Intentional limited resection for small peripheral lung cancer based on intraoperative pathologic exploration

OBJECTIVE: The aim of this study was to assess the adequacy of our intentional limited resection for small peripheral lung cancer based on intraoperative pathologic exploration. METHODS: Patients who had stage IA non-small cell lung cancer (NSCLC) with a maximum tumor diameter of 2 cm or less were candidates for limited resection. If bronchioloalveolar carcinoma (BAC) was suspected on computed tomography and intraoperative pathologic exploration revealed the lesion as BAC without foci of active fibroblastic proliferation (Noguchi type A and B), wedge resection was performed. If the tumor was not suspected of being Noguchi type A or B, extended segmentectomy with intraoperative lymph node exploration was performed. RESULTS: Limited resection was performed in 34 patients, wedge resection in 14, and extended segmentectomy in 20. The median follow-up period after wedge resection was 36 months, and all patients are alive with no signs of recurrence. The median follow-up period after extended segmentectomy was 54 months. No local recurrences were found, but distant metastasis was diagnosed in one patient. The 5-year survival rate after extended segmentectomy was 93%. In the same period, lobectomy was performed in 57 patients with stage IA NSCLC with a maximum tumor diameter of 2 cm or less, and the 5-year survival rate was 84%. There were no significant differences in 5-year survival between extended segmentectomy and lobectomy. CONCLUSIONS: Careful selection of patients based on high-resolution computed tomography findings and intraoperative pathologic exploration makes intentional limited resection an acceptable option for the treatment of small peripheral NSCLC.     

Intentional limited resection for small peripheral lung cancer based on intraoperative pathologic exploration

Objective: The aim of this study was to assess the adequacy of our intentional limited resection for small peripheral lung cancer based on intraoperative pathologic exploration. Methods: Patients who had stage IA non-small cell lung cancer (NSCLC) with a maximum tumor diameter of 2 cm or less were candidates for limited resection. If bronchioloalveolar carcinoma (BAC) was suspected on computed tomography and intraoperative pathologic exploration revealed the lesion as BAC without foci of active fibroblastic proliferation (Noguchi type A and B), wedge resection was performed. If the tumor was not suspected of being Noguchi type A or B, extended segmentectomy with intraoperative lymph node exploration was performed. Results: Limited resection was performed in 34 patients, wedge resection in 14, and extended segmentectomy in 20. The median follow-up period after wedge resection was 36 months, and all patients are alive with no signs of recurrence. The median follow-up period after extended segmentectomy was 54 months. No local recurrences were found, but distant metastasis was diagnosed in one patient. The 5-year survival rate after extended segmentectomy was 93%. In the same period, lobectomy was performed in 57 patients with stage IA NSCLC with a maximum tumor diameter of 2 cm or less, and the 5-year survival rate was 84%. There were no significant differences in 5-year survival between extended segmentectomy and lobectomy. Conclusions: Careful selection of patients based on high-resolution computed tomography findings and intraoperative pathologic exploration makes intentional limited resection an acceptable option for the treatment of small peripheral NSCLC. Read at the Fifty-sixth Annual Meeting of the Japanese Association for Thoracic Surgery, Panel Discussion, Tokyo, November 19–21, 2003.     

Review and evaluation of limited resection for early lung cancer

Limited resection for early lung cancer has been associated with significantly higher local recurrence rates based on previous reports such as those from lung cancer study groups. On the other hand, a few groups demonstrated that patients with small peripheral cancer who undergo limited resection have comparable survival rates with those who undergo lobectomy. Recent advances in radiologic investigation and pathologic analysis have broadened the indications for limited resection. Since the introduction of the adenocarcinoma classification by Noguchi surgery for localized bronchioloalveolar carcinoma has focused on limited resection. Caution is necessary when performing wedge resection even if 10 mm or less in diameter and in compromised segmentectomy for early lung cancer. Although limited resection is still controversial intentional segmentectomy for localized bronchioloalveolar carcinoma or less than 20 mm or less in diameter may be recommended without evidence-based medicine. It is important to accumulate further evidence clarifying the survival and function benefits of limited resection. New therapeutic modalities for limited surgery for small-sized lung cancer may increase patient life expectancy.     

Does lobectomy achieve better survival and recurrence rates than limited pulmonary resection for T1N0M0 non-small cell lung cancer patients?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'Does lobectomy achieve better survival and recurrence rates than limited pulmonary resection for T1N0M0 non-small cell lung cancer patients?' Altogether 225 papers were found using the reported search, of which nineteen represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. A meta-analysis published in 2005 showed a 0.7% (P=0.3659) survival difference at one year, 1.9% (P=0.5088) at three years and 3.6% (P=0.3603) at five years. The largest study prior to the meta-analysis was a randomized controlled study of 247 patients with T1N0 tumors that showed eight locoregional recurrences in the lobectomy group compared to 21 in the sublobar group, which was statistically significant. Since the meta-analysis we identified three studies, two of which showed no difference in survival and recurrence between wedge resection and lobectomy for T1N0 tumors and one that showed improved survival after lobectomy compared to wedge resection for T1N0 tumors. We conclude that wedge resection is not comparable to lobectomy for stage IA NSCLC. The increased long-term mortality associated with wedge resection is mainly due to non-cancer deaths, reflecting a higher risk patient group with many comorbid conditions. Segmental resection is comparable to lobectomy for small peripheral tumors. Sublobar resection is associated with shorter hospital stay. For bronchioalveolar carcinoma sublobar resection is recommended provided intra-operative pathologic consultation confirms pure bronchioalveolar histology without evidence of invasion, and surgical margins are free of disease.     

Current indications for sublobar resection in non-small-cell bronchogenic carcinoma

Over the past 30 years, there has been considerable controversy regarding the role of segmental and wedge resections in the management of stage I (T1-T2N0M0) non-small-cell lung cancer. Recently, a prospective randomized trial (Lung Cancer Study Group, 1995) revealed unfavorable results after limited resection, which, in early stage lung cancer, remains a reasonable option for patients with compromised pulmonary reserve, especially those in whom a previous contralateral resection has been performed. The following report describes the role of limited resection in the management of patients with T1-T2N0 non-small-cell lung cancer and presents a retrospective review of our series of 125 limited resections out of 1356 resections performed for lung cancer. In particular, long term survival and the frequency of local/regional recurrence were noted in 92 cases operated on with a curative intent. 26.6% vs 12.5% local/regional recurrence rates were observed among patients undergoing limited resections for T2 and T1 lung cancer, respectively. The five year survival in the limited resection group was 13.5% for T1 and 60% for T2 vs 51% and 72% in the standard procedure group, respectively. The lobectomy results were superior to those of sublobar resection. The latter should be reserved for patients in poor general condition contraindicating a standard lobectomy.     

Comparison of lobectomy and wedge resection for carcinoma of the lung

To evaluate comparatively lobectomy and wedge resection for carcinoma of the lung, we reviewed retrospectively 1,000 consecutive cases of lung cancer at a Veterans Administration Hospital. Of these cases, 252 were operable; 199 were resectable. Thirty-three patients underwent resection of their lesion as primary treatment. The indications for wedge resection were (1) insufficient pulmonary reserve, (2) resectable cerebral metastasis, (3) frozen-section results reportedly benign. One hundred twelve patients underwent standard lobectomy procedures. Of these patients, 40 were comparable to those patients undergoing wedge resection on the basis of age, histopathological examination, tumor size and location, and the presence of metastatic disease. One, 2, and 5 year survival rates were 85%, 58%, and 26%, respectively, for wedge resection and 75%, 55%, and 25%, respectively, for lobectomy. The operative mortality rate was 0% for wedge resection and 5% for lobectomy. These results indicate that for the patient with a peripheral lung carcinoma and no evidence of metastatic disease a wedge resection offers comparable survival rates with minimal risk of death.     

Limited resection for small peripheral lung cancer using intraoperative pathologic examination

From 1996 to 2002, we performed intentional limited resection for small peripheral lung cancer using intraoperative pathologic examination. Wedge resection was performed in patients who had small peripheral adenocarcinoma (< or = 20 mm), suspected of being Noguchi type A or B, and confirmed by intraoperative pathologic examination. Extended segmentectomy was performed in the rest of patients (tumor diameter < or = 20 mm), and not suspected of being Noguchi type A or B. Hilar and mediastinal lymph nodes sampling was performed in this group. If lymph node metastasis was detected by the intraoperative pathologic examination, the surgical procedures was converted into a lobectomy with lymph node dissection. Limited resection was performed in 27 patients, wedge resection in 8, and extended segmentectomy in 19. All patients received wedge resection are alive without sign of recurrence. In extended segmentectomy, 17 patients are alive with no evidence of disease, 1 patient died of non-pulmonary disease, and 1 patient is alive with recurrent disease. The overall survival rate at 5 years was 100% in wedge resection, 91% in extended segmentectomy, and 79% in standard lobectomy. We conclude that limited resection for small peripheral lung cancer using intraoperative pathologic examination may be safe and effective procedure.     

Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer

OBJECTIVE: The present study was undertaken to demonstrate that limited pulmonary resection for peripheral small-sized lung cancer yields outcomes not inferior to those of lobectomy. METHODS: During the 9-year period from 1992 to 2000, patients with cT1 N0 M0 peripheral non-small cell lung cancer whose maximum tumor diameter was 2 cm or less on diagnostic imaging and in whom lobectomy was determined to be feasible were treated with limited resection if the patient consented to the procedure and with lobectomy if consent to limited resection was not obtained. The survival and clinical outcome of the patients whose tumors were postoperatively staged as pT1 N0 M0 were compared between the limited resection group (n = 74) and the lobectomy group (n = 159). RESULTS: The limited resection group consisted of 60 patients treated with segmentectomy and 14 patients treated with wedge resection. Among patients followed up for a mean period of 52 months after the operation, neither the 3-year nor 5-year survivals differed significantly between the limited resection group (3-year survival, 94.0%; 5-year survival, 89.1%) and the lobectomy group (3-year survival, 97.0%; 5-year survival, 90.1%). Postoperative tumor recurrence was noted in 5 patients after limited resection and in 9 patients after lobectomy, and the difference in the incidence of postoperative recurrence between the 2 groups was not significant. CONCLUSIONS: The results of this study indicate that in patients with peripheral T1 N0 M0 non-small cell lung cancer whose maximum tumor diameter was 2 cm or less, the outcome of limited pulmonary resection is comparable with that of pulmonary lobectomy.     

Diagnosis and surgical treatment for small-sized peripheral lung cancer

Small-sized peripheral lung cancers have been detected more frequently as a result of recent developments in diagnostic imaging including high-resolution computed tomography (HRCT). Although the diagnosis of small-sized peripheral lung cancers is difficult, it makes an adequate diagnosis possible using transbronchial fine needle aspiration cytology or a new thin-type bronchoscope. Surgical treatment using mini-thoracotomy or video-assisted thoracic surgery is effective for early stage small-sized peripheral lung cancers. Lesser resection of lung cancer may provide many benefits to patients, such as preserving vital lung tissue and providing the chance for further resection if a second primary lung cancer develops, however, lobectomy with systematic hilar and mediastinal lymph node dissection should remain the standard surgical treatment, and an intentional limited resection should be adopted for very limited patients with a definitive early stage because of recurrence rates.     

Sublobar resection for the subcentimeter pulmonary nodule

Several studies have demonstrated an increased local recurrence rate with sublobar resection (SR) when compared with lobar resection for the treatment of non-small-cell lung cancer (NSCLC). Therefore, lobectomy has remained the gold standard therapy for NSCLC with lesser resection reserved as a compromise operation for high-risk patients. The increased identification of small NSCLC tumors by CT scan is leading many surgeons to question the appropriateness of lobectomy for these tumors. There has been increasing interest by many surgeons to use SR as intentional therapy for patients with small peripheral NSCLC. This article reviews the recent literature and evidence supporting intentional SR for NSCLC. Although lobectomy should continue to be regarded as the procedure of choice for NSCLC, we believe that a subset of patients with favorable characteristics may be appropriately treated with intentional SR as long as good assessment of nodal involvement is made. Future investigation is required to better define when SR is appropriate.     

Wedge resection for lung cancer

The role of wedge resection in lung cancer is reviewed. In the past century, many reports appeared dealing with limited resection for lung cancer, and it is clear that wedge resection should be performed in patients who are considered at high risk for not tolerating lobectomy; still there is no prospective or even retrospective study on wedge resection carried out in candidates for lobectomy. In recent years, progress in imaging diagnostic technology using high-resolution computed tomography has increased the opportunity to diagnose early adenocarcinoma presenting as small ground-glass opacity (GGO) which could not be detected on chest radiographs. Some patients with GGO may become candidates for wedge resection in this century, if additional favorable data result from prospective studies relevant to imaging diagnosis, pathology, and prognosis.     

Metachronous lung cancer: indication and outcome]

Although lobectomy is the standard surgical treatment for primary lung cancer, it is unclear whether lobectomy will be benefit for patients with metachronous lung cancer. The purpose of this study is to evaluate the difference of benefit between lobectomy and limited resection at second lung resection. Forty-eight patients, who had already undergone lobectomy due to primary lung cancer, undergoing second lobectomy (n = 30) or limited resection (n = 18) for metachronous lung cancer were investigated. The over-all 5-year survival rate of second operation was 51.9%. Although there was no significant difference of 5-year survival rates between lobectomy and limited resection, 50.4% and 49.4%, respectively, lobectomy for T1N0 subset prolonged the survival compared to limited resection, 5-year survival rates, 69.6% and 31.7%, respectively. However, lobectomy resulted in more postoperative complications and less preservation of lung function. Lobectomy should be considered the surgical procedure of choice for patients with metachronous T1N0 lung cancer when lung function is preserved.     

Clinical characteristics after surgery of non-small cell lung cancer which measures 20 mm or less in diameter

Today's advances in diagnostic image-technologies often enable us to find small lung cancers. However, we have few definite strategies including how to diagnosis and treat them. In this study, we performed a retrospective analysis of 122 consecutive patients who underwent surgery for non-small cell lung cancer 20 mm or less in diameter to clarify the clinical features of small lung cancer. Of 122 patients, there were 114 patients of pN0, and 8 patients with lymph node metastasis. Seventy three patients underwent lobectomy, 45 underwent segmentectomy, and 4 underwent wedge resection based on the findings of preoperative CT and anatomical and oncological view during operation. Overall survival rate( OS) and progression free survival( PFS) at 3-year was, 94% and 84%, respectively. There were no differences in OS or PFS between lobectomy group and limited resection group, which might suggest that we adapted appropriate surgical procedures. Multivariate analysis revealed that pathological pleural invasion, lymphatic vessel invasion, and vascular vessel invasion were likely to be unfavorable prognostic-factors. We believe that further investigations should be required to clarify the characteristics of small lung cancer.     

Clinical trials of peripheral stage I (T1N0M0) non-small cell lung cancer

Debate continues regarding the choice of resection for peripheral stage I (T1N0M0) non-small cell lung cancer (NSCLC). Anatomic lobectomy has been considered the standard of care for resectable NSCLC; however, intriguing results of clinical trials have been reported with the use of sublobar resection as primary therapy of selected small peripheral lung cancers. Most modern clinical studies comparing lobectomy to sublobar resection of stage I NSCLC demonstrate equivalent survival, but local recurrence following sublobar resection appears to be greater. Low energy computed tomography screening programs for lung cancer have increasingly identified small peripheral lesions potentially amenable to effective therapeutic management with sublobar resection. We discuss the possible management scenarios for stage I NSCLC in this age of early computed tomography detection of lung cancer, more precise molecular biologic staging of the disease, optimized peri-operative management of the marginally resectable patient, and improved adjunctive treatment measures for local control following lung cancer resection.     

Outcomes: wedge resection versus lobectomy for non–small cell lung cancer at the Cancer Centre of Southeastern Ontario 1998–2009

Background

Sublobar resection for non–small cell lung cancer (NSCLC) remains controversial owing to concern about local recurrence and long-term survival outcomes. We sought to determine the efficacy of wedge resection as an oncological procedure.

Methods

We analyzed the outcomes of all patients with NSCLC undergoing surgical resection at the Cancer Centre of Southeastern Ontario between 1998 and 2009. The standard of care for patients with adequate cardiopulmonary reserve was lobectomy. Wedge resection was performed for patients with inadequate reserve to tolerate lobectomy. Predictors of recurrence and survival were assessed. Appropriate statistical analyses involved the χ² test, an independent samples t test and Kaplan–Meier estimates of survival. Outcomes were stratified for tumour size and American Joint Committee on Cancer seventh edition TNM stage for non–small cell lung cancer.

Results

A total of 423 patients underwent surgical resection during our study period: wedge resection in 71 patients and lobectomy in 352. The mean age of patients was 64 years. Mean follow-up for cancer survivors was 39 months. There was no significant difference between wedge resection and lobectomy for rate of tumour recurrence, mortality or disease-free survival in patients with stage IA tumours less than 2 cm in diameter.

Conclusion

Wedge resection with lymph node sampling is an adequate oncological procedure for non–small cell lung cancer in properly selected patients, specifically, those with stage IA tumours less than 2 cm in diameter.     

Surgical results for second primary lung cancer

Of 897 patients who underwent operation for lung cancer between April 1996 and March 2010, 57 patients underwent pulmonary resection for 2nd primary lung cancer. There were 44 men and 13 women. The average age at the 2nd operation was 71. The initial pulmonary resection was lobectomy in 49 patients, segmentectomy in 4 and wedge resection in 4. The 2nd pulmonary resection was lobectomy in 10 patients, segmentectomy in 12 and wedge resection in 35. Preoperative stage of the 2nd primary lung cancer was IA in 43, IB in 13 and IIB in 1. Postoperative stage was IA in 38, IB in 10, IIA in 1, IIB in 3, IIIA in 2 and IIIB in 3. Surgical complications occurred in 4, but there were no perioperative deaths. The 5-year survival rate for 2nd primary lung cancers was 59.9%. The 5-year survival rate for patients treated with wedge resection was 71.1%. The 5-year survival rate of the patients with p-stage IA was 72.7%, and that for patients with p-stage IB or more advanced diseases was 32.9%. We conclude that an aggressive surgical approach for a 2nd primary lung cancer is effective and is linked with good outcome if the tumor is detected at stage IA, when the possible cure by performing wedge resection is promissing.     

Cancer of the lung: staging, radiology, surgery

Primary lung cancer is the leading cause of cancer-related deaths in industrialized countries. Despite advances in treatment, the overall 5-year survival remains poor due to the advanced stage of disease at presentation. Smoking remains the main risk factor being responsible for around 85% of all cases. The most important distinction is that between non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). Surgeons primarily deal with NSCLC (SCLC is an aggressive tumour that usually presents with systemic disease). NSCLC has a number of histological subtypes.Patient evaluation aims to establish the cell type of the tumour, determine the stage of the disease, and to determine fitness for surgery. Staging of NSCLC is based on the tumour/node/metastasis (TNM) classification. Procedures used to diagnose or stage lung cancer can include chest X-ray, chest computed tomography (CT) scan, combined positron emission tomography/CT, CT or transbronchial guided needle biopsy, and mediastinoscopy amongst others. Surgery is the only established method for ‘curing’ NSCLC. However, only a quarter of patients have resectable disease at presentation. Surgical resection can be performed using a variety of procedures including lobectomy, pneumonectomy or wedge resections. The 5-year survival of patients with stage I lung cancer following surgical resection is 51-60%.     

Evaluation of lung function as a prognostic index before and after surgical resection due to NSCLC

BACKGROUND: Although there were several studies on survival, death and morbidity rates after lung resection, considering both limited and extended resections, lung exercise capacity has been quite seldom taken into account as an index for prognosis. The aim of this study compare the consequences of three kinds of lung resections (pneumonectomy, lobectomy and wedge resection), to test pre- and post-surgery exercise capacity for patients affected by NSCLC in order to obtain more detailed prognostic indices. METHODS: All the patients were studied by means of thorough lung static function and hemogas analytical tests before and after surgical resection, from 15 days to 12 twelve months' time past surgery. RESULTS: In fact, in relation to lung resection due to neoplasms, several studies pointed out that zone-limited resections show an obvious anatomical benefit in terms of parenchyma spair compared to lobectomy; however, it is underlined that the functional benefits of small resections don't really prevail over post-lobectomy anatomical advantages. Furthermore local relapses are more common after small resections rather than after lobectomy. CONCLUSIONS: Neither limited lung resection nor lobectomy alone, therefore, in accordance with nearly all the recent and still ongoing studies in this huge research field, has a significant effect on exercise capacity. Only pneumonectomy is associated with impaired exercise performance, and, nevertheless, quite below our expectations.     

Indication for limited surgery on small lung cancer tumors measuring 1cm or less in diameter on preoperative computed tomography and long-term results

OBJECTIVE: Non-invasive lung cancers showed a good prognosis after limited surgery. But it is still uncertain about invasive lung cancers. We investigated the indications for limited surgery for small lung cancer tumors measuring 1 cm or less in diameter on preoperative computed tomography (CT). METHODS: This study retrospectively analyzed of 1,245 patients who underwent complete resection of lung cancer between 1989 and 2004 in our hospital. Sixty-two patients (5%) had tumors measuring 1 cm or less in diameter. The probability of survival was calculated using the Kaplan-Meier method. RESULTS: All diseases were detected by medical checkup, 52 % of the patients were not definitively diagnosed with lung cancer before surgery. Adenocarcinoma was histologically diagnosed in 49 patients (79%). Other histologic types included squamous cell carcinoma (8), large cell carcinoma (1), small cell carcinoma (1), carcinoid (2), and adenosquamous cell carcinoma (1). Fifty-seven patients (92%) showed pathologic stage IA. The other stages were IB (2), IIA (1), and IIIB (2). There were 14 bronchioloalveolar carcinomas (25% of IA diseases). The 5-year survival rates of IA patients were 90%. The 5-year survival rate of patients with tumors measuring 1cm or less diameter was 91% after lobectomy or pneumonectomy, and 90% after wedge resection or segmentectomy. There were 3 deaths from cancer recurrence, while there were no deaths in 14 patients with bronchioloalveolar carcinoma CONCLUSION: After limited surgery, non-invasive cancer showed good long-term results, while invasive cancer showed a recurrence rate of 2.3% to 79% even though the tumor measured 1 cm or less in diameter on preoperative CT.