Elsevier

The Annals of Thoracic Surgery

Volume 82, Issue 2, August 2006, Pages 431-443.e19
The Annals of Thoracic Surgery

J. Maxwell Chamberlain memorial paper for general thoracic surgery
Long-Term Follow-Up of Patients Receiving Lung-Volume-Reduction Surgery Versus Medical Therapy for Severe Emphysema by the National Emphysema Treatment Trial Research Group

Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006. Winner of the J. Maxwell Chamberlain Memorial Award for General Thoracic Surgery.
https://doi.org/10.1016/j.athoracsur.2006.05.069Get rights and content

Background

The National Emphysema Treatment Trial defined subgroups of patients with severe emphysema in whom lung-volume-reduction surgery (LVRS) improved survival and function at 2 years. Two additional years of follow-up provide valuable information regarding durability.

Methods

A total of 1218 patients with severe emphysema were randomized to receive LVRS or medical treatment. We present updated analyses (4.3 versus 2.4 years median follow-up), including 40% more patients with functional measures 2 years after randomization.

Results

The intention-to-treat analysis of 1218 randomized patients demonstrates an overall survival advantage for LVRS, with a 5-year risk ratio (RR) for death of 0.86 (p = 0.02). Improvement was more likely in the LVRS than in the medical group for maximal exercise through 3 years and for health-related quality of life (St. George’s Respiratory Questionnaire [SGRQ]) through 4 years. Updated comparisons of survival and functional improvement were consistent with initial results for four clinical subgroups of non-high-risk patients defined by upper-lobe predominance and exercise capacity. After LVRS, the upper-lobe patients with low exercise capacity demonstrated improved survival (5-year RR, 0.67; p = 0.003), exercise throughout 3 years (p < 0.001), and symptoms (SGRQ) through 5 years (p < 0.001 years 1 to 3, p = 0.01 year 5). Upper-lobe-predominant and high-exercise-capacity LVRS patients obtained no survival advantage but were likely to improve exercise capacity (p < 0.01 years 1 to 3) and SGRQ (p < 0.01 years 1 to 4).

Conclusions

Effects of LVRS are durable, and it can be recommended for upper-lobe-predominant emphysema patients with low exercise capacity and should be considered for palliation in patients with upper-lobe emphysema and high exercise capacity.

Section snippets

Patients and Methods

The design and methods of NETT have been described previously [9]. The proposed trial was reviewed and approved by the institutional review boards of the 17 clinical centers and 1 coordinating center that were involved. Informed consent was obtained from every patient before enrollment in the trial.

Results

Between January 1998 and July 2002, 3777 patients were evaluated and 1218 patients were randomized: 608 to surgery (LVRS group) and 610 to medical therapy (medical group). The groups had similar postrehabilitation baseline characteristics except for a higher proportion of men in the medical group (Table 1). Of the surviving patients, 70% participated in the extension of follow-up conducted between January 2003 and December 2003, and 76% participated in the mailed quality of life data collection

Comment

The original publication of NETT results had a median follow-up of 2.4 years. It provided robust estimates of the risks and benefits of LVRS because of the trial’s large sample size, stringent randomization, low crossover rates, multi-institutional setting, exacting follow-up, and well-defined measurements. Continued follow-up (median 4.3 years) confirms the fundamental observations and conclusions drawn in the initial NETT report and extends these findings by demonstrating the durability of

References (27)

  • D. Geddes et al.

    Effect of lung-volume reduction surgery in patients with severe emphysema

    N Engl J Med

    (2000)
  • F.C. Sciurba et al.

    Improvement in pulmonary function and elastic recoil after lung reduction surgery for diffuse emphysema

    N Engl J Med

    (1996)
  • Rationale and design of the National Emphysema Treatment Trial (NETT)a prospective randomized trial of lung volume reduction surgery

    J Thorac Cardiovasc Surg

    (1999)
  • Cited by (290)

    View all citing articles on Scopus

    Authors listed comprise NETT Research Group Writing Committee. The full list of NETT Research Group members appears at the end of the article in the NETT Credit Roster.

    The online version of this article contains extensive additional information and subgroup analyses of these patients in an Appendix, and is highly recommended for students of this National Institutes of Health trial. To access the online-only Appendix, please visit http://ats.ctsnetjournals.org and search for the article by Naunheim, Vol. 82, pages 431–43.e1–19.

    View full text