Abstract
Background/Aim: Atypical bronchoplasty is essential for complete tumor removal and preservation of peripheral lung tissue. This study compared surgical outcomes after atypical or typical bronchoplasty in patients who underwent pulmonary sleeve resection with bronchoplasty. Patients and Methods: Typical bronchoplasty was defined as that after one-lobe sleeve resection; atypical bronchoplasty was defined as that after sleeve bilobectomy or sleeve removal of one lobe plus segments. Double-barreled bronchoplasty was also included in the atypical group. Surgical outcomes were retrospectively investigated according to type of bronchoplasty. Results: Fifty-one patients underwent typical bronchoplasty and 20 atypical bronchoplasty. Recurrence was seen in 17 out of 51 (33%) patients after typical bronchoplasty and 10 out of 20 patients (50%) after atypical bronchoplasty. The recurrence-free survival rate was significantly poorer in the atypical bronchoplasty group (p=0.038). However, patients in the atypical bronchoplasty group were able to receive anticancer treatment for tumor recurrence, and there was no significant difference in overall survival rates between the groups. Conclusion: Preservation of pulmonary function by atypical bronchoplasty might contribute to tolerability of anticancer treatment for tumor recurrence. Pulmonary resection with atypical bronchoplasty is reliably beneficial for overall survival.
Sleeve lobectomy with bronchoplasty is essential for complete tumor removal and preservation of peripheral lung tissue in patients with centrally located lung cancer or lung cancer with hilar lymph node metastasis. One-lobe sleeve lobectomy is a typical procedure. Two-lobe or one-lobe plus segments sleeve resection with bronchoplasty is sometimes required to remove the tumor completely and avoid pneumonectomy. Extended sleeve lobectomy is defined as sleeve resection of more than one lobe with airway reconstruction between the main and segmental bronchi (1). Surgical outcomes of extended sleeve lobectomy were investigated in previous studies (2, 3). Atypical bronchoplasty includes several methods other than extended sleeve lobectomy. Additionally, complex airway reconstruction, such as double-barreled bronchoplasty, preserves two lobes that were uninvolved (4, 5). However, surgical outcomes of atypical bronchoplasty were not well investigated in these studies.
The current study investigated surgical outcomes after atypical bronchoplasty compared with typical bronchoplasty in patients who underwent pulmonary sleeve resection with bronchoplasty.
Patients and Methods
Between January 2011 and December 2021, 80 patients with primary lung cancer underwent pulmonary resection with bronchoplasty at Osaka Metropolitan University Hospital, Osaka, Japan. Surgical outcomes according to type of bronchoplasty were investigated. The local Institutional Ethics Committee approved this study (approval no. 4403; approval date, October 3, 2019).
Typical bronchoplasty was defined as that after one-lobe sleeve resection; atypical bronchoplasty was defined as that after sleeve bilobectomy or sleeve removal of one lobe plus segments. Double-barreled bronchoplasty after sleeve lobectomy was also included in the atypical bronchoplasty group. Patients who underwent preoperative treatment followed by surgery were excluded.
Enhanced computed tomography identified mediastinal lymph nodes with a short axis of ≥10 mm that were clinically positive for metastasis. The criteria for selecting patients for surgical resection included the absence of distant metastasis, cancer cell-positive pleural or pericardial effusion, bulky N2 disease, N3 disease, and a predicted postoperative vital capacity of ≥40%. Patients with pathological stage II or III lung cancer underwent adjuvant platinum-based doublet chemotherapy, while patients with stage I lung cancer received oral tegafur–uracil adjuvant chemotherapy.
Bronchoplasty was performed using 4-0 absorbable monofilament sutures. The deepest part was anastomosed using continuous sutures, whereas the other parts were anastomosed using interrupted sutures. To correct caliber mismatch, a large-caliber bronchial stump was sewn with wide pitches, and a small-caliber bronchial stump was sewn with narrow pitches. No other special methods were performed to correct this mismatch. Pericardiotomy around the pulmonary vein was useful to mobilize the preserved lung and avoid severe tension at the anastomotic site. Intraoperative pathological examination confirmed the absence of cancer cell infiltration in bronchial stumps, and each anastomotic site was circumferentially covered with a pedicle pericardial fat pad.
A standard bronchoscopic examination was performed one week postoperatively. When wound healing at the anastomotic site was markedly prolonged, the bronchoscopic examination was repeated until complete healing. Adverse events that occurred within three months postoperatively were evaluated according to the Common Terminology Criteria for Adverse Events (version 5.0) (6). Adverse events greater than grade 3 were recorded. Following discharge, all patients underwent follow-up chest radiographs and tumor marker measurements every 2-4 months. Computed tomographic scans were performed after 6 months and annually thereafter.
Body height and weight were measured at the time of hospital admission. Comorbidities were defined as disorders being treated at the time of primary lung cancer diagnosis. Differences in clinicopathological factors according to type of bronchoplasty were assessed using the Mann–Whitney U-test and chi-squared test. Overall and recurrence-free survival rates were calculated using the Kaplan–Meier method, and survival differences were compared using the log-rank test. A p<0.05 indicated statistical significance. Statistical analyses were performed using JMP version 10 software (SAS Institute, Cary, NC, USA).
Results
Details of the surgical procedures are shown in Table I. There were 51 patients in the typical bronchoplasty group and 20 in the atypical bronchoplasty group. Right upper sleeve lobectomy with bronchoplasty was the most common procedure in the typical bronchoplasty group. Several types of procedures were included in the atypical bronchoplasty group. Three double-barreled bronchoplasties after right lower sleeve lobectomy were included in the atypical bronchoplasty group.
Surgical procedures of patients in this study.
Table II shows the patient characteristics and outcomes according to the type of bronchoplasty. The incidence of complications was higher after atypical bronchoplasty, and the postoperative hospital stay was significantly longer (p=0.012). The opportunity for adjuvant chemotherapy was low in the atypical bronchoplasty group.
Characteristics and outcomes of patients according to the type of bronchoplasty.
Death during hospital stay or treatment-related death was not observed in this study. Overall survival curves after surgery are shown in Figure 1A, and there was no significant difference according to the type of bronchoplasty. However, the recurrence-free survival curves after surgery (Figure 1B) show that atypical bronchoplasty led to a significantly poorer outcome (p=0.038).
Overall (A) and recurrence-free (B) survival curves according to the type of bronchoplasty.
Figure 2 shows cancer recurrence and subsequent treatment according to type of bronchoplasty. Twenty-seven patients had recurrence and 21 received anticancer treatment for the recurrence. All local treatments were radiotherapy. Although the recurrence rate was high after atypical bronchoplasty, more patients in the atypical bronchoplasty group were able to receive anticancer treatment after recurrence.
Site of tumor recurrence and anticancer treatment after recurrence.
Discussion
We investigated surgical outcomes after atypical bronchoplasty in patients with primary lung cancer. The overall survival benefit of atypical bronchoplasty was reliable compared with that of typical bronchoplasty. The high incidence of complications might have been related to long hospital stays and few opportunities for adjuvant therapy after atypical bronchoplasty. We previously reported that caliber mismatch at the bronchoplastic site was a risk factor for respiratory complications after sleeve lobectomy (7). In particular, that study showed patients with a low body mass index were likely to have complications after bronchoplasty with caliber mismatch. There were caliber mismatches in many patients with atypical bronchoplasty, and body mass index before surgery was lower in the atypical than typical bronchoplasty group. These factors might have resulted in the high incidence of complications after atypical bronchoplasty.
Recurrence was more commonly observed after atypical than typical bronchoplasty. More advanced lung cancer, which infiltrated the central portion aggressively, was treated with extended removal of lung tissue and the central airway. The reason for the high recurrence rate after atypical bronchoplasty might have been that this group included patients with more advanced lung cancer. However, the overall survival rate after atypical bronchoplasty was similar to that after typical bronchoplasty. Anticancer treatment for recurrence was frequently administered in the atypical bronchoplasty group. Preservation of peripheral lung tissue enabled the introduction of anticancer treatment after recurrence, which might have had a beneficial effect on overall survival.
The beneficial effects of extended sleeve lobectomy were reported in previous studies (8, 9). However, because of the complex nature of the extended sleeve lobectomy procedure, it is not recognized as a standard method in lung cancer treatment. The procedures and outcomes of atypical bronchoplasty other than extended sleeve lobectomy have not been investigated. Compared with typical bronchoplasty, atypical bronchoplasty has included some rare procedures. There is a wide lumen at the bifurcation of the middle and basal segment bronchi; therefore, it is not necessary to pay attention to caliber mismatch in right upper lobe and segment six sleeve resections. Segmental bronchi do not have a cartilaginous ring; therefore, the distal stump is automatically expanded to fit the proximal stump. Tension at the anastomotic site is commonly overcome by pericardiotomy around the pulmonary vein of the preserved lung. We suggest that most atypical bronchoplasties can be successfully performed by careful techniques. However, because of excessive caliber mismatch and tension at the anastomotic site, we found bronchopleural fistula after bronchoplasty between the right middle and main bronchi. The preserved pulmonary volume was insufficient for conservation of respiratory function and reduction of the residual thoracic cavity; therefore, we concluded that right upper and lower sleeve bilobectomy should not be performed, in order to avoid severe complications.
Although intraoperative pathological examination confirmed the absence of cancer cell infiltration in the bronchial stumps, recurrence at the anastomotic site was observed in two patients after atypical bronchoplasty. Atypical bronchoplasty was commonly performed for advanced centrally located lung cancer. We were concerned about incomplete lymph tissue dissection around the preserved peripheral bronchus. Tsutani et al. (10) recommended strict diagnosis of lymph node status before and during surgery when they planned bronchoplasty at the segmental bronchus. It was reported that lymph flow may be blocked by tumor or metastatic lymph nodes (11). In patients with advanced centrally located lung cancer, the hilar lymphatic system might be disrupted and lymph might flow in unexpected directions. It is important to confirm that the lymphatic tissue around the peripheral bronchi is free of cancer cell infiltration during surgery for advanced, centrally located lung cancer.
This study had several limitations. Firstly, it was a retrospective study that included only a small number of patients. Because atypical bronchoplasty included some rare procedures, outcomes were not investigated according to each method. Accumulation of patient data for further examination is warranted. Secondly, treatment methods were selected by the physician in each case; therefore, clear selection criteria for treatment methods should be established for future studies. Finally, positron-emission tomography/computed tomography and endobronchial ultrasound-guided biopsy were not mandatory preoperative examinations during the study period. A standard preoperative examination schedule should be established to improve the accuracy of staging.
In conclusion, tumor recurrence was higher after atypical than typical bronchoplasty. However, the overall survival benefit was similar for the two procedures. More opportunities for anticancer treatment after recurrence in patients undergoing atypical bronchoplasty might have a beneficial effect on overall survival. Preservation of pulmonary function after atypical bronchoplasty might contribute to the tolerability of anticancer treatment for recurrence.
Footnotes
Authors’ Contributions
Takuma Tsukioka designed this study, analyzed the data, prepared the figures, and wrote the original draft. Nobuhiro Izumi and Noritoshi Nishiyama oversaw the study and revised the article. All Authors reviewed the article.
Conflicts of Interest
The Authors have no conflicts of interest to declare regarding this study.
- Received February 1, 2023.
- Revision received February 13, 2023.
- Accepted February 15, 2023.
- Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.
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