Bronchovascular Reconstruction for Lung Cancer: Does Induction Chemotherapy Influence the Outcomes?

doi:10.1016/j.athoracsur.2012.05.050

The Annals of Thoracic Surgery

Volume 94, Issue 3, September 2012, Pages 907-913

Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.

https://doi.org/10.1016/j.athoracsur.2012.05.050 Get rights and content

Background

Bronchoangioplastic interventions (BAIs) for lung cancer are challenging procedures associated with a high risk of postoperative morbidity and mortality. The role of induction chemotherapy (IC) in these patients is debated.

Methods

We reviewed clinical records of patients who underwent a BAI between 1998 and 2009 using a prospective clinical and operative database.

Results

Among 47 patients (39 men; mean age, 66 years) who underwent BAI, 26 (55.3%) received IC for N2 disease or for locally advanced lung cancer. We performed 35 pulmonary artery (PA) sleeve resections (31 partial and 4 circumferential), 10 PA reconstructions with a pericardial patch (8 autologous, and 2 heterologous), and 2 PA reconstructions using heterologous conduit. The 30-day mortality rate was 4.2% (n = 2). Morbidity occurred in 19 (40.4%) patients; 5 patients (10.6%) had major complications (3 [6.4%] patients with fatal bronchovascular fistulas and 1 patient each with cardiac dislocation and acute respiratory distress syndrome) (2.2%). Fourteen patients (29.8%) had minor complications: 6 (12.7%) cardiac, 7 (14.9%) pulmonary, and 1 (2.2%) stroke. IC did not influence the complication rate. Overall 5-year survival and disease-free survival was 39.2% and 36.9%, respectively. Early pathologic stage and the absence of nodal involvement significantly influenced survival (p = 0.005 and p = 0.002, respectively). Patients receiving IC had a better prognosis (62.7% versus 10.7%; p = 0.0003). At multivariate analysis, IC influenced long-term survival (p = 0.003 [95% CI, 2.92–8.56]).

Conclusions

BAIs are feasible and effective surgical procedures with acceptable morbidity and mortality. IC does not influence morbidity and allows good long-term outcomes.

Section snippets

Patients and Methods

We performed a retrospective analysis of a prospective database of patients with lung cancer who underwent BAI from September 1998 to August 2009 at the Division of Thoracic Surgery of the European Institute of Oncology in Milan, Italy. Institutional review board approval was obtained in order to perform this retrospective investigation.

The following data were collected from the clinical charts and operating reports: sex, age, induction therapy, type of sleeve resection (right upper sleeve

Results

Forty-seven patients with lung cancer underwent bronchovascular resection and reconstruction during the study period. The study population included 39 male and 7 female patients with a median age of 66 years (range, 26–80 years) (Table 1).

Ten patients (21.3%) were older than 70 years, and 83% (n = 39) were current or former smokers. Twelve patients (25.5%) had a history of cardiovascular disease, and 11 (23.4%) had a history of pulmonary disease.

Mean preoperative FEV₁ was 77.40% ± 18.81%; 20

Comment

Despite the advances that have been made in the multimodal therapy of lung cancer, surgical therapy still remains the most important tool if cure is attempted. Complete resection of NSCLC, if possible, not only removes all malignant tissue but also improves long-term survival. The completeness and extent of resection directly correlates with the probability of tumor recurrence and survival [12] as well as with perioperative morbidity and mortality [12, 13].

The preservation of pulmonary tissue

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From 2000 to 2018, 9 different surgeons performed 34 pulmonary arterial resections for primary or metastatic pulmonary malignancy, with independent determination of pneumonectomy candidacy and arterioplasty technique. Patients undergoing limited lateral stapled PA resection (n = 3) or resection for metastasis (n = 3) were excluded from survival analysis.
The PA was resected as a sleeve with primary anastomosis (14.7%) or noncircumferentially with primary (61.8%), stapled (8.8%), or patch (14.7%) closure. Arterial resections represented between 2.5% and 43% of each surgeon’s pneumonectomy volume. Sixteen (47%) patients were candidates for pneumonectomy. There was no operative mortality and 1 death at 47 days. Postoperative complications occurred in 21 (61.8%) patients. No patient required completion pneumonectomy. Overall 5-year survival was 33% (95% confidence interval [CI], 12-53). Compared with pulmonary arterioplasty alone, patients undergoing bronchial sleeve resection and pulmonary arterioplasty had better disease-free 5-year survival (50% [95% CI, 18-82] vs 19% [95% CI, 5-43]; P = .04), higher complete resection rate (100% [95% CI, 83-100] vs 80% [95% CI, 56-94]; P = .23) and lower disease recurrence (8% [n = 1 of 13] vs 47% [n = 7 of 15]; P = .04); 80% of disease recurrence was distant.
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Original articleGeneral thoracicBronchovascular Reconstruction for Lung Cancer: Does Induction Chemotherapy Influence the Outcomes?

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Original article
General thoracic
Bronchovascular Reconstruction for Lung Cancer: Does Induction Chemotherapy Influence the Outcomes?