HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Paul E. Van Schil Paul J. Knaepen Dominique J. Goossens Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Van Schil, P. E. Articles by van den Bosch, J. M. Search for Related Content PubMed PubMed Citation Articles by Van Schil, P. E. Articles by van den Bosch, J. M.

Ann Thorac Surg 1996;61:1087-1091
© 1996 The Society of Thoracic Surgeons

---

Original Article: General Thoracic

Long-Term Survival After Bronchial Sleeve Resection: Univariate and Multivariate Analyses

Departments of Thoracic Surgery and Pulmonary Medicine, Antonius Hospital, Nieuwegein, the Netherlands, and Department of Thoracic Surgery, University Hospital of Antwerp, Edegem, Belgium

Accepted for publication December 14, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. Long-term results after bronchial sleeve resection remain controversial, especially in relation to nodal involvement. In a previous report, there were no 10-year survivors among patients with N1 or N2 disease.

Methods. From 1960 to 1989, 145 patients underwent bronchial sleeve resection for a bronchogenic tumor. Follow-up was updated until the end of 1994, so the minimum follow-up was 5 years for surviving patients. A univariate analysis and a multivariate analysis were performed.

Results. For the whole group, 5-year, 10-year, and 15-year survival rates were 46%, 33%, and 22%, respectively. The median survival time was 53 months. Five-year and 10-year survival rates for the 71 patients with N0 disease were 62% and 51%, respectively; for the 58 patients with N1 disease, 31% and 10%; and for the 16 patients with N2 disease, 5-year and 7-year survival rates were 31% and 13%. There was a highly significant difference in survival between patients with N0 and N1 or N2 disease but not between those with N1 and N2 disease. Multivariate analysis showed only nodal stage and patient age to be significant factors in relation to survival.

Conclusions. Long-term results after bronchial sleeve resection are influenced chiefly by nodal stage. A significantly lower survival is found in patients with N1 and N2 disease, and most of these patients die of distant metastases.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
In select cases of bronchogenic carcinoma, sleeve lobectomy is a valid alternative to pneumonectomy with the advantage of preservation of functional lung parenchyma. In 1991, we [1] reported the results of 145 bronchial sleeve resections performed for bronchogenic tumors in the Antonius Hospital, Utrecht and Nieuwegein, the Netherlands, from 1960 to 1989. There were no 10-year survivors among the patients with N1 or N2 disease, a result consistent with earlier findings [2] but in contrast to other series [3, 4]. Follow-up was updated until the end of 1994, so minimum follow-up was 5 years for surviving patients. A univariate analysis and a multivariate analysis were performed to determine significant factors related to survival, with special emphasis on nodal involvement.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
From 1960 to 1989, a full bronchial sleeve resection, ie, removal of a circumferential part of the bronchus and bronchial end-to-end anastomosis, was performed in 145 patients. Patients having bronchial wedge excision or sleeve pneumonectomy were excluded. These 145 patients represent our total experience with bronchial sleeve resection for lung tumors during that period [1]. There were 132 men (91.0%) and 13 women (9.0%). Mean age was 60.3 ± 11.8 years (range, 22 to 80 years).

Preoperatively a cervical mediastinoscopy was performed in 128 patients (88.3%). Most of the 17 patients (11.7%) who did not have mediastinoscopy had carcinoid tumors. In 139 patients, a sleeve lobectomy was performed, on the right side in 119 and on the left side in 20. The most common procedure was sleeve lobectomy of the right upper lobe (117 patients, 80.7%). Six patients (4.1%) underwent a full sleeve resection of the main bronchus without resection of lung parenchyma, on the left side in 4 and on the right side in 2. In 9 patients (6.2%), a concomitant procedure on the pulmonary artery was performed: four sleeve resections, four wedge excisions, and one transection and reanastomosis of the pulmonary artery to facilitate bronchial access during sleeve resection of the right main bronchus.

Histologic examination of the resected specimen showed squamous cell carcinoma in 116 patients (80.0%), carcinoid tumor in 13 (9.0%), adenocarcinoma or adenosquamous carcinoma in 9 (6.2%), and other malignant diagnoses in the remaining 7 patients (4.8%).

All 145 patients were staged according to the most recent TNM classification [5]. Results are given in Table 1. Stage I disease was found in 61 patients (42.1%), stage II in 47 (32.4%), stage IIIA in 33 (22.8%), and stage IIIB in 4 (2.8%). The 58 patients with N1 disease were subdivided into those with N1 proximal disease (16 patients) (metastatic lymph nodes present between the upper lobe and main bronchus) and those with N1 distal disease (42 patients) (more peripheral lymph nodes involved).

Information was gathered from the files of the patients followed in our institution, and for the others, follow-up data were obtained from the referring pulmonary physicians. Survival rates were calculated and analyzed using SPSS version 6.1 for Windows (SPSS Inc, Chicago, IL). Survival curves were obtained according to the Kaplan-Meier actuarial method, and all causes of death were included. Survival between subgroups was compared with the log-rank test or Tarone-Ware test. Multivariate analysis was performed according to the Cox proportional hazards model. A stepwise forward logistic regression method was used. Eleven variables were entered into this model: age, sex, histology, nodal status, stage, concomitant procedure on pulmonary artery, completion pneumonectomy, diagnosis of second primary lung cancer, compromised lung function, side of tumor, and location of tumor.

A ² test with continuity correction where necessary was used for rectangular contingency tables. A p value of less than 0.05 was considered significant. Where appropriate, 95% confidence intervals (CI) were mentioned.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Follow-up was completed at the end of 1994, so minimum follow-up for surviving patients was 5 years. One patient was lost to follow-up 223 months after sleeve resection. Mean follow-up for all patients was 67.0 ± 5.2 months and for surviving patients, 115.5 ± 8.9 months. Maximum follow-up was 266 months.

Operative mortality was 4.8% (7 patients) and was included in the survival data [1]. The actuarial survival rate for all 145 patients was 0.46 ± 0.04 after 5 years, 0.33 ± 0.04 after 10 years, and 0.22 ± 0.05 after 15 years (Fig 1). Median survival time (MST) was 53 months (95% CI, 32 to 74 months). During follow-up, 102 patients (70.3%) died. Causes of death are listed in Table 2. At the end of follow-up, 43 patients (29.7%) were alive with no evidence of disease.

View larger version (8K): [in this window] [in a new window]   Fig 1. . Actuarial survival curve for 145 patients undergoing bronchial sleeve resection.

Regarding lymph node involvement, MST for the 71 patients with N0 disease was 124 months (95% CI, 86 to 162 months). Five-year, 10-year, and 15-year survival rates were 0.62 ± 0.06, 0.51 ± 0.06, and 0.34 ± 0.07, respectively (Fig 2). For the 58 patients with N1 disease, MST was 36 months (95% CI, 23 to 49 months), and 5-year and 10-year survival rates were 0.31 ± 0.06 and 0.10 ± 0.08, respectively. Median survival time for the 16 patients with N2 disease was 15 months (95% CI, 12 to 18 months), and 5-year and 7-year survival rates were 0.31 ± 0.12 and 0.13 ± 0.08, respectively. A highly significant difference was found between N0 and N1 disease (p = 0.0002) and between N0 and N2 disease (p < 0.0001) but not between N1 and N2 disease (p = 0.11).

View larger version (11K): [in this window] [in a new window]   Fig 2. . Actuarial survival curves with reference to lymph node involvement. (—= N0; • • • = N1; -• -= N2.)

Survival by stage for all 145 patients is given in Table 3. There was a significant difference between stage I and stage II disease (p = 0.0019) and between stage I and stage IIIB disease (p = 0.0034) but not between the other disease stages. There was no significant difference in survival between patients with T2 and T3 tumors (p = 0.17), compromised and noncompromised lung function (p = 0.21), right-sided and left-sided tumors (p = 0.82), upper and lower lobe tumors (p = 0.27), and concomitant procedure on pulmonary artery and no procedure (p = 0.98). There was a trend toward significance between male and female patients (p = 0.07 by log-rank test and p = 0.09 by Tarone-Ware test).

View larger version (11K): [in this window] [in a new window]   Fig 3. . Actuarial survival curves with reference to histologic type. (-• -= carcinoid; –= combined adenocarcinoma and adenosquamous carcinoma; —= squamous.)

Causes of death were analyzed by nodal category (Table 4). Among the different N groups, there was no difference in local recurrence rate as a cause of death (p > 0.25). However, comparing distant metastases between N0 disease and the two other subgroups, the difference was highly significant (p < 0.005).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Sleeve lobectomy has evolved as an alternative to pneumonectomy in carefully selected patients with bronchial carcinoma, especially those with centrally located lesions. It can be applied in 5% to 8% of patients with a resectable pulmonary malignancy [7]. Long-term results after sleeve lobectomy demonstrate that it is appropriate for curative resection of lung cancer and that it is not a procedure of compromise [8]. In 1987, Faber [9] concluded that sleeve lobectomy should be the procedure of choice whenever technically feasible. Functional lung parenchyma can be preserved, and the reimplanted lobes contribute to postoperative lung function [10]. If a second primary lung cancer develops, subsequent resection may be offered to selected patients [11]. However, sleeve resection is a technically more difficult procedure than a standard resection, and the bronchial or vascular anastomosis can give rise to specific anastomotic complications, which can be life threatening [6, 8, 12].

The review by Tedder and associates [7] published in 1992 included 1,915 patients who underwent bronchoplastic procedures for malignancy over a 12-year period. Sleeve lobectomy was most often performed for squamous cell carcinoma localized to the right upper lobe orifice. In our series, 80.7% of patients had sleeve lobectomy of the right upper lobe and in the recent series of Mehran and associates [4], 65.5%. Thirty-day mortality for sleeve lobectomy in the review by Tedder and co-workers [7] was 5.5%, and causes of death were mainly respiratory failure and cardiac-related events. In our series, operative mortality was 4.8% and in the series of Mehran and colleagues [4], only 2.1%. The review of Tedder and coauthors [7] showed that postoperative complications were mainly pneumonia and atelectasis (15.1%), benign stricture or stenosis (4.8%), bronchopleural fistula (3.0%), and bronchovascular fistula (2.5%). The local recurrence rate after sleeve lobectomy was 12.5% in that series [7], 23% in the series of Mehran and colleagues [4], and 20% (29 patients) in our series with a minimum follow-up of 5 years. Five of those 29 patients underwent completion pneumonectomy.

In the review [7], the 5-year survival rate after sleeve lobectomy for bronchogenic carcinoma was 40%; it was 63% for stage I disease, 37% for stage II disease, and 21% for stage III disease. We found similar results; the overall 5-year survival rate was 46%; 5-year survival was 59% for stage I disease, 30% for stage II disease, 48% for stage IIIA disease, and 25% for stage IIIB disease. Regarding histology, the longest survival was noted among patients with carcinoid tumor with a 15-year survival rate of 100%. This finding is consistent with the 5-year survival rate of 96% found by Tedder and colleagues [7].

The relationship between long-term survival after sleeve lobectomy and lymph node involvement remains controversial. Tedder and co-workers [7] reported a 5-year survival rate of 60% when there was no nodal involvement. In the first report from our institution [2], no 5-year survivors were found among patients with positive hilar lymph nodes. In a subsequent study, we [1] found no 10-year survivors among patients with N1 or N2 disease.

Several other reports analyzing long-term survival in relation to lymph node involvement have been published and are summarized in Table 5. The 5-year survival rate for patients with N1 disease ranges from 0% to 46% and with N2 disease, from 0% to 33%. In contrast to our earlier findings, in the present study with a longer follow-up, we have 10-year survivors among patients with N1 disease. There was a highly significant difference between N0 and N1 or N2 disease but not between N1 and N2 disease.

In the analysis of cause of death by N category, there was no difference in local recurrence rate, but there was a highly significant difference when comparing distant metastases between N0 and N1 or N2 disease. Mehran and coauthors [4] also found no difference in local recurrence rate between N0 and N1 disease but a highly significant difference between N0 and N2 disease (p < 0.001). In our multivariate analysis, nodal stage was the most significant factor related to long-term survival, both N1 and N2 disease having a definitely negative impact. The causes of death in patients with N1 or N2 disease were mainly distant metastases and combined local recurrence and distant metastases: 54.5% for N1 disease and 71.4% for N2 disease in contrast to 27.3% for N0 disease (see Table 4).

Although we have no data to prove this, we do not think that pneumonectomy instead of sleeve lobectomy would have resulted in better survival for patients with N1 or N2 disease, as most patients die of distant metastases. N1 disease is not a contraindication for sleeve resection, but patients with N1 or N2 disease should be regarded as having systemic disease, and adjuvant treatment should be considered. Recently in Europe, the International Adjuvant Lung Cancer Trial was opened to evaluate adjuvant chemotherapy after curative resection of non–small cell lung cancer, mainly to study its impact on long-term survival, local recurrence, and distant metastases.

In conclusion, sleeve lobectomy is a valuable alternative to pneumonectomy in approximately 5% to 8% of patients with operable lung cancer and is mostly performed for centrally located tumors of the upper lobes. Long-term results are influenced chiefly by nodal stage with a significantly lower survival for patients with N1 and N2 disease. As most patients with nodal involvement die of distant metastases, adjuvant treatment should be considered in these instances.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We thank Renelde Ruelle and Monique Van Thienen for typing the manuscript.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Van Schil, Department of Surgery, University Hospital of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

1. Van Schil PE, Brutel de la Rivière A, Knaepen PJ, van Swieten HA, Defauw JJ, van den Bosch JM. TNM staging and long-term follow-up after sleeve resection for bronchogenic tumors. Ann Thorac Surg 1991;52:1096–101.[Abstract]
2. Van den Bosch JMM, Bergstein PGM, Laros CD, Gelissen HJ, Schaepkens van Riempst AL, Wagenaar SS. Lobectomy with sleeve resection in the treatment of tumors of the bronchus. Chest 1981;80:154–7.[Abstract/Free Full Text]
3. Firmin RK, Azariades M, Lennox SC, Lincoln JCR, Paneth M. Sleeve lobectomy (lobectomy and bronchoplasty) for bronchial carcinoma. Ann Thorac Surg 1983;35:442–9.[Abstract]
4. Mehran RJ, Deslauriers J, Piraux M, Beaulieu M, Guimont C, Brisson J. Survival related to nodal status after sleeve resection for lung cancer. J Thorac Cardiovasc Surg 1994;107: 576–83.[Abstract/Free Full Text]
5. Mountain CF. The new international staging system for lung cancer. Surg Clin North Am 1987;67:925–35.[Medline]
6. Van Schil PE, Brutel de la Rivière A, Knaepen PJ, van Swieten HA, Defauw JJ, van den Bosch JM. Completion pneumonectomy after bronchial sleeve resection: incidence, indications, and results. Ann Thorac Surg 1992;53:1042–5.[Abstract]
7. Tedder M, Anstadt MP, Tedder SD, Lowe JE. Current morbidity, mortality, and survival after bronchoplastic procedures for malignancy. Ann Thorac Surg 1992;54:387–91.[Abstract]
8. Faber LP. Sleeve lobectomy. Chest Surg Clin North Am 1995;5:233–51.[Medline]
9. Faber LP. Results of surgical treatment of stage III lung carcinoma with carinal proximity. The role of sleeve lobectomy versus pneumonectomy and the role of sleeve pneumonectomy. Surg Clin North Am 1987;67:1001–14.[Medline]
10. Khargi K, Duurkens VAM, Verzijlbergen FF, Huysmans HA, Knaepen PJ. Pulmonary function after sleeve lobectomy. Ann Thorac Surg 1994;57:1302–4.[Abstract]
11. Van Schil PEY, Brutel de la Rivière A, Knaepen PJ, van Swieten HA, Defauw JJ, van den Bosch JMM. Second primary lung cancer after bronchial sleeve resection. Treatment and results in eleven patients. J Thorac Cardiovasc Surg 1992;104:1451–5.[Abstract]
12. Kawahara K, Akamine S, Takahashi T, et al. Management of anastomotic complications after sleeve lobectomy for lung cancer. Ann Thorac Surg 1994;57:1529–33.[Abstract]
13. Vogt-Moykopf I, Fritz T, Meyer G, Bulzerbruck H, Daskos G. Bronchoplastic and angioplastic operation in bronchial carcinoma: long-term results of a retrospective analysis from 1973 to 1983. Int Surg 1986;71:211–20.[Medline]
14. Naruke T. Bronchoplastic and bronchovascular procedures of the tracheobronchial tree in the management of primary lung cancer. Chest 1989;96:53S–6S.[Free Full Text]

This article has been cited by other articles:

				M. Lucchi, F. Melfi, A. Ribechini, P. Dini, L. Duranti, G. Fontanini, and A. Mussi Sleeve and wedge parenchyma-sparing bronchial resections in low-grade neoplasms of the bronchial airway J. Thorac. Cardiovasc. Surg., August 1, 2007; 134(2): 373 - 377. [Abstract] [Full Text] [PDF]

				J. Lemaitre, Z. Mansour, E. A. Kochetkova, C. Koriche, X. Ducrocq, J.-M. Wihlm, E. Quoix, and G. Massard Bronchoplastic lobectomy: do early results depend on the underlying pathology? A comparison between typical carcinoids and primary lung cancer. Eur. J. Cardiothorac. Surg., July 1, 2006; 30(1): 168 - 171. [Abstract] [Full Text] [PDF]

				C. Ludwig, E. Stoelben, M. Olschewski, and J. Hasse Comparison of Morbidity, 30-Day Mortality, and Long-Term Survival After Pneumonectomy and Sleeve Lobectomy For Non-Small Cell Lung Carcinoma Ann. Thorac. Surg., March 1, 2005; 79(3): 968 - 973. [Abstract] [Full Text] [PDF]

				J. Deslauriers, J. Gregoire, L. F. Jacques, M. Piraux, L. Guojin, and Y. Lacasse Sleeve lobectomy versus pneumonectomy for lung cancer: a comparative analysis of survival and sites or recurrences Ann. Thorac. Surg., April 1, 2004; 77(4): 1152 - 1156. [Abstract] [Full Text] [PDF]

				P. H. Hollaus, P. N. Wurnig, and N. S. Pridun The natural history of recurrence after bronchoplastic procedures for non-small cell lung cancer Ann. Thorac. Surg., August 1, 2003; 76(2): 363 - 369. [Abstract] [Full Text] [PDF]

				F. Chunwei, W. Weiji, Z. Xinguan, N. Qingzen, J. Xiangmin, and Z. Qingzhen Evaluations of bronchoplasty and pulmonary artery reconstruction for bronchogenic carcinoma Eur. J. Cardiothorac. Surg., February 1, 2003; 23(2): 209 - 213. [Abstract] [Full Text] [PDF]

				M. Mezzetti, T. Panigalli, L. Giuliani, F. Raveglia, F. Lo Giudice, and S. Meda Personal experience in lung cancer sleeve lobectomy and sleeve pneumonectomy Ann. Thorac. Surg., June 1, 2002; 73(6): 1736 - 1739. [Abstract] [Full Text] [PDF]

				A. Terzi, A. Lonardoni, G. Falezza, G. Furlan, P. Scanagatta, F. Pasini, and F. Calabro Sleeve lobectomy for non-small cell lung cancer and carcinoids: results in 160 cases Eur. J. Cardiothorac. Surg., May 1, 2002; 21(5): 888 - 893. [Abstract] [Full Text] [PDF]

				A.E. Martin-Ucar, N. Chaudhuri, J.G. Edwards, and D.A. Waller Can pneumonectomy for non-small cell lung cancer be avoided? An audit of parenchymal sparing lung surgery Eur. J. Cardiothorac. Surg., April 1, 2002; 21(4): 601 - 605. [Abstract] [Full Text] [PDF]

				J. Deslauriers Current surgical treatment of nonsmall cell lung cancer 2001 Eur. Respir. J., February 1, 2002; 19(35_suppl): 61S - 70s. [Abstract] [Full Text] [PDF]

				P. Solli, L. Spaggiari, F. Grasso, and U. Pastorino Double prosthetic replacement of pulmonary artery and superior vena cava and sleeve lobectomy for lung cancer Eur. J. Cardiothorac. Surg., November 1, 2001; 20(5): 1045 - 1048. [Abstract] [Full Text] [PDF]

				P. E. Van Schil Sleeve lobectomy and lymph node involvement J. Thorac. Cardiovasc. Surg., February 1, 2001; 121(2): 399 - 399. [Full Text] [PDF]

				F. Tronc, J. Gregoire, J. Rouleau, and J. Deslauriers Long-term results of sleeve lobectomy for lung cancer Eur. J. Cardiothorac. Surg., May 1, 2000; 17(5): 550 - 556. [Abstract] [Full Text] [PDF]

				M. Okada, H. Yamagishi, S. Satake, H. Matsuoka, Y. Miyamoto, M. Yoshimura, and N. Tsubota SURVIVAL RELATED TO LYMPH NODE INVOLVEMENT IN LUNG CANCER AFTER SLEEVE LOBECTOMY COMPARED WITH PNEUMONECTOMY J. Thorac. Cardiovasc. Surg., April 1, 2000; 119(4): 814 - 819. [Abstract] [Full Text] [PDF]

				P. E. Van Schil, J. Vankeirsbilck, A. B. de la Riviere, and J. M. van den Bosch Long-term survival after bronchial sleeve resection in relation to nodal involvement Eur. J. Cardiothorac. Surg., February 1, 2000; 17(2): 196 - 197. [Full Text] [PDF]

				E. A. Rendina, F. Venuta, T. De Giacomo, A. M. Ciccone, M. Moretti, G. Ruvolo, and G. F. Coloni Sleeve resection and prosthetic reconstruction of the pulmonary artery for lung cancer Ann. Thorac. Surg., September 1, 1999; 68(3): 995 - 1001. [Abstract] [Full Text] [PDF]

				Ph. Icard, J.F. Regnard, L. Guibert, P. Magdeleinat, B. Jauffret, and Ph. Levasseur Survival and prognostic factors in patients undergoing parenchymal saving bronchoplastic operation for primary lung cancer: a series of 110 consecutive cases Eur. J. Cardiothorac. Surg., April 1, 1999; 15(4): 426 - 432. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Paul E. Van Schil Paul J. Knaepen Dominique J. Goossens Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Van Schil, P. E. Articles by van den Bosch, J. M. Search for Related Content PubMed PubMed Citation Articles by Van Schil, P. E. Articles by van den Bosch, J. M.