Tracheal Sleeve Pneumonectomy for Bronchogenic Carcinoma: Report of 55 Cases

Tracheal Sleeve Pneumonectomv for Bronchogenic Carcinoma: Repok of 55 Cases Philippe G. Dartevelle, M.D., Joseph Khalife, M.D., Alain Chapelier, M.D., Jean Marzelle, M.D., Marcel0 Navajas, M.D., Philippe Levasseur, M.D., Antonio Rojas, M.D., and Jacques Cerrina, M.D. ABSTRACT From 1966 to 1986, a total of 55 patients underwent a tracheal sleeve pneumonectomy (53 right and 2 left) for bronchogenic carcinoma. Preoperative radiotherapy was given in only 5 patients. The overall operative death rate was 10.9%,but no patient has died since 1975 (32 survivors). Seven patients had a postoperative empyema (12.7%);4 of these patients had a bronchopleural fistula. Twenty-five patients had postoperative radiotherapy, 5 of whom also had chemotherapy. The actuarial survival rate, after exclusion of the 6 operative deaths, was 38%at 3 years and 23% at 5 years. Survival was correlated to regional lymph node involvement. The actuarial survival rate among patients with tumoral spread to bronchial lymph nodes was 43%at 3 years. Among the 13 patients with only subcarinal involvement, the actuarial survival rate was 34% at 3 years. None of the 8 patients with paratracheal lymph node involvement survived more than 30 months. These results indicate that tracheal sleeve pneumonectomy for bronchogenic carcinoma with extension to the carina is now fully justified considering the low operative mortality and the good results observed when lateral tracheal lymph nodes were not involved. Extension of bronchogenic carcinoma to the proximal main bronchus, the carina, and the distal trachea is a classic contraindication to operation. The poor results of radiotherapy and chemotherapy in these situations led several surgical teams to perform a pneumonectomy with carinal resection and anastomosis of the contralatera1 bronchus to the trachea [l-71, as described by Abbot [8] and Gibbon [9]. Despite improvements in indications, surgical procedures, anesthetic management, and postoperative care, recent series still show a significant operative mortality [ 10-121. The present report summarizes our experience with this type of surgical procedure, pointing out anesthetic and surgical modifications throughout the series and analyzing immediate and long-term results, with special emphasis on lymph node involvement.

From the Department of Thoracic and Vascular Surgery, Marie Lanne-

longue Hospital, Plessis Robinson, France. Accepted for publication Jan 14, 1988. Address reprint requests to Dr. Dartevelle, Hbpital Marie Lannelongue, 133 avenue de la Resistance, 92350 Plessis Robinson, France.

Patients and Methods From 1966 to 1986, a total of 55 tracheal sleeve pneumonectomies for primary lung cancer were performed at the Marie Lannelongue Hospital (Fig 1). The overwhelming majority of the patients were men (52 men and 3 women) and mean age was 55 years (Fig 2). A second localization developed on the right main bronchus in 3 patients treated earlier by radiotherapy for laryngeal carcinoma. Two patients had recurrence of a squamous cell carcinoma: 1 on the left main bronchus 4 years after a left lower lobectomy and 1 on the right main bronchus 1 year after a bilobectomy (lower and middle lobes). Five patients had undergone previous cardiovascular surgical procedures, and 45 had no major medical history. Fifty-one patients had abnormal roentgenographic findings (19 right hilar growths, 24 suprahilar opacities, and 8 subhilar opacities). Three patients had normal roentgenograms. Endoscopy for hemoptysis demonstrated cancers on the left main bronchus in 2 of these patients and on the right main bronchus in the third patient. Two of these tumors were second localizations. In 22 patients, endoscopy showed proxima! localization of the tumor: involvement of trachea and carina in 6, involvement of the proximal main bronchus in 12, and compression of right main bronchus in 4. In the 33 other patients, endoscopy demonstrated a more distal localization of the tumor: distal main bronchus in 12, right upper bronchus in 16, and intermediate bronchus in 7. Thirty-nine patients underwent pulmonary angiograms, sometimes associated with venacavograms. Angiograms were normal in 13 patients, demonstrated amputation or stenosis of the mediastinal artery in 18 patients, and involvement of the main pulmonary artery in 4 patients. Four patients had associated displacement of the superior vena cava. Forty-nine patients underwent tests including vital capacity, forced expiratory volume in 1 second, and ventilation/perfusion scanning [13]. The predicted forced expiratory volume in 1 second ranged from 30 to 64%, with a median of 45% of the theoretical value (CECA) (Fig 3). Five patients had preoperative radiotherapy ranging from 30 to 60 Gy. One patient with severe hemoptysis had embolization of a bronchial artery a few days before the surgical procedure. Tumors were staged according to the method of Renault and colleagues [14], as shown in the Table. Nineteen patients had T (tumor) 2, tumors involving the

68 Ann Thorac Surg 4668-72, July 1988. Copyright 0 1988 by The Society of Thoracic Surgeons __

69 Dartevelle et al: Tracheal Sleeve Pneumonectomy

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main bronchus without extension to the carina; technical or carcinological reasons prevented a standard pneumonectomy. Thirty-five patients had T3, tumors with direct extension to the mediastinum. One patient had a T3, tumor invading the chest wall. Regional lymph nodes were staged according to the same system (Fig 4; see the Table) [14]. Five patients with no demonstrable tumoral spread to lymph nodes were in nodal stage (N) 0. Twenty-two patients had cancers with tumoral spread to bronchial lymph nodes (Nl).Twenty-six patients were in N2: 14 patients exhibited a subcarinal involvement, and 12 patients had a paratracheal lymph node involvement. Two patients had mediastinal lymph nodes sterilized by preoperative radiotherapy (NX). Forty-nine tumors were squamous cell carcinoma (4 of which were poorly differentiated), 4 were adenocarcinomas, 1 was combined squamous and glandular carcinoma, and 1 was small cell carcinoma misdiagnosed before the surgical procedure. Among 55 sleeve pneumonectomies, 53 were performed on the right lung and 2 on the left. Tracheobronchial reconstruction was always performed through the same surgical approach. Tracheal sleeve pneumonectomy alone was performed in 37 patients. In the 18 other it was extended to the vena cava (4 patients), and to the left atrium and paratracheal lymph nodes (12 patients). In 3 patients frozen section failed to show tumor on carinal resection margin; it was only detected on final pathological examination. Twenty-five patients had postoperative radiotherapy (50-60 Gy), 5 of whom also had chemotherapy.

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Results Six patients (10.9%)died in the immediate postoperative course: 4 of early respiratory failure, 1 of gastrointestinal bleeding, and 1 of pulmonary embolism. No operative death has been observed since 1975 (32 patients). Seven patients had empyema in the postoperative course (12.7%).Four of these had a bronchopleural fistula. All but 1 patient recovered under medical treatment. We correlated the survival rate to the lymph node involvement after exclusion of the 6 operative deaths (1

in NX, 1 in N1, and 4 in N2). In the NO group (5 patients), 1 patient is alive 15 months postoperatively and 4 died at 12, 15, 67, and 120 months, respectively. In the N1 group (21 patients), the survival probability is 43% at 3 years (Fig 5). In the N2 group (21 patients), the survival probability is 34% at 3 years in the 13 patients with subcarinal lymph node involvement (Fig 6). Three patients survived up to 74, 81, and 90 months. None of the 8 patients in the N2 group with lateral tracheal

70 The Annals of Thoracic Surgery Vol 46 No 1 July 1988

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Fig 4. Node (N) classification in 55 pneumonectomy patients. (NX = patients without node invasion after preoperative radiotherapy; NO = absence of node invasion; N1 = invasion of pedicular lymph nodes without extension to the mediastinal lymph nodes; N2 SC = invasion of the subcarinal nodes; N2 LT = invasion of the lateral tracheal nodes with or without extension to the subcarinal nodes.)

Fig 7. Cuinulative survival of 9 patients in nodal stage 2 (NZ),with lateral tracheal lymph node involvement, excluding 3 postoperative deaths .

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Fig 6. Cumulative survival of 13 patients in nodal stage 2 (N2), with subcarinal invasion, excluding 1 postoperative death. Number of survivors is shown in parentheses.

lymph node involvement survived more than 30 months (Fig 7). The single patient in the NX group died at 38 months. For the entire series (49 patients), the actuarial survival rate is 38% at 3 years and 23% at 5 years: 18 survived over 3 years, and 7 survived over 5 years (Fig 8).

Fig 8. Actuarial survival rate of 49 pneumonectomy patients excluding 6 postoperative deaths. Number of survivors is shown in parentheses.

Comment Few teams have had extensive experience with tracheobronchial reconstruction [3-7, 15, 161. At the Marie-Lannelongue Hospital, the 55 tracheal sleeve pneumonectomies account for 2.8% in the 1,926 pneumonectomies for bronchogenic carcinoma performed from 1966 to 1986. We always perform ipsilateral thoracotomy, because it provides excellent exposure on the right side; on the left side, the quality of the exposure depends on the individual anatomy of the aortic arch. Although Abbey Smith and Nigam [17] described aortic mobilization in 6 cases, we did not use it in our 2 left sleeve pneumonectomies because of the theoretical risk of paraplegia. Although Moghissi [19] successfully used lateral carinal resection with pericardial patch reconstruction in 9 patients, we perform circumferential resection with endto-end tracheobronchial anastomosis. Both resection margins must be examined by frozen section, and the resection is extended accordingly (up to 4 cm of the trachea) because of the limitation of tracheal mobilization by the lateral approach. Tumors involving more than 2 cm of the distal trachea are not deemed operable.

71 Dartevelle et al: Tracheal Sleeve Pneumonectomy

A

Fig 9. Technique of tracheal anastomosis. (A) The suture is performed beginning on the left face of the resected stumps using a continuous inside-out suture. The high-frequency jet ventilation catheter obviates the need for intermittent intubation of the left bronchus through the operative field. (B)The anterior part of the anastomosis. A Carlens tube has been placed.

To reduce the suture-line granulation seen with nylon thread, we used polyglycolic acid thread from 1978 to 1982 and have used polydioxanone thread since 1983. The latter is an adsorbable monofilament that allows an easy and safe continuous suture, according to the principles of aortic surgery (Fig 9). The use of an extra tube through the operating field or of intermittent intubation hindered the performance of the anastomosis. Since 1982, we have been using high-

frequency jet ventilation [20] in carinal and tracheal surgery. It improves surgical exposure, avoids endotracheal manipulations, and provides satisfactory gas exchanges. The absence of operative mortality since 1975 is related to better preoperative staging of patients and improvement of postoperative care. We believe, like Deslauriers and colleagues [lo], that preoperative radiotherapy increases the risk of bronchopleural fistula. A multifactorial study [22-231 reviewing 1,285 pulmonary resections for bronchogenic carcinoma in our institution from 1960 to 1973emphasized that involvement of the main bronchus does not adversely affect the prognosis. A comparison between the actuarial survival rate after resection for lobar cancer T2, and for cancer involving the main bronchus T2, did not show any significant difference. Furthermore, among extended pneumonectomies, only tracheal sleeve pneumonectomy yielded an acceptable survival rate. Lymph node status was the most important prognostic factor. The mean survival was 33 months for N2 subcarinal patients and 11 months for N2 lateral tracheal patients, and the difference was statistically significant ( p < 0.02 by a one-tail, paired, Student's t test). The poor results achieved among patients with N2 lateral tracheal tumors makes this group unacceptable for operation. Better assessment by systematic computed tomographic scan and, perhaps, mediastinoscopy, as recommended by Deslauriers and colleagues [lo, 111, should avoid unwarranted thoracotomies. Extension of primary bronchogenic carcinoma to the proximal main bronchus or the distal trachea does not carry a poor prognosis per se, as opposed to extension to other mediastinal structures (i.e., left atrium and esophagus) [23]. Our results indicate that tracheal sleeve pneumonectomy provides a fair survival rate in selected patients; the prognosis depends mainly on lymph node involvement. Spread to superior mediastinal nodes is, in our opinion, a contraindication to operation. Tracheal sleeve pneumonectomy can now be considered a safe intervention, thanks to improvements in surgical techniques as well as anesthetic management. We thank Miss Fabienne Loneux for the artistic designs.

References 1. Paulson DL, Shaw RR: Results of bronchoplastic procedures for bronchogenic carcinoma. Ann Surg 151:729, 1960 2. Thomson D T Tracheal resection with left lung anastomosis following right pneumonectomy. Thorax 21:560, 1966 3. Mathey J, Binet JP, Galey JJ, et al: Tracheal and tracheobronchial resections: technique and results in 20 cases. J Thorac Cardiovasc Surg 51:1, 1966 4. Naef AP: Extensive tracheal resection and tracheobronchial reconstruction. Ann Thorac Surg 8:391, 1969 5. Eschapasse H, Vahdat F, Gaillard J, Besso JC: Reflexions sur la resection de la trachee inferieure et de la bifurcation bronchique. Ann Chir Thorac Cardiovasc 6:63, 1967

72 The Annals of Thoracic Surgery Vol 46 No 1 July 1988

6. Izshiara T, Ikeda T, Inowe H, Fukai S: Resection of cancer of lung and carina. J Thorac Cardiovasc Surg 73:936, 1977 7. Grillo HC: Carcinoma of the lung: what can be done if the canna is involved? Am J Surg 143:694, 1982 8. Abbott OA: Experiences with the surgical resection of the human carina, tracheal wall and contralateral bronchial wall in cases of right pneumonectomy. J Thorac Surg 19:906, 1950 9. Gibbon JH: Discussion of bronchogenic carcinoma: an aggressive surgical attitude. J Thorac Cardiovasc Surg 38727, 1959 10. Deslauriers J, Beaulieu M, Benaz6ra A, McClish A: Sleeve pneumonectomy for bronchogenic carcinoma. Ann Thorac Surg 28:465, 1978 11. Deslauriers J: Involvement of the main canna. In Delarue NC, Eschapasse H (eds): International Trends in General Thoracic Surgery. Philadelphia, Saunders, 1985, pp 139-145 12. Jensik RJ, Faber LP, Kittle CF, et al: Survival in patients undergoing tracheal sleeve pneumonectomy for bronchogenic carcinoma. J Thorac Cardiovasc Surg 84:489, 1982 13. Bria WF, Kanarek DJ, Kazemi H: Prediction of postoperative pulmonary function following thoracic operations: value of ventilation-perfusion scanning. J Thorac Cardiovasc Surg 86:186, 1983 14. Renault P, Merlier M, Lange J: La codification TNM appliquee aux cancers bronchopulmonaires op6r6s. Rev Fr Ma1 Resp 3:59, 1975 15. Houston HE, Payne WS, Harrison EG, et al: Primary cancers of the trachea. Arch Surg 99:132, 1969 16. Naruke T, Yoneyama T, Ogata T, et al: Bronchoplastic

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procedures for lung carcinoma. J Thorac Cardiovasc Surg 73:927, 1977 Abbey Smith R, Nigam BK: Resection of proximal left main bronchus carcinoma. Thorax 34:616, 1979 Pearson FG, Todd TRJ, Cooper JD: Experience with primary neoplasms of the trachea and carina. J Thorac Cardiovasc Surg 88:511, 1984 Moghissi K. Les procedes bronchoplastiques: a propos de 101 cas consecutifs. Chirurgie 105:460, 1979 El-Baz N, Jensik R, Faber JP, Far0 RS: One-lung highfrequency ventilation for tracheoplasty and bronchoplasty: a new technique. Ann Thorac Surg 34:564, 1982 Merlier M, Le Brigand H, Rojas A, et al: Etude retrospective de la survie eloignee apres exerese d’un cancer bronchique primitif. Chirurgie 109:590, 1983 Merlier M, Le Brigand H, Rojas A, et al: Generalit& sur la survie eloignee des ex6r6ses pulmonaires des cancers bronchiques primitifs (anaplasiques exclus). Rev Fr Ma1 Resp 9:493, 1981 Merlier M, Rojas A, Gharbi N, et al: Unification of criteria. In Delarue NC, Eschapasse H (eds): International Trends in General Thoracic Surgery. Philadelphia, Saunders, 1985, pp 27-36 Rojas A, Serrano J, Silbert D, et al: Influence sur la survie eloignee des diff6rents types de pneumonectomie dans le cancer bronchique. Rev Fr Ma1 Resp 9:507, 1981 Pearson FG, Delarue NC, Ilves R, et al: Significance of positive superior mediastinal nodes identified at mediastinoscopy in patients with resectable cancer of the lung. J Thorac Cardiovasc Surg 83:1, 1982

Notice from the American Board of Thoracic Surgery The American Board of Thoracic Surgery began its recertification process in 1984. Diplomates interested in participating in this examination should maintain a documented list of the cardiothoracic operations they performed during the year prior to application for recertification. They should also keep a record of their attendance at thoracic surgical meetings, and other continuing medical education activities pertaining to thoracic surgery and thoracic disease, for the two years prior to application. A minimum of 100 hours of approved CME activity is required. In place of a cognitive examination, candidates for recertification will be required to complete both the general thoracic and cardiac portions of the SESATS 111 syllabus (Self-EducatiodSelf-Assessment in Thoracic Surgery). It is not necessary for candidates to purchase

SESATS I11 booklets prior to applying for recertification. SESATS 111booklets will be forwarded to candidates after their applications have been accepted. Diplomates whose 10-year certificates will expire in 1990 may begin the recertification process in 1988. This new certificate will be dated 10 years from the time of expiration of the original certificate. Recertification is also open to any Diplomate with an unlimited certificate and will in no way affect the validity of the original certificate. The deadline for submission of applications was July 1, 1988. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, One American Plaza, Suite 803, Evanston, IL 60201.