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Ann Thorac Surg 1995;60:645
© 1995 The Society of Thoracic Surgeons
Centre Chirurgical Marie Lannelongue, 133 Avenue de la Resistance, 92350 Le Plessis Robinson, France
Doctor Massard and colleagues reported a large experience and examine the value of an operation about which little has been published. They raised the main questions about the place of bilobectomy for bronchogenic carcinomas: the operative risk and the carcinologic value of such resection and the functional value of the remaining lobe.
They observed an increased rate of morbidity (49%) in comparison with standard lobectomy, generally related to pleural space problems. Most of the complications resolved with medical treatment or tube thoracostomy, but 8 patients had to be reexplored (3 with bleeding, 2 with venous infarctions of the right upper lobe, and 3 with pleural space problems including 2 empyemas). Only 1 bronchopleural fistula developed, and the mortality rate was 3.5%, which seems acceptable and lower than the mortality rate after pneumonectomy in their experience. As a result, from this point of view, bilobectomy could be recommended if long-term results are also satisfactory. The third point is the least controversial, even if Massard and colleagues emphasized the absence of extensive information regarding the functional value of the remaining lobe: some years ago, we [1] tested 21 bilobectomy patients with radionuclide perfusion scan and found that all remaining lobes were functional with a mean perfusion of 24% ± 10%.
The most controversial question concerns the carcinologic value of bilobectomy. I do not agree with Massard and associates, who consider bilobectomy a compromise between carcinologically radical resection and preservation of functional lung tissue and not as a radical standard resection like lobectomies or pneumonectomies.
If lobectomy is considered the gold standard treatment for bronchogenic carcinomas, even in patients with N1 disease, bilobectomy should be considered a radical resection in most instances. In fact, the main indications of bilobectomy are the involvement of bronchial truncus intermedius or fissure. Considering the carcinologic aspect of lung resection, I believe that there is no significant difference between tumors arising from intermedius or right lower bronchus, in case of similar TNM staging. Besides, a left upper lobectomy for a peripheral tumor involving both culmen and lingula is, in my opinion, equivalent to a right upper and middle bilobectomy for a peripheral tumor involving the minor fissure. Thus, bilobectomy must be considered a radical procedure in the cases described above, especially in patients without lymph node involvement after systematic lymphadenectomy.
The most critical situation for deciding between bilobectomy and pneumonectomy concerns patients with N1 involvement of the bronchial truncus intermedius. Nevertheless, a similar circumstance exists in patients with peripheral tumor and N1 involvement against the right lower bronchus; these patients are generally treated by lobectomy in a curative attempt.
Massard and associates reported a poor survival in stage I patients (5 year survival rate, 41%) with a high locoregional rate which was explained by understaging. Massard and associates' demonstration is not convincing; in fact, the poor prognosis of these patients could simply be related to the high incidence of T2 N0 (61% stage I patients) and to the presence of 4 patients with double synchronous primary lung cancers who had a far worse prognosis. Such an incidence in a small group of patients may explain a poorer survival than expected. Furthermore, the 5-year survival rates for patients with stage II and III disease were, as expected, 50% and 17%, respectively. These patients did not seem to be understaged; as a result, it is difficult to believe that only patients with stage I disease were understaged.
On the other hand, even if pneumonectomy is effectively the alternative in patients requiring bilobectomy, in a carcinologic concept it should be better to compare locoregional recurrence rates after bilobectomies and lobectomies with similar TNM staging rather than bilobectomies and pneumonectomies. In fact the question is, should bilobectomy could be considered a radical resection like lobectomy for more proximal lesion (bronchial truncus intermedius) or for fissure involvement?
Finally, according to Massard and associates' series and to the literature, bilobectomy could be recommended in patients with disabled functional status contraindicating pneumonectomy with a good chance of curative treatment. On the other hand, for patients with good pulmonary reserve, surgical indication of bilobectomy remains controversial and only a prospective, randomized study could resolve this problem. Such a study should be stratified according to TNM staging and should be focused on either postoperative risk or oncologic results.
Reference
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