Tracheal Sleeve Pneumonectomy for Lung Cancer After Induction Chemotherapy

Objective: Non-small cell lung cancer (NSCLC) less than 2 cm from the carina or invading the tracheo-bronchial angle, formerly considered inoperable, may be amenable to an €œextended€ resection (tracheal sleeve pneumonectomy - TSP). In these patients the role of induction chemotherapy (IC) and their effects on morbidity and mortality are unclear. We evaluated the surgical results and the long-term outcome of patients who underwent TSP for locally advanced NSCLC after IC. Methods: From September 1998 to September 2008, 29 patients (19 men; median age of 58 years) with NSCLC of the carinal or tracheo-bronchial angle received induction chemotherapy (cisplatin based polichemotherapy) after mediastinoscopy. Patients with disease judged to be resectable at restaging underwent surgery. Results: All patients were available for re-staging. No complete response was observed. Twelve patients (41.4%) had a progression disease. Partial response rate was 41.4% (n=12), and stable disease 17.2% (n=5). All patient with partial response and stable disease (n=17, all with pN2) underwent surgery. Superior vena cava was involved and resected in 11 cases (64.7%). Complete resection was achieved in 14 patients (82.3%). Thirty-day mortality was 5.8% (n=1). Major complications occurred in 4 patients (23.5%): 3 bronchopleural fistulas (17.6%), 2 ARDS (11.7%), and 1 cardiac hernia (5.8%). Nodal downstaging was diagnosed in 9 (53%) patients (all passed from N2 to N1). Median survival was 12 months (range, 1 to 90 months). Overall 5-year survival rate was 34%. Overall, 5-year freedom from recurrence was 58.2%. Seven patients (41%) had recurrence: 1 local (5.8%) and 6 systemic (35.2%). Patients receiving postoperative radiotherapy (n=8) and those with downstaging had a significant 5-year survival rate (50.6% vs 0%; logrank, p= .007, and 63.5% vs 0%; log-rank, p = .04). Patients with squamous cell carcinoma (n=9) had a best prognosis in respect of those with adenocarcinoma (n=8) (76.2% vs 0%; logrank, p=.002). At multivariate analysis, postoperative radiotherapy influenced long-term survival (p=.04). Conclusion: Induction chemotherapy improves patient selection avoiding useless operation allowing a safety TSP with acceptable morbidity and mortality. In or experience, downstaging and squamous cell carcinoma are associated to a best prognosis. Postoperative radiotherapy improves long-term survival