Is the initial feasibility of lobectomy for stage I non-small cell lung cancer in severe heterogeneous emphysema justified by long-term survival?

Abstract

Background: The feasibility of anatomical lobectomy in patients with bronchial carcinoma in an area of severe heterogeneous emphysema whose respiratory reserve is outside operability guidelines has previously been confirmed. A review was undertaken to determine whether this approach is justified by long-term survival. Methods: A single surgeon's 8 year experience of 118 consecutive patients (74 men) of median age 70 years (range 45-84) who underwent upper lobectomy for pathological stage I non-small cell lung cancer (NSCLC) was reviewed. The preoperative characteristics, perioperative course and survival of the 27 cases with severe heterogeneous emphysema of apical distribution and a predicted postoperative forced expiratory volume in 1 s (ppoFEV 1 ) of ,40% (lobarLVRS group) were compared with the remaining 91 cases with a ppoFEV 1 of .40% (control group). Results: Postoperative mortality was 1 of 27 in the lobarLVRS group and 2 of 91 in the control group (p = NS). Five-year survival in the lobarLVRS group was 35% compared with 65% in the control group without concomitant severe emphysema (p = 0.001), although rates of tumour recurrence were similar. Conclusions: Long-term survival after lobarLVRS for stage I lung cancer is limited by physiological rather than oncological factors. However, outcomes are still better than those reported for any other modality of treatment in this group of high-risk patients. This finding justifies the decision to offer lobectomy in these selected cases.

Lung cancer surgery in the breathless patient — the benefits of avoiding the gold standard☆

“…For upper lobe tumours, a lobectomy would achieve both oncological control and symptomatic benefit through the volume reduction effect. The feasibility of a lobar volume reduction strategy, using the open approach to yield worthwhile long-term outcomes, has been previously demonstrated [6,8]. The current study takes this further and demonstrates the feasibility of 'VATS lobar LVRS' for lung cancer.…”

Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery

“…Several studies have demonstrated that low values for morbidity (about 15%-25%) and mortality (about 1%-15%) can be obtained, even in subjects with severe reduction in airfl ow; mean preoperative FEV 1 in these studies ranges from 26% to 45% predicted. 103,128,129 Note that these values for preoper ative FEV 1 were frequently below the threshold recommended for postoperative lung function, highlighting that surgery can be performed safely in selected patients with markedly abnormal lung function at baseline. The surgical techniques used in these studies varied and included limited wedge or segment resections, a combination of resection with lung volume reduction, and both open and video-assisted thoracoscopic approaches.…”

“…40; mean, 61%), the survival was still better than expected if resection had not been performed. 128 In addition, Lau et al 129 reported favorable results in patients with severe COPD when resection was performed using video-assisted thoracic surgery (VATS). In this study, improvements were also noted in both hospital mortality (8% vs 14%) and long-term survival (5-year survival, 48% vs 18%) with VATS compared with thoracotomy.…”

“…Long-term survival has been analyzed in subjects with severe airfl ow limitation undergoing surgical resection of lung tumors. Martin-Ucar et al 128 evaluated 5-year survival in patients with upper-lobe stage I e175S the expected and observed survival in subjects who did not undergo surgery. Although the results of this study are encouraging, applicability to all clinical centers would be limited based on availability of CPET.…”

Lung emphysema and lung cancer: what do we know about it?

“…This same group, Sanchez-Salcedo et al, reported the results of 14 years of experience of the P-IELCAP screening programme. Across this period, 60 LCs were diagnosed in 53 (36) studied the amount of emphysema and airway wall thickness in quantitative CT, and analysed whether this was related to a higher risk of cancer: quantitative chest CT scans and spirometry performed on 947 subjects with history of smoking habit drawn from the GenKOLS study (37) showed that risk of cancer increased with greater emphysema severity [low attenuation area (LAA) ≥10%: OR =3.33; 95% CI, 1.04-10.61 for LC, and OR =2.10; 95% CI, 1.14-3.87 for non-pulmonary cancer] but not with airway wall thickness (OR =0.39; 95% CI, 0.12-1.29 for LC, and OR =0.82; 95% CI, 042-1.59 for non-LC).…”