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Department of Thoracic Surgery, Thoraxklinik, The University of Heidelberg, Amalienstrasse 5, Heidelberg, D-69126 Germany
(Email: hans.hoffmann{at}urz.uni-heidelberg.de).
The authors retrospectively analyzed a case series of 159 sleeve resections for non-small cell cancer (NSCLC) performed in a single institution during a 21-year time period [1]. The report includes patients that underwent sleeve lobectomy with and without prior neoadjuvant (induction) chemotherapy. Their findings indicate that induction chemotherapy does not affect postoperative complications, and that good long-term outcomes were obtained after bronchial sleeve resection for lung cancer.
Overall, this is informative and useful. However, as is the case with all retrospective studies over a long time period, this study is also facing significant challenges subject to uncontrolled selection bias. Various chemotherapy regimens were used and staging underwent technological evolution during the long study period.
Moreover, stressing the advantages of sleeve resections in comparison with pneumonectomy seems obsolete. This is well known and generally accepted in cases with a given option for a sleeve resection [2, 3]. It may be misleading to suggest that in any case a pneumonectomy can be avoided. This is clearly not the case. During the reported study period, 1,077 pneumonectomies for NSCLC were performed at the author's institution reflecting a ratio of 7 pneumonectomies to 1 sleeve resection. In specialized centers this ratio is usually in the range of 0.5 to 2 pneumonectomies to 1 sleeve resection. It would have been of interest if the authors could have demonstrated a reduction in the rate of pneumonectomy over a specific time period based on the use of sleeve lobectomy.
Throughout their comments, the authors are consistently arguing that chemotherapy-induced downstaging allowed sleeve resections and helped avoid pneumonectomies. However, this conclusion cannot be reached from the data presented. Because all of their resection margins were free of disease and 72% of their patients had an incomplete pathologic response to chemotherapy, sleeve resections could have also been performed in these patients prior to chemotherapy. It is an ongoing discussion within the thoracic surgery community, whether induction chemotherapy can reduce the extent of resection required. Unfortunately, the data presented in this study do not add relevant news to this discussion.
In general (with all its limitations), this study is useful in that it confirms that a sleeve lobectomy can be performed safely with minimal complications with a multi-modality approach in the treatment of lung cancer.
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