative loss of	NSCLC of a main stem
	bronchoplastic∓angioplastic		FEV₁:	bronchus allowing for
	procedure (SL)		SL – 170 (range=0–500) ml	better long-term
			PN – 620	outcomes, while
			(range=200–1400) ml	preserving more lung
			(P=0.0003)	function

Kim et al., 2005,	This retrospective study	Ten-year	SL – 45.5%	This study suggests that
Ann Thorac Surg,	reviewed all the patients	survival	PN – 45.3%	SL should only be carried
Korea, [7]	with primary NSCLC who			out in selected patients,
	were operated on at Seoul	Five-year	SL – 59.5%	such as those that do not
Level 2b	National University Hospital	survival	PN – 53.7%	have positive lymph
	between January 1989 and			nodes, as SL has a higher
	December 1998. 200 PN	Three-year	SL – 63.8%	recurrence rate. For this
	were carried out and	survival	PN – 63.0%	patient group they
	49 SL			recommend using SL
		Early	SL – 51%	over PN as SL does not
		postoperative	PN – 35%	effect survival outcomes
		complications

		Operative	SL – 6.1%
		mortality	PN – 4.1%

		Recurrence	SL – 57%
			PN – 30%

Ludwig et al.,	This retrospective study	Overall five-year	SL – 39%	The study concluded that
2005, Ann Thorac	analysed the outcome of	survival	PN – 27%	SL should be performed
Surg, Germany, [8]	310 patients who		(P=0.0129)	whenever possible over
	underwent SL or PN for			PN due to its superior
Level 2b	NSCLC (stages I–IIIA)	Three-year	SL – 47.4%	outcomes in all areas
	between 1987 and 1997.	survival	PN – 37.1%
	116 patients had a SL and
	194 patients had a PN	One-year survival	SL – 72.4%
			PN – 62.9%

		30-day	SL – 4.3%
		mortality	PN – 4.6%

		Postoperative	SL – 44 complications
		complications	PN – 50 complications

Takeda et al., 2006,	This was a retrospective	Overall five-year	SL – 53.4%	Based on their results,
Eur J Cardiothorac	study, comparing surgical	survival	PN – 32.9%	this study concluded
Surg, Japan, [9]	results after SL and PN for		(P=0.0028)	there was no difference
	NSCLC over 20 years in			in morbidity, mortality
Level 2b	one institution. Results	Five-year	No statistical difference:	and overall survival
	generated from analysing	Survival in	SL – n=45	between each procedure
	outcomes of	stage I and II	PN – n=38
	62 consecutive SLs to	patients
	110 consecutive PNs
		30-day	SL – 1.6%
		postoperative	PN – 1.8%
		mortality

		Hospital deaths	SL – 4.8%
			PN – 3.6%

		Local	SL – 9.7%
		recurrence	PN – 10.9%

		Distant	SL – 29.0%
		recurrence	PN – 42.7%

Gaissert et al.,	The study analysed the	Actuarial	SL – 42±6.5%	The study confirmed that
1996, J Thorac	outcomes of SLs and PNs	survival at	PN – 44±7.3%	SL is the first choice
Cardiovasc Surg,	carried out at	Five-year		procedure where the lung
USA, [10]	Massachusetts General			cancer is anatomically
	Hospital. The study	Actuarial	SL – 80±4.8%	suited for this procedure.
Level 2b	compared 72 patients	survival at	PN – 76±5.9%	They concluded survival
	undergoing SL between	One-year		is acceptable and is
	1962 and 1991 with			comparable with PN. The
	56 patients that	Hospital	SL – 4%	study suggests a better
	underwent PN between	mortality	PN – 9%	quality of life is expected
	1986 and 1990			with a SL due to the
		Major	SL – 11%	preservation of
		complications	PN – 16%	functioning lung

Yoshino et al.,	Retrospective study	Three-year	SL – 65.7%	The study concluded that
1997, J Surg	comparing 29 SL patients	disease-free	PN – 58.8%	an SL should be
Oncol, Japan, [11]	between 1977 and 1993, to	survival		performed whenever
	29 PN patients selected			feasible for centrally
Level 2b	according to set criteria	Operation-	SL – 0%	located lung cancer. This
	from 129 PNs performed.	related	PN – 6.9%	was due to the operation
	There was no differences	mortality	(P<0.05)	being safer and just as
	observed between the two			curable as a PN for lung
	groups regarding stage,	Postoperative	SL – 13.7%	cancer as no statistical
	histological population, or	complications	PN – 24.1%	significance was seen
	age. Operations were		(P<0.05)	between recurrence
	carried out at the			rates
	Department of Chest	Local	SL – n=3
	Surgery, National Kyushu	recurrence	PN – n=6
	Cancer Center
		Distant	SL – n=6
		metastases	PN – n=7

Suen et al., 1999,	Department retrospective	Overall five-year	SL for NSCLC – 37.5%	This study suggests SL
Ann Thorac Surg,	review of their experience	actuarial	SL for low grade – 100%	should be standard
USA, [12]	of SL and PN for NSCLC,	survival	PN for NSCLC – 35.8%	procedure for patients
	and SL for low grade			with low grade malignant
Level 2b	malignancy between	Operative	SL for NSCLC – 5.2%	tumour involving the
	January 1988 and	mortality	SL for low grade – 0%	main bronchus, as SL
	September 1998. 77 SL: 58		PN for NSCLC – 4.9%	conserves lung
	for NSCLC and 19 for low			parenchyma and have
	grade malignancies. 142			excellent short- and
	PN for NSCLC			long-term outcomes.
				They also conclude SL is
				a good alternative for PN
				for patients with NSCLC
				involving the main
				bronchus, as the
				outcomes are similar

Ghiribelli et al.,	This retrospective study	Overall five-year	SL – 38%	This study confirms SL,
2002, J Cardiovasc	analyses the outcomes of	survival	PN – 25%	when performed in
Surg (Torino),	patients with NSCLC		(P=0.03)	selected patients with
Italy, [13]	which underwent SL or			NSCLC, provides at least
	PN at The University	30-day	SL – 5.2%	similar long-term
Level 2b	Hospital of Siena. (January	postoperative	PN – 3.9%	outcomes as PN. As lung
	1990–December 1995.)	mortality		parenchyma is reserved
	38 patients underwent SL,			SL should be first choice
	127 patients underwent	Postoperative	SL – 23.6%
	PN	complications	PN – 23.2%

		Local	SL – 5.2%
		recurrence	PN – 4.8%


Deslauriers et al.,	A single institution analysed	Five-year	SL – 52%	This study concluded
2004, Ann Thorac	the survival and recurrence	actuarial	PN – 31%	that SL is effective and
Surg, Canada, [14]	rates in 1230 consecutive	survival	(P<0.0001)	can be accomplished
	patients with NSCLC who			safely in patients with
Level 2b	underwent PN (n=1046)	Five-year	SL – 58%	resectable NSCLC. They
	or SL (n=184). From	actuarial	PN – 33%	showed that SL has
	January 1972 to	survival	(P=0.021)	better outcomes for
	December 2000	(patients		survival, lower mortality
		with complete		rates and lower
		resection)		locoregional recurrence

		Operative	SL – 1.3%
		mortality	PN – 5.3%
			(P=0.036)

		Locoregional	SL – 22%
		recurrence	PN – 35%

Bagan et al., 2005,	This retrospective study	Five-year	SL – 72.5%	This study concludes that
Ann Thorac Surg,	analysed the outcomes of	actuarial	PN – 53.2%	SL where possible is a
France, [15]	surgery carried out on	survival	(P=0.0025)	safer option than PN for
	patients between 1984 and			patients with NSCLC
Level 2b	2002 who underwent lung	Operative	SL – 4.5%	affecting the right lobe,
	resection for NSCLC of	mortality	PN – 12.6%	as SL has better long- and
	involving the right upper		(P=0.07)	short-term results
	lobe. SL – n=66,
	PN – n=151	Postoperative	SL – 28.8%
		complications	PN – 29.9%
			(P=0.88)

		Locoregional	SL – 4.5%
		recurrence	PN – 7.6%
			(P=0.15)


Lausberg et al.,	This paper is a	Two-year	SL – 61.9%	This study shows that SL
2005, Ann Thorac	retrospective review of one	survival	PN – 56.1%	is a good option in
Surg, Germany,	department's experience		(P=NS)	treating centrally located
[16]	of lung resections for			lung tumours, as you get
	bronchogenic carcinoma	Operative	SL – 1.2%	similar outcomes as PN
Level 2b	from October 1995 to June	mortality	PN – 7.5%	without the
	1999. 422 lung resections		(P<0.03)	complications. They
	where performed, with			currently state that local
	regards to this best	Bronchial	SL – 0%	recurrence rates are
	evidence topic there 81 SLs	complications	PN – 7.5%	similar between the two
	and 40 PNs performed		(P<0.001)	procedures, however,
				they have only followed
		Local disease	SL – 4.3%	their study group up for
		recurrence	PN – 9.1%	two years, so further
			(P=NS)	follow-up will be needed
				for a definitive answer

SL, sleeve lobectomy; PN, pneumonectomy; NSCLC, non-small cell lung cancer; CI, confidence interval.

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Table 1.

Best evidence papers

Author, date and country,	Patient group	Outcomes	Key results	Comments
Study type
(level of evidence)
Ma et al., 2007,	Twelve studies were	Five-year overall	Extracted from 10 studies:	This meta-analysis
Eur J Cardiothorac	identified with a combined	survival	SL group – 50.3%	showed that SL can be
Surg, China, [2]	total of 2984 subjects. 876		PN group – 30.6%	carried out instead of a
	underwent SL and 2108			PN without increasing
Level 2a	underwent PN	One-year survival	Extracted from 10 studies:	the morbidity and
			reported as a risk difference	mortality in appropriate
			of 0.10 (95% CI: 0.07–0.18)	patients
			in favour of a SL	SL has been shown to
				offer better long-term
		Postoperative	Reported in 12 studies:	survival
		mortality	SL 3.5% (31/876), PN 5.7%
			(121/2108).
			(OR: 0.65; 95% CI:
			0.42–1.01)

		Postoperative	Reported in eight studies:
		complications	SL – 31.3% (154/492)
			PN – 31.6% (245/776)
			(OR: 1.01; 95% CI:
			0.70–1.44)

		Locoregional	SL – 16.1% (72/447)
		recurrence	PN – 27.8% (402/1443)
			(OR: 0.91; 95% CI:
			0.45–1.82)

Ferguson and	Twelve studies were	Five-year	SL – 52.4%	The meta-analysis
Lehman, 2003,	identified: 860 underwent	survival	PN – 48.7%	showed that SL has a
Ann Thorac Surg,	SL and 746 underwent PN			better long-term survival
USA, [3]		Operative	SL – 4.1% (CI: 2.3–5.9%)	and quality of life than
		mortality	PN – 6.0% (CI: 1–11%)	PN in patients with early
Level 2a			(P=0.3)	stage lung cancer. SL has
				also been shown to be
		Local/regional	The likelihood of isolated	more cost effective than
		recurrence	local/regional recurrence:	PN
			SL – 20%
			PN – 10%

		QALYS	SL – 4.37
			PN – 2.48

Melloul et al., 2008,	Retrospective single	30-day	Patients <70 years of age:	This study also showed
Interact	institution analysis of	mortality	SL – 0%, PN – 3% (P=0.5)	that PN resulted in a
CardioVasc Thorac	patients undergoing SL or			higher postoperative loss
Surg, Switzerland,	PN between 2000 and		Patients >70 years of age:	of FEV₁ than SL. The
[4]	2005. 78 patients		SL – 0%, PN – 15%	study, therefore,
	underwent PN (65 patients		(P=0.2)	suggests that SL has a
Level 2b	<70 years of age in PN			therapeutic advantage
	group) and 69 underwent	Overall	Patients aged <70 years of	over PN
	SL. (50 patients <70 years	complication	age: SL – 44%, PN – 26%
	of age in SL group)	rate	(P=0.05)

			Patients >70 years of age:
			SL – 32%, PN – 23%
			(P=0.7)

Okada et al., 2000,	The study compared the	Ten-year	SL – 36%	This study shows SL to
J Thorac	outcomes of SL to PN in	survival	PN – 21%	be more beneficial than
Cardiovasc Surg,	patients with NSCLC.			PN in all areas studied.
Japan, [5]	151 patients underwent SL	Five-year	SL – 48%	The study, therefore,
	and 50 underwent PN. For	survival	PN – 29%	suggests that SL should
Level 2b	bias reduction in			be performed in all
	comparison with a	Three-year	SL – 61%	patients with NSCLC
	non-randomized control	survival	PN – 36%	regardless of their nodal
	group, they generated the			status as long as total
	results by pairing 60 SL	30-day	SL – 0%	resection is achievable
	patients with 60 PN	mortality	PN – 2%
	patients


		Postoperative	SL – 13%
		complication	PN – 22%

		Local	SL – 8%
		recurrence	PN – 10%

Martin-Ucar et al.,	This was a prospective	One-year survival	SL – 73% (±8%)	As the study progressed
2002, Eur J	study looking at a 119		PN – 64% (±5%)	the number of PN being
Cardiothorac Surg,	consecutive patients			done decreased. The
UK, [6]	operated on by a single	30-day	SL – 10.5% (4/38)	study shows that SL can
	surgeon. 81 patients	mortality	PN – 9.9% (8/81)	be carried out in a large
Level 2b	underwent PN and			number of patients with
	38 underwent	FEV₁	Mean perioperative loss of	NSCLC of a main stem
	bronchoplastic∓angioplastic		FEV₁:	bronchus allowing for
	procedure (SL)		SL – 170 (range=0–500) ml	better long-term
			PN – 620	outcomes, while
			(range=200–1400) ml	preserving more lung
			(P=0.0003)	function

Kim et al., 2005,	This retrospective study	Ten-year	SL – 45.5%	This study suggests that
Ann Thorac Surg,	reviewed all the patients	survival	PN – 45.3%	SL should only be carried
Korea, [7]	with primary NSCLC who			out in selected patients,
	were operated on at Seoul	Five-year	SL – 59.5%	such as those that do not
Level 2b	National University Hospital	survival	PN – 53.7%	have positive lymph
	between January 1989 and			nodes, as SL has a higher
	December 1998. 200 PN	Three-year	SL – 63.8%	recurrence rate. For this
	were carried out and	survival	PN – 63.0%	patient group they
	49 SL			recommend using SL
		Early	SL – 51%	over PN as SL does not
		postoperative	PN – 35%	effect survival outcomes
		complications

		Operative	SL – 6.1%
		mortality	PN – 4.1%

		Recurrence	SL – 57%
			PN – 30%

Ludwig et al.,	This retrospective study	Overall five-year	SL – 39%	The study concluded that
2005, Ann Thorac	analysed the outcome of	survival	PN – 27%	SL should be performed
Surg, Germany, [8]	310 patients who		(P=0.0129)	whenever possible over
	underwent SL or PN for			PN due to its superior
Level 2b	NSCLC (stages I–IIIA)	Three-year	SL – 47.4%	outcomes in all areas
	between 1987 and 1997.	survival	PN – 37.1%
	116 patients had a SL and
	194 patients had a PN	One-year survival	SL – 72.4%
			PN – 62.9%

		30-day	SL – 4.3%
		mortality	PN – 4.6%

		Postoperative	SL – 44 complications
		complications	PN – 50 complications

Takeda et al., 2006,	This was a retrospective	Overall five-year	SL – 53.4%	Based on their results,
Eur J Cardiothorac	study, comparing surgical	survival	PN – 32.9%	this study concluded
Surg, Japan, [9]	results after SL and PN for		(P=0.0028)	there was no difference
	NSCLC over 20 years in			in morbidity, mortality
Level 2b	one institution. Results	Five-year	No statistical difference:	and overall survival
	generated from analysing	Survival in	SL – n=45	between each procedure
	outcomes of	stage I and II	PN – n=38
	62 consecutive SLs to	patients
	110 consecutive PNs
		30-day	SL – 1.6%
		postoperative	PN – 1.8%
		mortality

		Hospital deaths	SL – 4.8%
			PN – 3.6%

		Local	SL – 9.7%
		recurrence	PN – 10.9%

		Distant	SL – 29.0%
		recurrence	PN – 42.7%

Gaissert et al.,	The study analysed the	Actuarial	SL – 42±6.5%	The study confirmed that
1996, J Thorac	outcomes of SLs and PNs	survival at	PN – 44±7.3%	SL is the first choice
Cardiovasc Surg,	carried out at	Five-year		procedure where the lung
USA, [10]	Massachusetts General			cancer is anatomically
	Hospital. The study	Actuarial	SL – 80±4.8%	suited for this procedure.
Level 2b	compared 72 patients	survival at	PN – 76±5.9%	They concluded survival
	undergoing SL between	One-year		is acceptable and is
	1962 and 1991 with			comparable with PN. The
	56 patients that	Hospital	SL – 4%	study suggests a better
	underwent PN between	mortality	PN – 9%	quality of life is expected
	1986 and 1990			with a SL due to the
		Major	SL – 11%	preservation of
		complications	PN – 16%	functioning lung

Yoshino et al.,	Retrospective study	Three-year	SL – 65.7%	The study concluded that
1997, J Surg	comparing 29 SL patients	disease-free	PN – 58.8%	an SL should be
Oncol, Japan, [11]	between 1977 and 1993, to	survival		performed whenever
	29 PN patients selected			feasible for centrally
Level 2b	according to set criteria	Operation-	SL – 0%	located lung cancer. This
	from 129 PNs performed.	related	PN – 6.9%	was due to the operation
	There was no differences	mortality	(P<0.05)	being safer and just as
	observed between the two			curable as a PN for lung
	groups regarding stage,	Postoperative	SL – 13.7%	cancer as no statistical
	histological population, or	complications	PN – 24.1%	significance was seen
	age. Operations were		(P<0.05)	between recurrence
	carried out at the			rates
	Department of Chest	Local	SL – n=3
	Surgery, National Kyushu	recurrence	PN – n=6
	Cancer Center
		Distant	SL – n=6
		metastases	PN – n=7

Suen et al., 1999,	Department retrospective	Overall five-year	SL for NSCLC – 37.5%	This study suggests SL
Ann Thorac Surg,	review of their experience	actuarial	SL for low grade – 100%	should be standard
USA, [12]	of SL and PN for NSCLC,	survival	PN for NSCLC – 35.8%	procedure for patients
	and SL for low grade			with low grade malignant
Level 2b	malignancy between	Operative	SL for NSCLC – 5.2%	tumour involving the
	January 1988 and	mortality	SL for low grade – 0%	main bronchus, as SL
	September 1998. 77 SL: 58		PN for NSCLC – 4.9%	conserves lung
	for NSCLC and 19 for low			parenchyma and have
	grade malignancies. 142			excellent short- and
	PN for NSCLC			long-term outcomes.
				They also conclude SL is
				a good alternative for PN
				for patients with NSCLC
				involving the main
				bronchus, as the
				outcomes are similar

Ghiribelli et al.,	This retrospective study	Overall five-year	SL – 38%	This study confirms SL,
2002, J Cardiovasc	analyses the outcomes of	survival	PN – 25%	when performed in
Surg (Torino),	patients with NSCLC		(P=0.03)	selected patients with
Italy, [13]	which underwent SL or			NSCLC, provides at least
	PN at The University	30-day	SL – 5.2%	similar long-term
Level 2b	Hospital of Siena. (January	postoperative	PN – 3.9%	outcomes as PN. As lung
	1990–December 1995.)	mortality		parenchyma is reserved
	38 patients underwent SL,			SL should be first choice
	127 patients underwent	Postoperative	SL – 23.6%
	PN	complications	PN – 23.2%

		Local	SL – 5.2%
		recurrence	PN – 4.8%


Deslauriers et al.,	A single institution analysed	Five-year	SL – 52%	This study concluded
2004, Ann Thorac	the survival and recurrence	actuarial	PN – 31%	that SL is effective and
Surg, Canada, [14]	rates in 1230 consecutive	survival	(P<0.0001)	can be accomplished
	patients with NSCLC who			safely in patients with
Level 2b	underwent PN (n=1046)	Five-year	SL – 58%	resectable NSCLC. They
	or SL (n=184). From	actuarial	PN – 33%	showed that SL has
	January 1972 to	survival	(P=0.021)	better outcomes for
	December 2000	(patients		survival, lower mortality
		with complete		rates and lower
		resection)		locoregional recurrence

		Operative	SL – 1.3%
		mortality	PN – 5.3%
			(P=0.036)

		Locoregional	SL – 22%
		recurrence	PN – 35%

Bagan et al., 2005,	This retrospective study	Five-year	SL – 72.5%	This study concludes that
Ann Thorac Surg,	analysed the outcomes of	actuarial	PN – 53.2%	SL where possible is a
France, [15]	surgery carried out on	survival	(P=0.0025)	safer option than PN for
	patients between 1984 and			patients with NSCLC
Level 2b	2002 who underwent lung	Operative	SL – 4.5%	affecting the right lobe,
	resection for NSCLC of	mortality	PN – 12.6%	as SL has better long- and
	involving the right upper		(P=0.07)	short-term results
	lobe. SL – n=66,
	PN – n=151	Postoperative	SL – 28.8%
		complications	PN – 29.9%
			(P=0.88)

		Locoregional	SL – 4.5%
		recurrence	PN – 7.6%
			(P=0.15)


Lausberg et al.,	This paper is a	Two-year	SL – 61.9%	This study shows that SL
2005, Ann Thorac	retrospective review of one	survival	PN – 56.1%	is a good option in
Surg, Germany,	department's experience		(P=NS)	treating centrally located
[16]	of lung resections for			lung tumours, as you get
	bronchogenic carcinoma	Operative	SL – 1.2%	similar outcomes as PN
Level 2b	from October 1995 to June	mortality	PN – 7.5%	without the
	1999. 422 lung resections		(P<0.03)	complications. They
	where performed, with			currently state that local
	regards to this best	Bronchial	SL – 0%	recurrence rates are
	evidence topic there 81 SLs	complications	PN – 7.5%	similar between the two
	and 40 PNs performed		(P<0.001)	procedures, however,
				they have only followed
		Local disease	SL – 4.3%	their study group up for
		recurrence	PN – 9.1%	two years, so further
			(P=NS)	follow-up will be needed
				for a definitive answer

Author, date and country,	Patient group	Outcomes	Key results	Comments
Study type
(level of evidence)
Ma et al., 2007,	Twelve studies were	Five-year overall	Extracted from 10 studies:	This meta-analysis
Eur J Cardiothorac	identified with a combined	survival	SL group – 50.3%	showed that SL can be
Surg, China, [2]	total of 2984 subjects. 876		PN group – 30.6%	carried out instead of a
	underwent SL and 2108			PN without increasing
Level 2a	underwent PN	One-year survival	Extracted from 10 studies:	the morbidity and
			reported as a risk difference	mortality in appropriate
			of 0.10 (95% CI: 0.07–0.18)	patients
			in favour of a SL	SL has been shown to
				offer better long-term
		Postoperative	Reported in 12 studies:	survival
		mortality	SL 3.5% (31/876), PN 5.7%
			(121/2108).
			(OR: 0.65; 95% CI:
			0.42–1.01)

		Postoperative	Reported in eight studies:
		complications	SL – 31.3% (154/492)
			PN – 31.6% (245/776)
			(OR: 1.01; 95% CI:
			0.70–1.44)

		Locoregional	SL – 16.1% (72/447)
		recurrence	PN – 27.8% (402/1443)
			(OR: 0.91; 95% CI:
			0.45–1.82)

Ferguson and	Twelve studies were	Five-year	SL – 52.4%	The meta-analysis
Lehman, 2003,	identified: 860 underwent	survival	PN – 48.7%	showed that SL has a
Ann Thorac Surg,	SL and 746 underwent PN			better long-term survival
USA, [3]		Operative	SL – 4.1% (CI: 2.3–5.9%)	and quality of life than
		mortality	PN – 6.0% (CI: 1–11%)	PN in patients with early
Level 2a			(P=0.3)	stage lung cancer. SL has
				also been shown to be
		Local/regional	The likelihood of isolated	more cost effective than
		recurrence	local/regional recurrence:	PN
			SL – 20%
			PN – 10%

		QALYS	SL – 4.37
			PN – 2.48

Melloul et al., 2008,	Retrospective single	30-day	Patients <70 years of age:	This study also showed
Interact	institution analysis of	mortality	SL – 0%, PN – 3% (P=0.5)	that PN resulted in a
CardioVasc Thorac	patients undergoing SL or			higher postoperative loss
Surg, Switzerland,	PN between 2000 and		Patients >70 years of age:	of FEV₁ than SL. The
[4]	2005. 78 patients		SL – 0%, PN – 15%	study, therefore,
	underwent PN (65 patients		(P=0.2)	suggests that SL has a
Level 2b	<70 years of age in PN			therapeutic advantage
	group) and 69 underwent	Overall	Patients aged <70 years of	over PN
	SL. (50 patients <70 years	complication	age: SL – 44%, PN – 26%
	of age in SL group)	rate	(P=0.05)

			Patients >70 years of age:
			SL – 32%, PN – 23%
			(P=0.7)

Okada et al., 2000,	The study compared the	Ten-year	SL – 36%	This study shows SL to
J Thorac	outcomes of SL to PN in	survival	PN – 21%	be more beneficial than
Cardiovasc Surg,	patients with NSCLC.			PN in all areas studied.
Japan, [5]	151 patients underwent SL	Five-year	SL – 48%	The study, therefore,
	and 50 underwent PN. For	survival	PN – 29%	suggests that SL should
Level 2b	bias reduction in			be performed in all
	comparison with a	Three-year	SL – 61%	patients with NSCLC
	non-randomized control	survival	PN – 36%	regardless of their nodal
	group, they generated the			status as long as total
	results by pairing 60 SL	30-day	SL – 0%	resection is achievable
	patients with 60 PN	mortality	PN – 2%
	patients


		Postoperative	SL – 13%
		complication	PN – 22%

		Local	SL – 8%
		recurrence	PN – 10%

Martin-Ucar et al.,	This was a prospective	One-year survival	SL – 73% (±8%)	As the study progressed
2002, Eur J	study looking at a 119		PN – 64% (±5%)	the number of PN being
Cardiothorac Surg,	consecutive patients			done decreased. The
UK, [6]	operated on by a single	30-day	SL – 10.5% (4/38)	study shows that SL can
	surgeon. 81 patients	mortality	PN – 9.9% (8/81)	be carried out in a large
Level 2b	underwent PN and			number of patients with
	38 underwent	FEV₁	Mean perioperative loss of	NSCLC of a main stem
	bronchoplastic∓angioplastic		FEV₁:	bronchus allowing for
	procedure (SL)		SL – 170 (range=0–500) ml	better long-term
			PN – 620	outcomes, while
			(range=200–1400) ml	preserving more lung
			(P=0.0003)	function

Kim et al., 2005,	This retrospective study	Ten-year	SL – 45.5%	This study suggests that
Ann Thorac Surg,	reviewed all the patients	survival	PN – 45.3%	SL should only be carried
Korea, [7]	with primary NSCLC who			out in selected patients,
	were operated on at Seoul	Five-year	SL – 59.5%	such as those that do not
Level 2b	National University Hospital	survival	PN – 53.7%	have positive lymph
	between January 1989 and			nodes, as SL has a higher
	December 1998. 200 PN	Three-year	SL – 63.8%	recurrence rate. For this
	were carried out and	survival	PN – 63.0%	patient group they
	49 SL			recommend using SL
		Early	SL – 51%	over PN as SL does not
		postoperative	PN – 35%	effect survival outcomes
		complications

		Operative	SL – 6.1%
		mortality	PN – 4.1%

		Recurrence	SL – 57%
			PN – 30%

Ludwig et al.,	This retrospective study	Overall five-year	SL – 39%	The study concluded that
2005, Ann Thorac	analysed the outcome of	survival	PN – 27%	SL should be performed
Surg, Germany, [8]	310 patients who		(P=0.0129)	whenever possible over
	underwent SL or PN for			PN due to its superior
Level 2b	NSCLC (stages I–IIIA)	Three-year	SL – 47.4%	outcomes in all areas
	between 1987 and 1997.	survival	PN – 37.1%
	116 patients had a SL and
	194 patients had a PN	One-year survival	SL – 72.4%
			PN – 62.9%

		30-day	SL – 4.3%
		mortality	PN – 4.6%

		Postoperative	SL – 44 complications
		complications	PN – 50 complications

Takeda et al., 2006,	This was a retrospective	Overall five-year	SL – 53.4%	Based on their results,
Eur J Cardiothorac	study, comparing surgical	survival	PN – 32.9%	this study concluded
Surg, Japan, [9]	results after SL and PN for		(P=0.0028)	there was no difference
	NSCLC over 20 years in			in morbidity, mortality
Level 2b	one institution. Results	Five-year	No statistical difference:	and overall survival
	generated from analysing	Survival in	SL – n=45	between each procedure
	outcomes of	stage I and II	PN – n=38
	62 consecutive SLs to	patients
	110 consecutive PNs
		30-day	SL – 1.6%
		postoperative	PN – 1.8%
		mortality

		Hospital deaths	SL – 4.8%
			PN – 3.6%

		Local	SL – 9.7%
		recurrence	PN – 10.9%

		Distant	SL – 29.0%
		recurrence	PN – 42.7%

Gaissert et al.,	The study analysed the	Actuarial	SL – 42±6.5%	The study confirmed that
1996, J Thorac	outcomes of SLs and PNs	survival at	PN – 44±7.3%	SL is the first choice
Cardiovasc Surg,	carried out at	Five-year		procedure where the lung
USA, [10]	Massachusetts General			cancer is anatomically
	Hospital. The study	Actuarial	SL – 80±4.8%	suited for this procedure.
Level 2b	compared 72 patients	survival at	PN – 76±5.9%	They concluded survival
	undergoing SL between	One-year		is acceptable and is
	1962 and 1991 with			comparable with PN. The
	56 patients that	Hospital	SL – 4%	study suggests a better
	underwent PN between	mortality	PN – 9%	quality of life is expected
	1986 and 1990			with a SL due to the
		Major	SL – 11%	preservation of
		complications	PN – 16%	functioning lung

Yoshino et al.,	Retrospective study	Three-year	SL – 65.7%	The study concluded that
1997, J Surg	comparing 29 SL patients	disease-free	PN – 58.8%	an SL should be
Oncol, Japan, [11]	between 1977 and 1993, to	survival		performed whenever
	29 PN patients selected			feasible for centrally
Level 2b	according to set criteria	Operation-	SL – 0%	located lung cancer. This
	from 129 PNs performed.	related	PN – 6.9%	was due to the operation
	There was no differences	mortality	(P<0.05)	being safer and just as
	observed between the two			curable as a PN for lung
	groups regarding stage,	Postoperative	SL – 13.7%	cancer as no statistical
	histological population, or	complications	PN – 24.1%	significance was seen
	age. Operations were		(P<0.05)	between recurrence
	carried out at the			rates
	Department of Chest	Local	SL – n=3
	Surgery, National Kyushu	recurrence	PN – n=6
	Cancer Center
		Distant	SL – n=6
		metastases	PN – n=7

Suen et al., 1999,	Department retrospective	Overall five-year	SL for NSCLC – 37.5%	This study suggests SL
Ann Thorac Surg,	review of their experience	actuarial	SL for low grade – 100%	should be standard
USA, [12]	of SL and PN for NSCLC,	survival	PN for NSCLC – 35.8%	procedure for patients
	and SL for low grade			with low grade malignant
Level 2b	malignancy between	Operative	SL for NSCLC – 5.2%	tumour involving the
	January 1988 and	mortality	SL for low grade – 0%	main bronchus, as SL
	September 1998. 77 SL: 58		PN for NSCLC – 4.9%	conserves lung
	for NSCLC and 19 for low			parenchyma and have
	grade malignancies. 142			excellent short- and
	PN for NSCLC			long-term outcomes.
				They also conclude SL is
				a good alternative for PN
				for patients with NSCLC
				involving the main
				bronchus, as the
				outcomes are similar

Ghiribelli et al.,	This retrospective study	Overall five-year	SL – 38%	This study confirms SL,
2002, J Cardiovasc	analyses the outcomes of	survival	PN – 25%	when performed in
Surg (Torino),	patients with NSCLC		(P=0.03)	selected patients with
Italy, [13]	which underwent SL or			NSCLC, provides at least
	PN at The University	30-day	SL – 5.2%	similar long-term
Level 2b	Hospital of Siena. (January	postoperative	PN – 3.9%	outcomes as PN. As lung
	1990–December 1995.)	mortality		parenchyma is reserved
	38 patients underwent SL,			SL should be first choice
	127 patients underwent	Postoperative	SL – 23.6%
	PN	complications	PN – 23.2%

		Local	SL – 5.2%
		recurrence	PN – 4.8%


Deslauriers et al.,	A single institution analysed	Five-year	SL – 52%	This study concluded
2004, Ann Thorac	the survival and recurrence	actuarial	PN – 31%	that SL is effective and
Surg, Canada, [14]	rates in 1230 consecutive	survival	(P<0.0001)	can be accomplished
	patients with NSCLC who			safely in patients with
Level 2b	underwent PN (n=1046)	Five-year	SL – 58%	resectable NSCLC. They
	or SL (n=184). From	actuarial	PN – 33%	showed that SL has
	January 1972 to	survival	(P=0.021)	better outcomes for
	December 2000	(patients		survival, lower mortality
		with complete		rates and lower
		resection)		locoregional recurrence

		Operative	SL – 1.3%
		mortality	PN – 5.3%
			(P=0.036)

		Locoregional	SL – 22%
		recurrence	PN – 35%

Bagan et al., 2005,	This retrospective study	Five-year	SL – 72.5%	This study concludes that
Ann Thorac Surg,	analysed the outcomes of	actuarial	PN – 53.2%	SL where possible is a
France, [15]	surgery carried out on	survival	(P=0.0025)	safer option than PN for
	patients between 1984 and			patients with NSCLC
Level 2b	2002 who underwent lung	Operative	SL – 4.5%	affecting the right lobe,
	resection for NSCLC of	mortality	PN – 12.6%	as SL has better long- and
	involving the right upper		(P=0.07)	short-term results
	lobe. SL – n=66,
	PN – n=151	Postoperative	SL – 28.8%
		complications	PN – 29.9%
			(P=0.88)

		Locoregional	SL – 4.5%
		recurrence	PN – 7.6%
			(P=0.15)


Lausberg et al.,	This paper is a	Two-year	SL – 61.9%	This study shows that SL
2005, Ann Thorac	retrospective review of one	survival	PN – 56.1%	is a good option in
Surg, Germany,	department's experience		(P=NS)	treating centrally located
[16]	of lung resections for			lung tumours, as you get
	bronchogenic carcinoma	Operative	SL – 1.2%	similar outcomes as PN
Level 2b	from October 1995 to June	mortality	PN – 7.5%	without the
	1999. 422 lung resections		(P<0.03)	complications. They
	where performed, with			currently state that local
	regards to this best	Bronchial	SL – 0%	recurrence rates are
	evidence topic there 81 SLs	complications	PN – 7.5%	similar between the two
	and 40 PNs performed		(P<0.001)	procedures, however,
				they have only followed
		Local disease	SL – 4.3%	their study group up for
		recurrence	PN – 9.1%	two years, so further
			(P=NS)	follow-up will be needed
				for a definitive answer

SL, sleeve lobectomy; PN, pneumonectomy; NSCLC, non-small cell lung cancer; CI, confidence interval.

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6. Results

Ma et al. [2] performed a meta-analysis of 12 studies in 2007, they showed that a sleeve lobectomy can be carried out instead of pneumonectomy without increasing morbidity and mortality. They in fact found that sleeve lobectomy has a better long-term survival, their results for survival were generated from 10 papers with nearly 3000 patients. At one year, a risk difference of 0.10 [95% confidence interval (CI): 0.07–0.18] was reported in favour of the sleeve lobectomy group. They reported a five-year survival of 50.3% in the sleeve lobectomy group compared to 30.6% in the pneumonectomy group.

Ferguson and Lehman [3] also carried out a meta-analysis on 12 studies. They showed that sleeve lobectomy is associated with better long-term survival and quality of life than pneumonectomy in patients with early stage lung cancer. This was particularly evident from the quality adjusted life years quoted which were 4.37 for sleeve lobectomy and 2.48 for the pneumonectomy group.

Melloul et al. [4] carried out a retrospective study which suggested sleeve lobectomy has a therapeutic advantage over pneumonectomy. This was due to sleeve lobectomies resulting in a higher postoperative FEV₁ than pneumonectomies. They also highlighted that sleeve lobectomy gave more favourable outcomes in overall complication rate and 30-day mortality.

A prospective study carried out by Martin-Ucar et al. [6] reported similar, favourable results for sleeve lobectomy with regards to preservation of FEV₁ [FEV₁ loss sleeve lobectomy 170 ml (range=0–500 ml), pneumonectomy 620 ml (range=200–1400 ml) P<0.0003] and 30-day mortality.

Okada et al. [5] and Ludwig et al. [8], concluded that sleeve lobectomy should be carried out over pneumonectomy whenever technically possible. Both of their studies demonstrated that sleeve lobectomy has a better survival rate and a lower complication rate. Kim et al. [7] also had similar results, but restricted their recommendation for sleeve lobectomy to patients with negative lymph nodes as they found a higher local recurrence rate in the sleeve lobectomy group.

Takeda et al. [9], Gaissert et al. [10] and Ghiribelli et al. [13] found sleeve lobectomy and pneumonectomy to have similar outcomes for survival and complication rate. They all, however, recommend sleeve lobectomy to be the first choice procedure wherever possible as there is preservation of lung parenchyma and therefore a better lung function and quality of life. Suen et al. [12] found similar outcomes between the two procedures when the NSCLC affected the main bronchus, although with low-grade tumours, they found sleeve lobectomy patients to have far superior short- and long-term outcomes.

Yoshino et al. [11] found sleeve lobectomy to be safer than pneumonectomy with lower postoperative complications [sleeve lobectomy – 13.7%, pneumonectomy – 24.1% (P<0.05)] and operative-related mortality [sleeve lobectomy – 0%, pneumonectomy – 6.9% (P<0.05)]. They found no statistical difference in recurrence rate between the two procedures.

Deslauriers et al. [14] and Bagan et al. [15] found sleeve lobectomy to be the safer option for patients suffering from resectable NSCLC as it gives better survival (P=0.021 and P=0.0025, respectively) and lower mortality rates. They also discovered sleeve lobectomy to have a lower locoregional recurrence than pneumonectomy.

Lausberg et al. [16] found sleeve lobectomy to be a better option than pneumonectomy as the bronchial complications were 0% and 7.5%, respectively (P<0.001). All other outcomes were found to be similar, however, they identified that to give a definitive answer on local recurrence they needed a longer follow-up.

7. Clinical bottom line

Results from two meta-analyses and the 13 largest cohort studies on this subject, presented in this paper conclusively show improved survival, reduced loss in lung function, improved operative mortality and in most cases no difference in locoregional recurrence. In the biggest meta-analysis of nearly 3000 patients, the five-year survival was 50% for sleeve lobectomy compared to 30% for pneumonectomy. Operative mortality was 3% vs. 6% for pneumonectomy, and locoregional recurrence 17% vs. 30%. These results are broadly consistent across all the cohort studies.

There are significant issues in all cohort studies on this subject, as due to their non-randomized nature, the reason for not performing a sleeve resection may well have been more advanced disease in many of these cases, which would necessarily mean that the pneumonectomy patients would have a lower expected survival and higher local recurrence. In addition, there have been many large cohort studies to date and thus no more are required as this issue could not be overcome in the future. Thus, the only study that would adequately correct for this issue would be a randomized trial, but to prove a 10% increase in five-year survival a 300 patient study is needed. This is bigger than any cohort study ever done in this area and some centres took up to 30 years to collect these numbers of potential sleeve patients, thus we conclude that an RCT is not a realistic possibility. Therefore, we conclude that no more cohort studies should be performed, as the results will be consistent with the meta-analyses and an RCT to eliminate their bias is unattainable, and thus no more research should be done on this topic and surgeons should use the figures presented above to govern their management in the future.

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Article Contents

Is a sleeve lobectomy significantly better than a pneumonectomy?

Abstract

1. Introduction

2. Three-part question

3. Clinical scenario

4. Search strategy

5. Search outcome

6. Results

7. Clinical bottom line

References

Citations

Views

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Article Contents

Is a sleeve lobectomy significantly better than a pneumonectomy?

Abstract

1. Introduction

2. Three-part question

3. Clinical scenario

4. Search strategy

5. Search outcome

6. Results

7. Clinical bottom line

References

Citations

Views

Altmetric

Email alerts

Related articles in

Citing articles via

Latest

Most Read

Most Cited

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