Sleeve Resection After Neoadjuvant Treatment via Minimally Invasive Approaches for Lung Cancer
Sleeve resection, a surgical procedure involving the resection and reconstruction of bronchial and/or pulmonary arteries, is a valid therapeutic approach for centrally located lung cancer. With the establishment and development of comprehensive treatment concepts, neoadjuvant treatments such as neoadjuvant immunotherapy have become effective strategies for managing locally advanced, centrally located lung cancer. Neoadjuvant treatment can reduce tumor size, increasing the likelihood of complete resection and enabling parenchyma-sparing procedures like sleeve resection. This approach improves postoperative respiratory function, enhances quality of life, and achieves lower postoperative morbidity and mortality compared to pneumonectomy, while maintaining similar oncological outcomes.
Traditionally, sleeve resection has been performed via thoracotomy. However, over the past two decades, minimally invasive surgery has emerged as a viable alternative due to advancements in surgical instruments and techniques. Despite these developments, minimally invasive sleeve resection using video-assisted thoracoscopic surgery (VATS) or robot-assisted thoracoscopic surgery (RATS) remains technically challenging. Concerns persist regarding its safety and feasibility, particularly in terms of perioperative and oncological outcomes, especially after neoadjuvant treatment.
Sleeve resection is most commonly indicated for centrally located lung cancer or metastatic N1 lymph nodes infiltrating the origin of the lobar bronchus and/or pulmonary arterial branches. It is also used to achieve radical resection when frozen sections confirm microscopic residual disease on the bronchial or arterial margin after standard lobectomy.
The application of minimally invasive approaches in sleeve resection has evolved significantly. In 2002, Santambrogio et al. reported the first case of left lower sleeve lobectomy via VATS. Since then, hybrid VATS (mini-thoracotomy with VATS) and complete VATS approaches have been used for sleeve lobectomy. The procedure has further evolved from multiple-port VATS (four or three ports) to biportal or uniportal VATS, which is associated with less chest pain. In RATS, the first case of sleeve lobectomy using a combined robotic and thoracoscopic approach was reported by Schmid et al. in 2011. A landmark study by Jiao et al. in 2019 established the technological maturity of RATS for sleeve resections, demonstrating excellent clinical outcomes in a large series of 67 patients. In 2020, Qiu et al. reported the evolution of surgical approaches from thoracotomy to VATS and then to RATS for sleeve resections, including single and double sleeve lobectomies. Further advancements, such as biportal and uniportal RATS and the use of v-loc sutures, have enhanced the feasibility of minimally invasive sleeve resection.
Studies have shown that minimally invasive sleeve resection is safe, with acceptable perioperative outcomes. The conversion rate to thoracotomy ranges from 0% to 21.1%, the R0 resection rate ranges from 84.5% to 100%, the postoperative morbidity rate ranges from 0% to 44.4%, the 30-day mortality rate ranges from 0% to 6.8%, and the 90-day mortality rate ranges from 0% to 6.8%. Compared to thoracotomy, minimally invasive sleeve resection does not compromise perioperative outcomes and may even offer advantages. A meta-analysis revealed that VATS sleeve lobectomy results in less blood loss, a longer operation time, similar lymph node dissection, and similar postoperative complications compared to thoracotomy. There were no significant differences in R0 rate, drainage duration, postoperative hospital stay, or 30-day mortality rate between VATS and thoracotomy. Preventive measures, such as interposing viable tissue flaps around the anastomosis and irrigating the artery with heparin, have been adopted to reduce complications. Recent studies suggest that minimally invasive approaches are independently favorable factors for reducing postoperative complications, even in patients who have undergone neoadjuvant treatment.
RATS sleeve resection has also demonstrated excellent perioperative outcomes. Jiao et al. reported no intraoperative blood transfusions, conversions to open thoracotomy, or 90-day mortality in their series of 67 patients. Qiu et al. found that RATS sleeve lobectomy had a shorter operative time, less blood loss, shorter tube drainage time, shorter hospital stay, and similar postoperative morbidity and mortality compared to VATS and thoracotomy. These findings suggest that RATS sleeve resection is technically feasible with acceptable clinical outcomes, particularly in high-volume institutions with experienced surgeons.
Sleeve lobectomy, including double sleeve lobectomy, following neoadjuvant treatment can be safely performed with similar postoperative mortality and morbidity to direct surgery. However, neoadjuvant treatment may cause therapy-related changes, such as fibrosis or adhesion, making hilar dissection and reconstruction more challenging. Minimally invasive sleeve resection after neoadjuvant therapy has been increasingly attempted, with the proportion of neoadjuvant therapy in minimally invasive sleeve resection cohorts ranging from 2% to 45.5%. Conversion to thoracotomy, though representing a failed attempt at minimally invasive surgery, does not result in worse perioperative mortality, readmission rates, or long-term survival compared to thoracotomy. Recent data indicate that 11.3% to 20.0% of patients who initially underwent minimally invasive sleeve resection after neoadjuvant therapy required conversion surgery. Preliminary findings suggest that minimally invasive sleeve resection following neoadjuvant treatment is safe and feasible, with similar perioperative outcomes to thoracotomy. However, more high-quality studies and prospective randomized controlled trials are needed to validate its safety and efficacy.
Oncological outcomes are crucial for evaluating the efficacy of surgical procedures. Minimally invasive sleeve resection has demonstrated satisfactory survival rates. The 3-year disease-free survival (DFS) rate ranges from 60.8% to 76.3%, and the 3-year overall survival (OS) rate ranges from 64.9% to 89.7%. The 5-year DFS rate ranges from 50.7% to 67.9%, and the 5-year OS rate ranges from 56.1% to 85.0%. No significant differences in oncological outcomes have been observed between minimally invasive and thoracotomy sleeve resection. Meta-analyses have shown that VATS sleeve resection has similar OS and DFS to thoracotomy. For RATS sleeve resection, the 2-year DFS and OS rates are 81.3% and 82.4%–88.2%, respectively, the 3-year DFS and OS rates are 76.3% and 89.7%, and the 5-year DFS and OS rates are 67.9% and 73.0%. While current data suggest potential survival advantages of RATS sleeve resection, further studies with larger sample sizes and longer follow-up times are required.
Neoadjuvant chemoimmunotherapy has been shown to increase major pathological response rates and improve survival compared to mono-neoadjuvant chemotherapy or chemoradiotherapy. Sleeve resection following neoadjuvant chemoimmunotherapy achieves pathological complete responses more easily than neoadjuvant chemotherapy, potentially indicating better survival. However, the minimally invasive approach has not been identified as an independently favorable prognostic factor for survival. Many studies on minimally invasive sleeve resection have short follow-up times, and more evidence from 5- or 10-year survival analyses is needed, particularly for cases involving neoadjuvant chemoimmunotherapy.
In summary, minimally invasive sleeve resection is safe and feasible, offering similar perioperative outcomes, better postoperative recovery, and comparable survival rates to thoracotomy. However, more definitive evidence is needed to confirm the efficacy of minimally invasive sleeve resection after neoadjuvant treatment. VATS and RATS are well-established approaches and can be considered complementary procedures in high-volume institutions. The choice of the optimal procedure should be based on the clinical experience and technical level of the surgical team.
doi.org/10.1097/CM9.0000000000002924
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