诱导治疗后支气管袖式切除术

Current guidelines recommend chemotherapy with or without radiotherapy for induction therapy in selected patients with stage IIIA non-small cell lung cancer (NSCLC). However, national practice patterns vary with strong institutional preference for either neoadjuvant chemotherapy (NC) or neoadjuvant chemoradiation (NCR). A challenging subset of patients with locally advanced NSCLC is those likely to require complex resection and reconstruction or pneumonectomy. Due to significant short-term and long-term advantages, sleeve resection is preferred over pneumonectomy when possible.

In a timely study, Jaradeh and colleagues evaluated the National Cancer Database for patients who underwent sleeve resection after NCR versus NC alone. NCR was associated with higher perioperative mortality without a long-term survival benefit, despite a higher rate of pathologic complete response (pCR). The significant risk of short-term morality in the NCR group is especially sobering given that this cohort represents carefully selected patients deemed robust enough to undergo resection after induction therapy. 

Short-term mortality after major lung resection is closely related to perioperative morbidity, particularly pulmonary complications. Radiation therapy (RT) is associated with development of microvascular ischemia. This is uniquely important in planning bronchial sleeve resection, where the distal bronchus receives blood flow only through the microvasculature perfused in retrograde fashion via the pulmonary circulation. Radiation therapy may also be associated with airway edema, further compromising healing and clearance of secretions. Finally, 15-40% of patients undergoing RT develop radiation pneumonitis, which can predispose to postoperative complications or necessitate delay of surgery.

Similar to the current study, prior reports have not demonstrated a survival advantage for NCR in the overall cohort of patients with stage IIIA lung cancer undergoing surgery (sleeve resection or otherwise) after induction therapy. They also noted increased 90-day mortality in the NCR group (6% NCR vs 2.9% NC). The theoretical benefit of NCR in this population may be for improved local control; however, studies have demonstrated that 80% of patients with IIIA NSCLC have distant recurrences. 

Overall, the current study reinforces that especially in patients with locally advanced NSCLC who are likely to require a complex sleeve resection, neoadjuvant chemotherapy alone provides a balance of oncologic benefit without increasing perioperative risk.