Indication and results of thoracoscopic segmentectomy for small peripheral lung cancer

Since 2008, 46 patients have undergone thoracoscopic segmentectomy without mini-thoracotomy for almost pure ground-glass opacity (GGO) lesion by thin-section computed tomography (CT) finding which was difficult to be performed wedge resection. No patient was converted to both thoracotomy and lobectomy. The operation time ranged from 75 to 240 min (mean, 161 min), and blood loss ranged from 1 to 110 g( mean, 25 g). We used stapler in 29 patients and electrocautery in 17 patients to deviate inter segmental plane. Postoperative complications were seen in 6 patients (13%), major complication was air leakage in 6 patients. There was no in-hospital mortality. Only 1 patient had bone metastasis on 11 months after operation. Thoracoscopic segmentectomy considered to be a safe and feasible procedure for the selected patients with small-sized peripheral lung cancer.     

Surgical procedure of thoracoscopic and video-assisted anatomical segmentectomy for small peripheral lung cancer

Recently, small peripheral lung cancers which is indicated limited resection are frequently found by HRCT or PET. The limited resection for lung cancer includes thoracic and video-assisted anatomical segmentectomy (VATS segmentectomy) and wedge resection of the lung parenchyma. In anatomical segmentectomy, intra-plumonary lymph nodes are dissected, on the other hand, those lymph nodes can not be dissected in wedge resection. Consequently, segmentectomy will be radical procedure for lung cancer compared with wedge resection. Thoracic surgeons are required to perform anatomical segmentectomy for small peripheral lung cancer. The anatomical segmentectomy is not familiar procedure for recent thoracic surgeons. Thoracic surgeons should be skilled in that procedures. This is a review of basic procedures of VATS segmentectomy for lung cancer for young thoracic surgeones.     

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.     

Pulmonary function after segmentectomy for small peripheral carcinoma of the lung.

OBJECTIVE: The aim of this study is to compare the pulmonary function after a segmentectomy with that after a lobectomy for small peripheral carcinoma of the lung. Patients And Methods: Between 1993 and 1996, segmentectomy and lobectomy were performed on 48 and 133 good-risk patients, respectively. Lymph node metastases were detected after the operation in 6 and 24 patients of the segmentectomy and lobectomy groups, respectively. For bias reduction in comparison with a nonrandomized control group, we paired 40 segmentectomy patients with 40 lobectomy patients using nearest available matching method on the estimated propensity score. RESULTS: Twelve months after the operation, the segmentectomy and lobectomy groups had forced vital capacities of 2.67 +/- 0.73 L (mean +/- standard deviation) and 2.57 +/- 0.59 L, which were calculated to be 94.9% +/- 10.6% and 91.0% +/- 13.2% of the preoperative values (P =.14), respectively. The segmentectomy and lobectomy groups had postoperative 1-second forced expiratory volumes of 1.99 +/- 0.63 L and 1.95 +/- 0.49 L, which were calculated to be 93.3% +/- 10.3% and 87.3% +/- 14.0% of the preoperative values, respectively (P =.03). The multiple linear regression analysis showed that the alternative of segmentectomy or lobectomy was not a determinant for postoperative forced vital capacity but did affect postoperative 1-second forced expiratory volume. CONCLUSION: Pulmonary function after a segmentectomy for a good-risk patient is slightly better than that after a lobectomy. However, segmentectomy should be still the surgical procedure for only poor-risk patients because of the difficulty in excluding patients with metastatic lymph nodes from the candidates for the procedure.     

Video-assisted thoracoscopic surgery (VATS) segmentectomy for small peripheral lung cancer tumors: intermediate results

Background We investigated the feasibility and suitability of video-assisted thoracoscopic surgery (VATS) segmentectomy for curing selected non-small cell lung cancer (NSCLC) with this less invasive technique Methods We performed VATS segmentectomy for small (<20 nm) peripherally located tumors and pathologically confirmed lobar lymph node-negative disease by frozen-section examination during surgery. Of the 34 patients who underwent this limited resection, 22 were treated with complete hilar and mediastinal lymph node dissection (intentional group), whereas 12 patients who were deemed to be high risk in their toleration for lobectomy underwent VATS segmentectomy with incomplete hilar and mediastinal lymph node dissection (compromised group). The surgical and clinical parameters were evaluated and compared with those of segmentectomy under standard thoracotomy to evaluate the technical feasibility of VATS segmentectomy. Results We found that VATS segmentectomy could be performed safely with a nil mortality rate and acceptably low morbidity. The mean period of observation was relatively short at 656.7±572.1 and 783.4±535.8 days in the intentional and compromised groups, respectively. At the time of writing, all intentional patients remain alive and free of recurrence. There were two cases of non-cancer-related death in the compromised group. Clinical data indicated that VATS segmentectomy caused the same number or fewer surgical insults compared with segmen-tectomy under standard thoractomy Conclusions The present results are intermediate only; the rate of long-term survival and the advantages of the less invasive procedure still need further investigation. Nevertheless, we believe that VATS segmentectomy with complete lymph node dissection is a reasonable treatment option for selected patients with small peripheral NSCLC.     

Extended segmentectomy for small lung tumors

To identify the benefits of limited surgery on small-sized lung tumors, the following subjects are discussed: 1) an updated report from a prospective group study (January 1992-December 1994) for extended segmentectomy for small lung tumors (n = 55); 2) a histopathological study of resected adenocarcinoma specimens less than 2 cm in size (n = 94), proposed by Noguchi; and 3) lung function after limited surgery and the quality of video-assisted thoracoscopic surgery. RESULTS: 1) Among 10 deaths, 4 patients died of their disease including one with local recurrence. The survival rate at 5 years was 91%, not including 6 unrelated deaths. 2) Of 94 patients, twelve with localized bronchioalveolar tumors (type A and B), and 23 of 57 patients with active fibroblastic proliferation (type C), underwent extended segmentectomy. Those 35 patients are all free of disease. The remaining 59 patients had a 70% 5-year survival rate. 3) Forced vital capacity was maintained at 92% of the preoperative level, which was much better than 81% for patients undergoing lobectomy. Card-sized thoracotomy using a thoracoscope was carried out in 92 patients, including 21 patients who underwent segmentectomy, in a series of 175 consecutive lung cancer operations. This approach resulted in less bleeding, the same operating time, and better preservation of vital capacity. CONCLUSIONS: Extended segmentectomy for small lung tumors did not affect the prognosis, and was associated with a better quality of life postoperatively.     

Extended segmentectomy for small-sized peripheral CN0 non-small cell lung cancer

With advances in diagnostic imaging techniques, small-sized lung cancers are now diagnosed much more often. Lobectomy has been the standard surgical procedure even for small lung for decades. Is it necessary to remove uniformly such a large amount of lung tissue for all tiny cancers? Extended segmentectomy as an intentional lesser resection for a peripheral clinical N0 lung cancer tumor 2 cm or less in diameter in patients able to tolerate a lobectomy, in which the resection line of the lung is placed beyond the burdened segment if required for sufficient margins, requires confirmation of surgical N0 disease by intraoperative examination of lymph node frozen sections. The procedure should be converted to standard lobectomy if the sections are positive. Recently, several reports have suggested that the prognosis after lesser resection in such highly selected patients is no worse than that following standard lobectomy. In addition to preservation of pulmonary function, this lung-saving surgery provides a second chance to patients who have a higher risk of metachronous disease after surviving the first disease. Extended segmentectomy might be an alternative standard surgery for patients with small peripheral lung cancers. However, patient selection with intraoperative pathologic examination and accurate technique with wide lesion margins must be strictly adhered to.     

Thoracoscopic segmentectomy for lung cancer

Lobectomy has long been considered the standard procedure for early-stage lung cancer, and minimally invasive techniques have been demonstrated to be associated with superior outcomes compared with lobectomy by thoracotomy. The use of segmentectomy is under investigation for selected patients with small tumors, and the use of minimally invasive strategies is applicable as well. In this review, we analyzed studies that have compared (1) thoracoscopic segmentectomy versus the open approach, (2) thoracoscopic segmentectomy versus thoracoscopic lobectomy, and (3) thoracoscopic segmentectomy versus thoracoscopic lobectomy versus thoracoscopic wedge resection. When compared with open segmentectomy, preliminarily, thoracoscopic segmentectomy was found to have equivalent oncologic results, with shorter hospital length of stay, reduced rates of morbidity, and lower cost. When compared with thoracoscopic lobectomy, thoracoscopic segmentectomy had equivalent rates of morbidity, recurrence, and survival. Preliminarily, thoracoscopic segmentectomy was found to result in greater preservation of lung function and exercise capacity than the thoracoscopic lobectomy.     

Anatomical thoracoscopic segmentectomy for lung cancer

Minimally invasive surgery for lung cancer has seen considerable progress. A segmentectomy is less invasive than a lobectomy as it preserves lung parenchyma. The preservation of pulmonary function can reduce complications. The combination of a thoracoscopic approach with a segmentectomy should be less invasive, and retrospective studies have shown that the thoracoscopic approach is safe and feasible due to the lower postoperative mortality and complication rates as compared to an open thoracotomy. The validity of a segmentectomy for ground-glass-opacity-type lung cancer has been demonstrated, and it has also been evaluated for small, predominantly solid, lung cancers. Two prospective studies of segmentectomy versus lobectomy for ≤2-cm non-small-cell lung cancer are now underway (CALGB 140503 and JCOG0802/WJTOG4607L) and should clarify the role of segmentectomy. Regarding thoracoscopic segmentectomy, few retrospective studies have reported the oncological outcome for lung cancer and there is inadequate evidence regarding the long-term oncological outcome, although the perioperative complication rate and duration of hospital stay seem to be non-inferior to those of an open approach. For preoperative simulation, three-dimensional multidetector computed tomography (3D-CT) is essential for performing an atypical thoracoscopic segmentectomy safely. Preoperative 3D-CT angiography and bronchography (3D-CTAB) enable accurate identification of the venous branches in the affected segment and the intersegmental vein. This review describes the surgical and oncological outcomes, utility of 3D-CTAB, and surgical techniques and procedure used for a thoracoscopic segmentectomy.     

电视胸腔镜辅助小切口肺叶切除术在肺癌中的应用体会

目的探讨电视胸腔镜辅助小切口肺叶切除术治疗肺癌的效果。方法随机将52例肺癌患者分为实验组和对照组,各26例。对照组实施传统开胸肺叶切除术,实验组应用电视胸腔镜辅助小切口肺叶切除术。观察比较两2患者治疗效果。结果实验组手术时间、住院时间、术中出血量、切口长度和并发症发生率均显著低于对照组患者,2组比较,差异具有统计学意义(P0.05)。结论对肺癌患者采用电视胸腔镜辅助小切口肺叶切除术,可以明显降低并发症发生率,缩短住院时间,降低术中出血量,提高患者生存质量。     

Non-tuberculous mycobacterial infection along the staple-suture line after segmentectomy for small peripheral lung cancer; report of a case

A 60-year-old non-immunocompromised man who had undergone right upper lobectomy and subsequent left superior segmentectomy for small peripheral lung cancers (stage I well-differentiated adenocarcinomas) 2 years earlier, was referred to us for further investigation of an asymptomatic abnormal shadow observed on a chest radiograph. Chest computed radiography showed air-space consolidation along the staple-suture line associated with the left superior segmentectomy, the abnormality was 4 x 5 x 5 cm. Completion lower lobectomy was performed because transbronchial biopsy did not provide for a definite diagnosis. Pathological examination revealed a large granuloma infected by Mycobacterium intercellulare. The lung parenchyma may be exposed along the staple-suture line and somewhat vulnerable to infection in cases of partial pulmonary resection. We should be aware of this possibility after lesser pulmonary resection for small peripheral lung cancer.     

A case-matched study of anatomical segmentectomy versus lobectomy for stage I lung cancer in high-risk patients.

OBJECTIVE: Sublobar resections may offer a method of increasing resection rates in patients with lung cancer and poor lung function, but are thought to increase recurrence and therefore compromise survival for stage I non-small cell lung cancer (NSCLC). To test this hypothesis we have compared the long-term outcome from lobectomy and anatomical segmentectomy in high-risk cases as defined by predicted postoperative FEV1 (ppoFEV1) less than 40%. METHODS: Over a 7-year period 55 patients (27% of all resections for stage I NSCLC) with ppoFEV1<40% underwent resection of stage I NSCLC. The 17 patients who underwent anatomical segmentectomy were individually matched to 17 patients operated by lobectomy on the bases of gender, age, use of VATS, tumour location and respiratory function. We compared their perioperative course, tumour recurrence and survival. RESULTS: There were no significant differences in hospital mortality (one case in each group), complications or hospital stay. Overall 5-year survival was 69%. There were no differences in recurrence rates (18% in both groups) or survival (64% after lobectomy and 70% after segmentectomy). There was preservation of pulmonary function after segmentectomy (median gain of 12%) compared to lobectomy (median loss of 12%) (P=0.02). CONCLUSIONS: Anatomical segmentectomy allowed for surgical resection in patients with stage I NSCLC and impaired respiratory reserve without compromising oncological results but with preservation in respiratory function.     

Outcomes with segmentectomy versus lobectomy in patients with clinical T1cN0M0 non–small cell lung cancer

ObjectiveWe hypothesize that segmentectomy is associated with similar recurrence-free and overall survival when compared with lobectomy in the setting of patients with clinical T1cN0M0 non–small cell lung cancer (NSCLC; >2-3 cm), as defined by the American Joint Committee on Cancer 8th edition staging system.MethodsWe performed a single-institution retrospective study identifying patients undergoing segmentectomy (90) versus lobectomy (279) for T1c NSCLC from January 1, 2003, to December 31, 2016. Univariate, multivariable, and propensity score–weighted analyses were performed to analyze the following endpoints: freedom from recurrence, overall survival, and time to recurrence.ResultsPatients undergoing segmentectomy were older than patients undergoing lobectomy (71.5 vs 68.8, respectively, P = .02). There were no differences in incidence of major complications (12.4% vs 11.7%, P = .85), hospital length of stay (6.2 vs 7 days, P = .19), and mortality at 30 (1.1% vs 1.7%, P = 1) and 90 days (2.2% vs 2.3%, P = 1). In addition, there were no statistical differences in locoregional (12.2% vs 8.6%, P = .408), distant (11.1% vs 13.9%, P = .716), or overall recurrence (23.3% vs 22.5%, P = 1), as well as 5-year freedom from recurrence (68.6% vs 75.8%, P = .5) or 5-year survival (57.8% vs 61.0%, P = .9). Propensity score–matched analysis found no differences in overall survival (hazard ratio [HR], 1.034; P = .764), recurrence-free survival (HR, 1.168; P = .1391), or time to recurrence (HR, 1.053; P = .7462).ConclusionsIn the setting of clinical T1cN0M0 NSCLC, anatomic segmentectomy was not associated with significant differences in recurrence-free or overall survival at 5 years. Further prospective randomized trials are needed to corroborate the expansion of the role of anatomic segmentectomy to all American Joint Committee on Cancer 8th Edition Stage 1A NSCLC.