SESSION TYPE: Thoracic Surgery II
PRESENTED ON: Tuesday, October 23, 2012 at 04:30 PM - 05:45 PM
PURPOSE: Hilar tumors present significant surgical and oncological challenges, particularly in cases where pneumonectomy may be required. Nonetheless, tumors with clinical N0 status mandate surgical consideration. Our objective was to evaluate the clinical outcome of patients undergoing pneumonectomy compared with lobectomy (with or without bronchoplasty) for clinical stage IB-IIB lung cancers.
METHODS: 253 patients (60 pneumonectomies, 70 sleeve resections, 123 lobectomies) with clinical stage IB-IIB NSCLC based on CT radiographic hilar involvement were evaluated. Mean tumor size was 4.7 cm. Outcome variables included morbidity, mortality, recurrence and survival. Comparisons between groups were performed utilizing the t-test and Fisher’s exact test. Overall and recurrence-free survival estimates were performed utilizing the Kaplan-Maier method.
RESULTS: The pneumonectomy group was younger than the sleeve resection (63.4 vs. 66.0, p=0.15) and lobectomy groups (63.4 vs. 68.4, p=0.001), and were more commonly of male gender (p=0.020). Perioperative mortality was higher in the pneumonectomy group at both 30 (6.7% vs. 1.4% vs. 0.8%) and 90 (13.3% vs. 5.7% vs. 2.4%) days when compared to sleeve resection and lobectomy. Mean follow-up was 28.7, 26.6 and 31.6 months for pneumonectomy, sleeve resection and lobectomy, respectively. Recurrence-free survival was similar between groups (Pneumonectomy - 26% vs. Sleeve Resection - 34% vs. Lobectomy - 44%), though there was a trend favoring lobectomy [p>0.077]. Pneumonectomy was associated with reduced overall survival when compared to lobectomy (30% vs. 40% at 5 years, p=0.040). An increased rate of tumor upstaging was observed in the pneumonectomy patients (30%) when compared to sleeve resection (22.8% and lobectomy (22.0%). By comparison, peripheral Stage IB-IIB tumors (n=307) resected at our institution during this same time period were associated with a significantly increased survival (55% vs. 33% at 5 years, p=0.026).
CONCLUSIONS: Large, hilar, clinically N0 malignancies have differential outcomes unique to their anatomic location, especially when compared to more peripheral tumors. However, this group has a higher perioperative mortality and oncologic risk of recurrence regardless of procedure performed.
CLINICAL IMPLICATIONS: Mature surgical expertise and judgment is required to promote the appropriate use of lobectomy or sleeve resection rather than reflexively employing pneumonectomy for hilar tumors, although this approach may be necessary for selected patients.
DISCLOSURE: The following authors have nothing to disclose: Matthew Schuchert, Ryan Macke, Ghulam Abbas, Andre Pitanga, Joshua Landreneau, Omar Awais, Arjun Pennathur, Peter Ferson, Neil Christie, James Luketich, Jill Siegfried, David Wilson, Rodney Landreneau
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