Outcomes of superior segmentectomy versus lower lobectomy for superior segment Stage I non-small-cell lung cancer are equivalent: An analysis of 196 patients at a single, high volume institution

Complete anatomic segmentectomy shows improved oncologic outcomes compared to incomplete anatomic segmentectomy

OBJECTIVES

To compare oncologic outcomes after segmentectomy with division of segmental bronchus, artery and vein (complete anatomic segmentectomy) versus segmentectomy with division of <3 segmental structures (incomplete anatomic segmentectomy).

METHODS

We conducted a single-centre, retrospective analysis of patients undergoing segmentectomy from March 2005 to May 2020. Operative reports were audited to classify procedures as complete or incomplete anatomic segmentectomy. Patients who underwent neoadjuvant therapy or pulmonary resection beyond indicated segments were excluded. Survival was estimated with Kaplan-Meier models and compared using log-rank tests. Cox proportional hazards models were used to estimate hazard ratios (HRs) for death. Cumulative incidence functions for loco-regional recurrence were compared with Gray's test, with death considered a competing event. Cox and Fine-Gray models were used to estimate cause-specific and subdistribution HRs, respectively, for loco-regional recurrence.

RESULTS

Of 390 cases, 266 (68.2%) were complete and 124 were incomplete anatomic segmentectomy. Demographics, pulmonary function, tumour size, stage and perioperative outcomes did not significantly differ between groups. Surgical margins were negative in all but 1 case. Complete anatomic segmentectomy was associated with improved lymph node dissection (5 vs 2 median nodes sampled; P < 0.001). Multivariable analysis revealed reduced incidence of loco-regional recurrence (cause-specific HR = 0.42; 95% confidence interval 0.22-0.80; subdistribution HR = 0.43; 95% confidence interval 0.23-0.81), and non-significant improvement in overall survival (HR = 0.66; 95% confidence interval: 0.43-1.00) after complete versus incomplete anatomic segmentectomy.

CONCLUSIONS

This single-centre experience suggests complete anatomic segmentectomy provides superior loco-regional control and may improve survival relative to incomplete anatomic segmentectomy. We recommend surgeons perform complete anatomic segmentectomy and lymph node dissection whenever possible.

Sublobar Resections

Sublobar resections are commonly performed operations that have seen an increase in applicability. The sublobar approach, comprising segmentectomy and wedge resections, can provide lung preservation and thus is better tolerated in select patients in comparison to lobectomy. These operations are offered for a variety of benign and malignant lesions. Understanding the indications and technical aspects of these approaches is paramount as improvements in lung cancer screening protocols and the imaging modalities has led to an increase in the detection of early-stage cancer. In this article, we discuss the anatomy, indications, technical approaches, and outcomes for sublobar resection.

Sublobar resections for lung cancer: Finally, some answers and some more questions?

The Lung Cancer Study Group Trial, published in 1995, set the tone for lobectomy as the standard of care for early-stage nonsmall cell lung cancer. Twenty-seven years and two randomized trials later, does the thoracic oncology community have clarity regarding the choice type of resection, or more questions?

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 2: systematic review of evidence regarding resection extent in generally healthy patients

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, stereotactic body radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in generally healthy patients is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons with at least some adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In healthy patients there is no short-term benefit to sublobar resection vs. lobectomy in randomized and non-randomized comparisons. A detriment in long-term outcomes is demonstrated by adjusted non-randomized comparisons, more marked for wedge than segmentectomy. Quality-of-life data is confounded by the use of video-assisted approaches; evidence suggests the approach has more impact than the resection extent. Differences in pulmonary function tests by resection extent are not clinically meaningful in healthy patients, especially for multi-segmentectomy vs. lobectomy. The margin distance is associated with the risk of recurrence.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in healthy patients with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation on which to build a framework for individualized clinical decision-making.

A Retrospective Study of Effectiveness of Thoracoscopic Lobectomy and Segmentectomy in Patients with Early-Stage Non-Small-Cell Lung Cancer

Background

Surgical treatment is the first choice for non-small-cell lung cancer. To date, there are only few studies on the changes in laboratory indexes in two types of surgery, namely, thoracoscopic lobectomy and segmental pneumonectomy.

Aim

To investigate the clinical impact of thoracoscopic lobectomy and segmentectomy in patients with early-stage non-small-cell lung cancer.

Methods

We retrospectively reviewed the medical records of 94 patients with early-stage NSCLC in our hospital from October 2017 to October 2019. The patients were divided into two groups. The patients in control and observation groups received thoracoscopic lobectomy and thoracoscopic segmentectomy, respectively. The perioperative indicators, complications, lung function, T cell subsets, tumor markers, follow-up of tumor recurrence rate, and survival rate were compared between two groups.

Results

The operation time of the observation group was longer, and the chest drainage volume was less at 24-48 h after the operation, and the chest tube indwelling time and postoperative hospital stay were shorter than those of the control group. No significant differences in complication probability were observed between two groups. The levels of FEV1, FVC, and MVV in the two groups were lower than those before the operation at 3 days after surgery, but the FEV1, FVC, and MVV levels in the observation group were higher than those in the control group. The CD3+, CD4+, and CD4+/CD8+ levels in the two groups were lower than those before the operation at 24 h and 72 h after the operation, but CD3+, CD4+, and CD4+/CD8+ levels in the observation group were higher than those of the control group.

Conclusion

Thoracoscopic lobectomy and segmental resection have similar clinical effects in the treatment of early-stage NSCLC patients, but segmental resection can preserve healthy lung tissue as much as possible, with less trauma, protect lung function, and promote postoperative recovery.