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 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.     

Results of surgical treatment for small (2 cm or Under) adenocarcinomas of the lung

Purpose The objectives of this study were to identify the clinicopathologic characteristics and prognostic factors of small (2 cm or less in diameter) adenocarcinomas, and furthermore to assess the acceptability of performing a limited pulmonary resection in such patients. Methods We retrospectively reviewed 523 cases of cT1N0M0 peripheral adenocarcinoma measuring 2 cm or less on diagnostic images treated by a complete resection between 1991 and 2004. Results The overall 5-year survival rate of the patients with small adenocarcinomas was 83.6%. Univariate and multivariate analyses identified an older age, male sex, wedge resection, advanced stage, and Noguchi classification of C, D, E, or F as independent prognostic factors that adversely affected overall survival. However, there were no significant differences in the survival according to surgical procedure in the patients whose tumors had a maximum diameter of 1.0 cm or less or in Noguchi type A and B cases. Conclusions Age, sex, surgical procedure, p-stage, and Noguchi classification were independent prognostic factors for survival in patients with small adenocarcinomas. A segmentectomy is therefore considered to be an acceptable alternative to a lobectomy for adenocarcinomas of 2 cm or less in diameter. A wedge resection may be acceptable for tumors measuring 1 cm or less in diameter or Noguchi type A and B tumors.     

Intraoperative frozen section diiagnosis of small peripheral lung adenocarcinoma for limited operation

Sixty-two cases of peripheral lung adenocarcinoma 2 cm or less in diameter were diagnosed as type A, B, or C according to Noguchi classifications by intraoperative frozen section diagnosis. Four of 19 type A were changed finally to type B by postoperative pathologic examination. Likewise 10 of 34 type B were changed finally to 1 type A, 8 type C, and 1 type D. Three of 9 type C were changed finally to 2 type B and 1 type D. Frozen section diagnosis for small peripheral lung adenocarcinoma has some special problems and limitations. Only cases of type A diagnosed by frozen section diagnosis should be permitted to undergo limited surgical resection.     

Clinicopathological study of early peripheral adenocarcinoma of the lung

Fifty surgically resected small peripheral adenocarcinomas measuring 20 mm or less in greatest diameter were reviewed according to Noguchi classification (1995). Type A (localized bronchioloalveolar carcinoma: LBAC) and type B (LBAC with foci of structural collapse of alveoli) showed no lymph node metastasis and in these two types, 5-year survival was 100%. Histologic types A and B in Noguchi classification are thought to be early peripheral adenocarcinoma. By further evaluation of preoperative imaging diagnosis, operative procedure and pathological study patients with early peripheral adenocarcinoma would be able to become candidates for limited surgery (segmentectomy or partial resection).     

Intentional limited resection for lung adenocarcinoma of 2 cm in size or less according to intraoperative frozen section and high-resolution computed tomography

One hundred twenty-six cases of resected lung adenocarcinoma of 2 cm in size or less were studied about intra and postoperative Noguchi's classification, high-resolution computed tomography (HRCT) findings and lymph node metastases in cases of lobectomy. Intentional limited resection for lung adenocarcinoma of 2 cm in size or less was recommended for selected patients with tumors of type A of Noguchi's classification diagnosed by intraoperative frozen diagnosis or tumors of intraoperative type B of 0.5 in ground-glass opacity (GGO) diameter ratio or more of HRCT. These patients are almost equal to patients of 0.5 in GGO diameter ratio or more with any type of Noguchi's classification. This GGO diameter ratio of 0.5 is easily available as a criteria of intentional limited resection for lung adenocarcinoma of 2 cm in size or less.     

Criteria for intentional limited pulmonary resection in cT1N0M0 peripheral lung cancer.

OBJECTIVE: The purpose of this study was to establish selection criteria for intentional limited resection in patients with peripheral lung cancer. METHODS: Six hundred eighty-nine cases of cT1N0M0 peripheral non-small cell lung cancer were divided into groups according to maximum tumor diameter. The cases in each group were examined for histopathological invasive factors, and the results of a pilot study of intentional limited resection were assessed. RESULTS: The positive rate of invasive factors was 30.8% among the patients with tumors 2 cm or less in diameter, and significantly lower than the 44.0% noted in those whose tumor diameter was in the 2.1-3.0 cm range. The positive rate was significantly lower in 90 patients with type A or B adenocarcinoma, and none of these patients developed postoperative recurrence. In 24 of these 90 patients, the tumor diameter was in the 2.1-3.0 cm range. The 5-year survival rate in the 74 patients with pT1N0M0 and tumors 2 cm or less in diameter who underwent limited resection was 89.1%. CONCLUSIONS: We attempted to establish selection criteria for limited resection, with the aim of obtaining survival rates that was comparable to those obtained after lobectomy. The selection criteria established in this study are: 1, cT1N0M0 peripheral non-small cell lung cancer; 2, maximum tumor diameter 2 cm or less on diagnostic images, but a tumor diameter in the range of 2-3 cm in adenocarcinoma of Noguchi type A or B cases; 3, limited resection feasible based on tumor location.     

Criteria for intentional limited pulmonary resection in cT1N0M0 peripheral lung cancer

Objective: The purpose of this study was to establish selection criteria for intentional limited resection in patients with peripheral lung cancer. Methods: Six hundred eighty-nine cases of cT1N0M0 peripheral non-small cell lung cancer were divided into groups according to maximum tumor diameter. The cases in each group were examined for histopathological invasive factors, and the results of a pilot study of intentional limited resection were assessed. Results: The positive rate of invasive factors was 30.8% among the patients with tumors 2 cm or less in diameter, and significantly lower than the 44.0% noted in those whose tumor diameter was in the 2.1–3.0 cm range. The positive rate was significantly lower in 90 patients with type A or B adenocarcinoma, and none of these patients developed postoperative recurrence. In 24 of these 90 patients, the tumor diameter was in the 2.1–3.0 cm range. The 5-year survival rate in the 74 patients with pT1N0M0 and tumors 2 cm or less in diameter who underwent limited resection was 89.1%. Conclusions: We attempted to establish selection criteria for limited resection, with the aim of obtaining survival rates that was comparable to those obtained after lobectomy. The selection criteria established in this study are: 1, cT1N0M0 peripheral non-small cell lung cancer; 2, maximum tumor diameter 2 cm or less on diagnostic images, but a tumor diameter in the range of 2–3 cm in adenocarcinoma of Noguchi type A or B cases; 3, limited resection feasible based on tumor location.     

Routine frozen-section biopsy from the surgical bed should be performed during nephron-sparing surgery for renal cell carcinoma

OBJECTIVE: It has been reported in recent studies that nephron-sparing surgery (NSS) is as effective as radical nephrectomy (RN) for pT1a and pT1b renal cell carcinoma (RCC). In order to decrease the rate of tumor recurrence, resection of a small amount of normal parenchyma surrounding the tumor is widely recommended. Although a 0.5-1.5-cm wide resection margin is recommended no agreement has been reached concerning the thickness of the surgical margin. In this study we tried to determine whether routine frozen-section biopsy from the surgical bed is mandatory during NSS for RCC. MATERIAL AND METHODS: The study involved 19 renal units of 18 patients who underwent partial nephrectomy for solid renal tumors (<7 cm) at different centers in Ankara. Hypothermic ischemia was instituted after placing the kidney in an intestinal bag full of ice slush and cross-clamping the renal artery. In all cases an approximately 1-cm margin of normal tissue was removed with the tumor. Then, intraoperatively, at least three frozen-section biopsies were taken from the surgical bed to determine the surgical margin. If the biopsy was positive, RN was performed. RESULTS: All patients were staged as pT1a or pT1b according to the 2002 TNM classification. The average tumor size was 3.8 cm. In three cases we performed RN due to positive surgical margins. Surgical margins were negative in 16 tumors, with a mean negative margin size of 5 mm (range 2-11 mm). One patient died of a non-cancer-related cause. The mean distance to the renal capsule was 7 mm (range 1-11 mm). Seventeen patients were followed up for 18 months with no local or systemic recurrence. CONCLUSION: In some cases an approximately 1-cm margin is not sufficient to ensure a negative margin and frozen-section biopsies must be taken from the tumor bed, even if it seems normal macroscopically.     

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.     

Frozen-Section Diagnosis of Small Adenocarcinoma of the Lung for Intentional Limited Surgery

Purpose To determine if Noguchi's classification can be evaluated accurately by frozen-section diagnosis before limited surgery. Methods We performed frozen-section diagnosis in 31 of 343 patients who underwent excision of primary lung cancer at our hospital between 1993 and 2004. All 31 patients had pulmonary adenocarcinoma, with a tumor diameter of ≦20 mm. There were 20 men and 11 women, ranging in age from 42 to 79 years (mean, 63.2 years). We assessed the rate of correct Noguchi's classification by categorizing all lesions into the following three groups on the basis of tumor diameter: ≤10 mm, 11–15 mm, and 16–20 mm. Results The overall rate of correct frozen-section diagnosis during surgery was 67.7%; being 100%, 41.7%, and 70% in the ≦10 mm, 11–15 mm, and 16–20 mm groups, respectively. Conclusion Limited surgery for primary lung cancer can be performed when the tumor diameter is ≦10 mm, by confirming it as either type A or B according to Noguchi's classification, using frozen-section diagnosis. Thus, examination of frozen sections might be an important diagnostic procedure before intentional limited surgery for lung cancer.     

Implication of the CT characteristics of subcentimeter pulmonary nodules

Screening by low-dose helical computed tomography (CT) detects many small pulmonary nodules less than 1 cm in diameter. Pulmonary nodules can be practically classified into three types by their CT appearance: pure ground-glass opacity (GGO), GGO with a solid central component, and solid nodule. Ground-glass opacity on thin-section CT is considered to most commonly represent focal bronchoalveolar carcinoma. However, one-third of pure GGOs represent atypical adenomatous hyperplasia. Noguchi has classified small adenocarcinomas into pathological subtypes (A through F) that appear to have clinical significance. Noguchi types D-F can be differentiated from types A, B, and C by CT findings--however, CT does not appear to be able to reliably distinguish D-F lesions and squamous cell carcinoma from benign tumors. The rate of obtaining a correct preoperative diagnosis on the basis of CT findings was significantly elevated after we instituted a program of preoperative evaluation based on defined thin-section CT characteristics of small nodules. Although emerging data suggest that limited resection for malignant lesions 10 mm or less may be appropriate, particularly for Noguchi types A-C, this remains controversial.     

Prospective study of extended segmentectomy for small lung tumors: the final report

BACKGROUND: Minimal resection of small lung tumors is still controversial. This study was conducted to clarify whether this type of operation is acceptable. METHODS: From January 1992 to December 1994, 73 patients were registered in a multiinstitutional trial of limited resection for peripheral lung tumors less than 2 cm in diameter. The operative procedure consisted of extended segmentectomy in which the cut line of the lung was beyond the burdened segment, confirming N0 disease by intraoperative lymph node examination of frozen sections. The operation was changed to other procedures if the report was positive. RESULTS: All the patients were observed more than 5 years. There were no perioperative deaths and no major complications. A total of 55 patients were finally enrolled in this study. Ten patients died postoperatively, 4 of lung cancer and the remaining 6 died of other diseases, with no signs of recurrence. The 5-year survival rate, excluding these 6 patients, was 91.8%; for all patients including those who died it was 81.8%. A total of 18 patients were not included in this study for various reasons. The decrease in forced vital capacity was 11.3% +/- 9.8% compared with the preoperative value. CONCLUSIONS: Extended segmentectomy is an alternative method as a standard operation for patients with small peripheral lung tumors, and the loss of lung function is minimal. However, patient selection must be strict, with intraoperative pathologic examination, and a wide margin to the lesion beyond the burdened segment is mandatory.     

Surgical experience of 6 multiple primary lung cancers

Recently, we often meet multiple primary lung cancers with ground glass opacity (GGO). It is necessary for us to find suitable strategy to each case. We report a rare case with 6 lesions all of which were resected surgically. A 60-year old male visited our hospital for examination of abnormal shadows on the chest X-ray. Computed tomography (CT) scan showed 5 GGO lesions in the lung field (2 in the left lower lobe, 2 in the right upper lobe, 1 in the right middle lobe). He underwent left S6 segmentectomy as a 1st surgery, followed by wedge resection of the right upper lobe with right middle as a 2nd surgery. Pathologically, they were type A and B of the Noguchi classification. After 3-year follow-up, a new lesion developed in the right lower lobe and was resected by right lower lobectomy. It was invasive papillary adenocarcinoma. As a consequence, 6 lesions were all removed safely. The patient has been well without recurrence for 1 year after the last surgery.     

Should mediastinal nodal dissection be routinely undertaken in patients with peripheral small-sized (2 cm or less) lung cancer? Retrospective analysis of 225 patients.

OBJECTIVE: We retrospectively reviewed nodal status of the patients with peripheral small-sized lung cancer grouped by cell type and tumor size to evaluate the necessity of systematic nodal dissection in this group of patients. METHODS: From 1973 to 1998, 1713 patients underwent pulmonary resection for primary lung cancer in Kanazawa University. Among them, 225 patients (13.1%) with peripheral small-sized (2 cm or less) lung cancer underwent lobectomy and systematic nodal dissection were retrospectively reviewed. The maximum diameter of the tumor was measured on formalin-fixed surgical specimens. RESULTS: The histological types were adenocarcinoma in 170 (75.6%), squamous cell carcinoma in 20 (8.9%), small cell carcinoma in 19 (8.4%) and others in 16 (7.1%). Among 170 adenocarcinoma patients, 38 (22.4%) showed hilar or mediastinal lymph node metastases. No mediastinal lymph node metastasis was encountered in all squamous cell carcinoma (n = 20), adenocarcinoma < or = 1 cm (n = 16), small cell carcinoma < or = 1 cm (n = 4), and adenocarcinoma of Noguchi's classification type A or B (n = 24). CONCLUSIONS: Mediastinal nodal dissection would be unnecessary in the patients with peripheral small-sized lung cancer fulfilling these criteria: (1) squamous cell carcinoma < or = 2 cm; (2) adenocarcinoma < or = 1 cm; (3) localized bronchioloalveolar carcinoma < or = 2 cm without foci of active fibroblastic proliferation in histology (Noguchi's classification type A or B adenocarcinoma); (4) small cell carcinoma < or = 1 cm. Candidates fulfilling above criteria were 28.4% (64/225) of small-sized lung cancer and 10.9% of stage IA patients. The establishment of a universally accepted therapeutic strategy for small-sized lung cancer is indispensable in the clinical spread of various sort of limited resections.     

A review of the prognostic factors in patients with recurrence after liver resection for hepatocellular carcinoma

BACKGROUND: Liver transplantation achieves better results when hepatocellular carcinoma fits the Milan criteria. This study investigated predictors of recurrent hepatocellular carcinoma exceeding the Milan criteria. METHODS: Among 285 patients with hepatocellular carcinoma fitting the Milan criteria who underwent curative resection, 143 patients suffered initial recurrence (92 had tumors fitting the criteria) and 71 patients suffered a second recurrence (40 conforming tumors). RESULTS: Survival after hepatectomy was significantly worse when initial recurrence was nonconforming. Similarly, survival after initial recurrence was significantly worse when the second recurrence was nonconforming. A preoperative increase of protein induced by vitamin K absence/antagonist II, a tumor diameter of 3 cm or greater, age of 65 years or younger, and intraoperative blood transfusion increased the risk of nonconforming initial recurrence. CONCLUSIONS: Liver transplantation should be considered initially for younger patients with hepatocellular carcinoma fitting the Milan criteria, larger tumors, and an increase of protein induced by vitamin K absence/antagonist II.     

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.     

Leiomyosarcoma and transitional cell carcinoma in the urinary bladder: a case report

A 74-year-old man was admitted for asymptomatic macroscopic hematuria. He had undergone transurethral resection of bladder tumor (TURBT) due to transitional cell carcinoma 30 years ago. Pelvic CT showed two invasive bladder tumors. A 5 cm tumor was on the dome and a 1 cm tumor was on the left lateral wall. TURBT was performed. Pathological examination revealed that they were leiomyosarcoma and transitional cell carcinoma. Radical cystectomy plus bilateral cutaneousureterostomy was performed. He died of lung metastases and local recurrence after 6 months.     

Positron Emission Tomography in Relation to Noguchi’s Classification for Diagnosis of Peripheral Non-Small-Cell Lung Cancer 2 cm or Less in Size

BACKGROUND: F-18 fluorodeoxyglucose positron emission tomography ((18)F-FDG-PET) scanning has become a critically important tool in diagnosis and management of non-small-cell lung cancer. However, the effectiveness of (18)F-FDG-PET as a diagnostic tool for small-sized lung cancer is controversial. The purpose of this study was to examine the accuracy of( 18)F-FDG-PET in relation to Noguchi's classification in the diagnosis of small peripheral non-small-cell lung cancer. METHODS: Between January 2003 and April 2006, 150 patients with peripheral lung lesions who were undergoing chest computed tomography (CT),( 18)F-FDG-PET, and operation were analyzed. RESULTS: Eighty-three patients had malignant lesions, and 67 patients had benign lesions. PET had a sensitivity, specificity, positive predictive value, and negative predictive value of 75.9%, 64.1%, 72.4%, and 68.3%, respectively. In 37 patients with peripheral lung cancer measuring 2.0 cm or less in the greatest diameter, the sensitivity was 51.4% and the specificity was 51.9%. Among them, all 4 cases of Noguchi type A adenocarcinoma [localized bronchioloalveolar carcinoma (LBAC)], 4 of 5 type B and 8 of 17 type C were false negative, while 9 of 11 (81.8%) types D, E, and F (invasive carcinomas without a BAC component) were true positive. CONCLUSION: The accuracy of( 18)F-FDG-PET is generally low in distinguishing malignancy from benign lesions in small lesions (<2.0-cm diameter). The significance of PET as a diagnostic tool is small, especially when the tumor has a ground-glass component at a high rate. The sensitivity of PET is high in small invasive carcinomas without a BAC component, but it is difficult to distinguish carcinoma from benign tumor from its image.