Long-Term Prognosis After Segmentectomy for cT1 N0 M0 Non-Small Cell Lung Cancer

Could less be enough: sublobar resection vs lobectomy for clinical stage IA non-small cell lung cancer patients with visceral pleural invasion or spread through air spaces

BACKGROUND

While recent randomized controlled trials have demonstrated that sublobar resection (SLR) is non-inferior to lobectomy, the comparative efficacy of these procedures remains uncertain for early-stage non-small cell lung cancer (NSCLC; ≤3 cm) exhibiting invasive features postoperatively, such as visceral pleural invasion (VPI) or spread through air spaces (STAS).

MATERIALS AND METHODS

To identify eligible studies, a comprehensive search of PubMed, Embase, MEDLINE, the Cochrane Library, and Web of Science was conducted through 25 July 2024. Studies were screened according to predefined criteria in accordance with PRISMA guidelines. The primary endpoints were 5-year overall survival (OS) and recurrence-free survival (RFS). Hazard ratios (HR) and 95% confidence intervals (CI) were used to perform a meta-analysis.

RESULTS

The final analysis included 14 retrospective studies and 1 randomized controlled trial, encompassing a total of 8054 patients with NSCLC (tumors ≤3 cm) exhibiting VPI or STAS. The meta-analysis revealed that SLR was associated with impaired 5-year OS (HR: 1.25; 95% CI: 1.10-1.41) and slightly inferior RFS (HR: 1.25; 95% CI: 0.99-1.58) compared to lobectomy for pT2a (VPI) NSCLC patients with tumor ≤3 cm. Similarly, SLR was associated with significantly worse 5-year OS (HR: 2.58; 95% CI: 1.92-3.45) and 5-year RFS (HR: 2.42; 95% CI: 1.69-3.46) compared to lobectomy for stage IA NSCLC patients with STAS. Subgroup analysis revealed that statistically significant differences in 5-year OS (HR: 1.13; 95% CI: 0.92-1.38) and 5-year RFS (HR: 0.87; 95% CI: 0.56-1.36) were not observed between the SLR and lobectomy groups for pT2a (VPI) NSCLC patients with tumor ≤2 cm. Additionally, no statistically significant survival difference was observed between the segmentectomy and lobectomy groups for NSCLC patients (≤3 cm) with VPI (5-year OS: HR: 1.16; 95% CI: 0.89-1.52; 5-year RFS: HR: 1.07; 95% CI: 0.88-1.30) or STAS (5-year OS: HR: 3.88; 95% CI: 0.82-18.31; 5-year RFS: HR: 1.64; 95% CI: 0.70-3.80).

CONCLUSIONS

For early-stage (≤3 cm) NSCLC with VPI or STAS, SLR was associated with worse survival outcomes compared to lobectomy. However, segmentectomy achieved survival outcomes comparable to those of lobectomy. For pT2a (VPI) NSCLC patients with tumor ≤2 cm, the differences in survival outcomes between SLR and lobectomy were not statistically significant.

Segmentectomy for non-peripheral and peripheral small-sized non-small-cell lung cancer

OBJECTIVES

To compare the oncological outcomes of segmentectomy for non-peripheral versus peripheral small-sized non-small-cell lung cancer (NSCLC).

METHODS

This retrospective observational study included patients with clinical stage IA1-A2 NSCLC who underwent segmentectomy. Patients were separated based on tumour distance index (DI, which was calculated as the ratio of the distance from the entrance of the segmental bronchus to the proximal tumour margin to the distance to the lobar pleura along the same line): non-peripheral group (DI ≤ 2/3) and peripheral group (DI > 2/3). Disease-free survival (DFS) and overall survival were compared with log-rank tests.

RESULTS

850 patients were included, comprising 274 in the non-peripheral group and 576 in the peripheral group. Recurrence occurred in 68 patients (24 in the peripheral group and 44 in the non-peripheral group), and 56 patients died (22 in the peripheral group and 34 in the non-peripheral group). Log-rank tests showed no statistical differences in 5-year DFS (92.2% vs 91.2%) and 5-year overall survival (96.3% vs 93.6%) between the two groups, but higher margin recurrence occurred in the non-peripheral group. Multivariable analysis revealed that age, tumour diameter, consolidation-to-tumour ratios, pathological subtype and pathologic stage were independent risk factors for DFS. Subgroup analysis indicated that patients with a non-peripheral solid NSCLC had a worse 5-year DFS (62.1% vs 76.3%) and a higher margin recurrence rate (13.2% vs 2.0%).

CONCLUSIONS

Segmentectomy for small-sized non-peripheral NSCLC could gain a comparable outcome to the peripheral, but worse DFS and higher margin recurrence occurred in the non-peripheral solid NSCLC.

Risk Factors for Locoregional Relapse After Segmentectomy: Supplementary Analysis of the JCOG0802/WJOG4607L Trial

INTRODUCTION

The JCOG0802/WJOG4607L trial revealed superior overall survival in segmentectomy compared with lobectomy for small-peripheral NSCLC. Nevertheless, locoregional relapse (LR) is a major issue for segmentectomy. An ad hoc supplementary analysis aimed to determine the risk factors for LR and the degree of advantages of segmentectomy on the basis of primary tumor sites.

METHODS

Participants in multi-institutional and intergroup, open-label, phase 3 randomized controlled trial in Japan were enrolled from August 10, 2009, to October 21, 2014. Risk factors for LR after segmentectomy and clinical features following the primary tumor site were investigated.

RESULTS

Of 1105 patients, 576 and 529 underwent lobectomy and segmentectomy, respectively. The primary tumor site for segmentectomy was the left upper division, left lingular segment, left S6, left basal segment, right upper lobe, right S6, or right basal segment. Multivariable analysis in the segmentectomy group revealed that pure-solid appearance on thin-section computed tomography (OR = 3.230; 95% confidence interval [CI]: 1.559-6.690; p = 0.0016), margin distance less than the tumor size (OR = 2.682; 95% CI: 1.350-5.331; p = 0.0049), and male sex (OR = 2.089; 95% CI: 1.047-4.169; p = 0.0366) were significantly associated with LR. Patients with left lingular segment tumors (OR = 4.815; 95% CI: 1.580-14.672) tended to experience LR more frequently than those with left upper division tumors, although primary tumor sites were not statistically significant.

CONCLUSIONS

Thin-section computed tomography findings and margin distance are important factors to avoid LR in segmentectomy.

Long-term outcomes and risk factors for recurrence after lung segmentectomy

OBJECTIVES

The long-term oncological outcomes and risk factors for recurrence after lung segmentectomy are unclear. The aims of this study were to investigate the long-term prognosis and to evaluate risk factors for recurrence after segmentectomy.

METHODS

Between January 2008 and December 2012, a total of 177 patients underwent segmentectomy for clinical stage I non-small cell lung cancer. The median follow-up period was 120.1 months. The overall survival (OS) and recurrence-free survival curves were analysed using the Kaplan-Meier method with a log-rank test. Univariable and multivariable analyses were used to identify significant factors that predicted recurrence.

RESULTS

The study included 177 patients with a median age of 67 years. The median operative time was 155 min. No 30-day deaths were observed. Nine patients (5.1%) had recurrences: loco-regional in 3, distant in 3 and both in 3. The 5-year and 10-year recurrence-free survival rates were 89.7% and 79.8%, and the OS rates were 90.9% and 80.4%, respectively. On multivariable analysis, the risk factor associated with recurrence was a pure solid tumour [hazard ratio, 23.151; 95% confidence interval 2.575-208.178; P = 0.005]. The non-pure solid tumour group had a significantly better probability of survival (5-year OS: 95.4% vs 77.2%; 10-year OS: 86.5% vs 61.8%; P < 0.0001). A total of 113 patients received preoperative positron emission tomography/computed tomography. Patients with a higher maximum standardized uptake value had a significantly higher recurrence rate.

CONCLUSIONS

Segmentectomy for clinical stage I non-small cell lung cancer produced acceptable long-term outcomes. Pure solid radiographic appearance was associated with recurrence and decreased survival.

Mean computed tomography value to predict spread through air spaces in clinical N0 lung adenocarcinoma

BACKGROUND

The aim of this study was to assess the ability of radiologic factors such as mean computed tomography (mCT) value, consolidation/tumor ratio (C/T ratio), solid tumor size, and the maximum standardized uptake (SUVmax) value by F-18 fluorodeoxyglucose positron emission tomography to predict the presence of spread through air spaces (STAS) of lung adenocarcinoma.

METHODS

A retrospective study was conducted on 118 patients those diagnosed with clinically without lymph node metastasis and having a pathological diagnosis of adenocarcinoma after undergoing surgery. Receiver operating characteristics (ROC) analysis was used to assess the ability to use mCT value, C/T ratio, tumor size, and SUVmax value to predict STAS. Univariate and multiple logistic regression analyses were performed to determine the independent variables for the prediction of STAS.

RESULTS

Forty-one lesions (34.7%) were positive for STAS and 77 lesions were negative for STAS. The STAS positive group was strongly associated with a high mCT value, high C/T ratio, large solid tumor size, large tumor size and high SUVmax value. The mCT values were - 324.9 ± 19.3 HU for STAS negative group and - 173.0 ± 26.3 HU for STAS positive group (p < 0.0001). The ROC area under the curve of the mCT value was the highest (0.738), followed by SUVmax value (0.720), C/T ratio (0.665), solid tumor size (0.649). Multiple logistic regression analyses using the preoperatively determined variables revealed that mCT value (p = 0.015) was independent predictive factors of predicting STAS. The maximum sensitivity and specificity were obtained at a cutoff value of - 251.8 HU.

CONCLUSIONS

The evaluation of mCT value has a possibility to predict STAS and may potentially contribute to the selection of suitable treatment strategies.

The correlation between tumor radiological features and spread through air spaces in peripheral stage IA lung adenocarcinoma: a propensity score-matched analysis

BACKGROUND

The consolidation tumor ratio (CTR) is a predictor of invasiveness in peripheral T1N0M0 lung adenocarcinoma. However, its association with spread through air spaces (STAS) remains largely unexplored. We aimed to explore the correlation between the CTR of primary tumors and STAS in peripheral T1N0M0 lung adenocarcinoma.

METHODS

We collected data from patients who underwent surgery for malignant lung neoplasms between January and November 2022. Univariate and multivariate analyses following propensity-score matching with sex, age, BMI, were performed to identify the independent risk factors for STAS. The incidence of STAS was compared based on pulmonary nodule type. A smooth fitting curve between CTR and STAS was produced by the generalized additive model (GAM) and a multiple regression model was established using CTR and STAS to determine the dose-response relationship and calculate the odds ratio (OR) and 95% confidence interval (CI).

RESULTS

17 (14.5%) were diagnosed with STAS. The univariate analysis demonstrated that the history of the diabetes, size of solid components, spiculation, pleural indentation, pulmonary nodule type, consolidation/tumor ratio of the primary tumor were statistically significant between the STAS-positive and STAS-negative groups following propensity-score matching(p = 0.047, 0.049, 0.030, 0.006, 0.026, and < 0.001, respectively), and multivariate analysis showed that the pleural indentation was independent risk factors for STAS (with p-value and 95% CI of 0.043, (8.543-68.222)). Moreover, the incidence of STAS in the partially solid nodule was significantly different from that in the solid nodule and ground-glass nodule (Pearson Chi-Square = 7.49, p = 0.024). Finally, the smooth fitting curve showed that CTR tended to be linearly associated with STAS by GAM, and the multivariate regression model based on CTR showed an OR value of 1.24 and a p-value of 0.015.

CONCLUSIONS

In peripheral stage IA lung adenocarcinoma, the risk of STAS was increased with the solid component of the primary tumor. The pleural indentation of the primary tumor could be used as a predictor in evaluating the risk of the STAS.

Long-term changes in psoas muscle mass after lobectomy and segmentectomy for early-stage lung cancer

BACKGROUND

Segmentectomy is considered a less invasive procedure than lobectomy for patients with non-small cell lung cancer (NSCLC); however, little is known about the physiological mechanism underlying the lower invasiveness of segmentectomy. This study is aimed to compare the differences in the long-term changes in the psoas muscle mass after segmentectomy and lobectomy in patients with NSCLC.

METHODS

Overall 315 recurrence-free patients who underwent segmentectomy (n = 93) or lobectomy (n = 222) for clinical stage 0-I NSCLC between January 2016 and December 2018 and underwent computed tomography during the entire period of 6 months ≤ postoperative year (POY) 0.5 < 12 months, 12 months ≤ POY 1 < 24 months, 24 months ≤ POY 2 < 36 months, and 36 months ≤ POY 3 < 48 months were included. Bilateral psoas muscle area (PMA) at the L3 level was measured using each cross-sectional computed tomography scan. Differences between the segmentectomy and lobectomy groups in the mean change of postoperative PMA from the preoperative period were analysed using Student's t-test and mixed analysis of variance. Multivariable analysis was performed to identify the risk factors for PMA loss on POY 3 using logistic regression analysis.

RESULTS

The lobectomy group had a significantly larger PMA change than the segmentectomy group during each postoperative period (P < 0.001). Mixed analysis of variance revealed that the mean PMA change was significantly smaller in the segmentectomy group than in the lobectomy group during the observation period (P < 0.001). The mean change in the PMA was significantly larger from POY1 (-2.5%) to POY2 (-3.9%) and POY3 (-4.7%) in the lobectomy group (P = 0.003 and P < 0.001). However, PMA remained unchanged during the postoperative observation period in the segmentectomy group. In the multivariable analysis, the risk factors for PMA change ≤-3.3% (cut-off: mean change of PMA) at POY3 included lobectomy [odds ratio (OR), 3.32; 95% confidence interval (CI), 1.90-5.82; P < 0.001], male sex (OR, 1.92; 95% CI, 1.02-3.62; P = 0.044) and open thoracotomy (OR, 1.84; 95% CI, 1.11-3.05; P = 0.017). After propensity score matching, the mean change in PMA was smaller in the segmentectomy group (n = 75) than in the lobectomy group (n = 75) during the postoperative observation period (P < 0.001).

CONCLUSIONS

Psoas muscle mass was better maintained during the postoperative period by segmentectomy than by lobectomy. Psoas muscle mass reduction progressed over a long postoperative period after lobectomy. Segmentectomy via complete video-assisted thoracic surgery is associated with a lower likelihood of sarcopenia progression.

Segmentectomy for patients with early-stage pure-solid non-small cell lung cancer

For decades, lobectomy has been the recommended surgical procedure for non-small cell lung cancer (NSCLC), including for small-sized lesions. However, two recent pivotal clinical trials conducted by the Japanese Clinical Oncology Group/West Japan Oncology Group (JCOG0802/WJOG4607L) and the Cancer and Leukemia Group B (CALGB140503), which compared the survival outcomes between lobectomy and sublobar resection (the JCOG0802/WJOG4607L included only segmentectomy, not wedge resection), demonstrated the efficacy of sublobar resection in patients with early-stage peripheral lung cancer measuring ≤ 2 cm. The JCOG0802/WJOG4607L demonstrated the superiority of segmentectomy over lobectomy with respect to overall survival, implying the survival benefit conferred by preservation of the lung parenchyma. Subsequently, the JCOG1211 also demonstrated the efficacy of segmentectomy, even for NSCLC, measuring up to 3 cm with the predominant ground-glass opacity phenotype. Segmentectomy has become the standard of care for early-stage NSCLC and its indications are expected to be further expanded to include solid lung cancers > 2 cm. However, local control is still a major concern for segmentectomy for higher-grade malignant tumors. Thus, the indications of segmentectomy, especially for patients with radiologically pure-solid NSCLC, remain controversial due to the aggressive nature of the malignancy. In this study, we reviewed previous studies and discussed the efficacy of segmentectomy for patients with such tumors.

Prospective randomized study on the efficacy of three-dimensional reconstructions of bronchovascular structures on preoperative chest CT scan in patients who are candidates for pulmonary segmentectomy surgery: the PATCHES (Prospective rAndomized sTudy efficaCy of tHree-dimensional rEconstructions Segmentecomy) study protocol

INTRODUCTION

Pulmonary segmentectomy, when combined with hilar and mediastinal lymphadenectomy, is currently considered the gold standard treatment for early-stage lung tumors (NSCLC) smaller than 2 cm in diameter. The preoperative planning for segmentectomies usually includes a contrast-enhanced CT with 2D reconstructions (axial, coronary, and sagittal). Recent technological advances allow 3D (volume rendering) reconstructions of preoperative CT scans, intended to improve the surgeon's understanding of the segmental anatomy. The study aims to investigate the added value of 3D reconstruction in enhancing the surgeon's understanding of anatomical structures, thus facilitating surgical planning and improving oncological outcomes.

METHODS AND ANALYSIS

This is a prospective, randomized, controlled study. Patients will be randomized into two groups: 1. Group 2D: the preoperative workup for these patients will consist of a contrast-enhanced chest CT with two-dimensional (2D) reconstructions (axial, coronary, and sagittal); 2. Group 3D: the preoperative workup for these patients will consist of a contrast-enhanced chest CT with two-dimensional (2D) reconstructions (axial, coronary, and sagittal) and a 3D reconstruction (volume rendering) of the same chest CT employing dedicated software. The primary endpoints will be negative margin (R0) resection rate, resection margin (staple line-to-tumor distance), and thoracotomy conversions. We will use Fisher's exact test for binary outcomes and Mann-Whitney U test for continuous outcomes. For subgroup analyses, we will use regression. Multivariable analyses will be based on logistic regression for binary outcomes and linear regression for continuous outcomes.

ETHICS AND DISSEMINATION

The protocol and the model informed consent forms have been reviewed and approved by the ethics committee (N.: 1-2023) concerning scientific content and compliance with applicable research and human subject regulations. A Subcommittee on Publications was established to review all publications and report its recommendations to the steering committee. The anonymized participant-level dataset and statistical code for generating the results will not be publicly available.

TRIAL REGISTRATION

The protocol was registered at ClinicalTrials.gov (ID: NCT05716815; Prospective rAndomized sTudy efficaCy tHree-dimensional rEconstructions Segmentectomy - Full-Text View - ClinicalTrials.gov). Jan 19, 2023.

Segmentectomy for cancer control in radiologically pure-solid clinical stage IA3 lung cancer

OBJECTIVES

This study aimed to compare cancer control after segmentectomy and lobectomy in patients with radiologically pure-solid clinical stage IA3 non-small-cell lung cancer (NSCLC).

METHODS

Patients with radiologically pure-solid clinical stage IA3 NSCLC who underwent lobectomy or segmentectomy at 3 institutions between 2010 and 2019 were identified. We estimated propensity scores to adjust for confounding variables regarding tumour malignancy, including age, sex, smoking history, tumour size, maximum standardized uptake value on 18F-fluorodeoxyglucose positron emission tomography, lymph node dissection, histological type and lymphatic, vascular and pleural invasion. Cumulative incidence of recurrence (CIR) was evaluated as a primary end point.

RESULTS

Among 412 patients, postoperative recurrence occurred in 7 of 44 patients (15.9%) undergoing segmentectomy, and 71 of 368 patients (19.3%) undergoing lobectomy. CIR was comparable between patients undergoing segmentectomy (5-year rate, 21.9%) and those undergoing lobectomy (5-year rate, 20.8%; P = 0.88). Locoregional recurrence did not differ between patients undergoing segmentectomy (6.8%) and those undergoing lobectomy (9.0%). In multivariable analysis, segmentectomy (versus lobectomy) was not identified as an independent prognostic factor for CIR (hazard ratio, 1.045; 95% confidence interval, 0.475-2.298; P = 0.91). In propensity score matching of 40 pairs, CIR was not significantly different between patients undergoing segmentectomy (5-year rate, 20.7%) and those undergoing lobectomy (5-year rate, 18.4%; P = 0.81).

CONCLUSIONS

Cancer control may be comparable between segmentectomy and lobectomy in patients with radiologically pure-solid clinical stage IA3 NSCLC. Further studies are warranted to clarify the survival benefits of segmentectomy in these patients.

Survival and quality-of-life outcomes in early-stage NSCLC patients: a literature review of real-world evidence

Aim

Assess the long-term survival and quality-of-life outcomes in early-stage NSCLC (eNSCLC) patients.

Methods

Review of long-term survival and quality-of-life after curative treatment in eNSCLC patients in observational studies.

Results

Disease-free proportion decreased in stage III vs stage I patients. Recurrence-free proportion decreased with age and disease stage. Advanced stage and vascular invasion increased risk of late recurrence. Conditional 5-year relative survival rates did not exceed 87%, indicating higher mortality in eNSCLC survivors. Lower conditional survival rates and relative survival rates were associated with older age and advanced disease. Survivors of eNSCLC had poorer physical quality-of-life.

Conclusion

Despite curative-intent therapy, survivors of eNSCLC still face significant risks of recurrence, excess mortality, and diminished quality-of-life.

Post-operative and early oncological results of simple and complex full thoracoscopic segmentectomies for non-small-cell lung cancer

BACKGROUND

The role of video-assisted thoracoscopic segmentectomy in the treatment of clinical IA non-small-cell lung cancer is not well established. The aim of our retrospective analysis was to evaluate the oncological results of complex and simple video-assisted thoracoscopic segmentectomy.

METHODS

From 2015 to June 2020, data of n = 163 consecutive patients undergoing video-assisted thoracoscopic segmentectomy for solitary pulmonary nodule were analysed. The Kaplan-Meier method, log-rank test and Cox regression were used to estimate, compare survivals and identify risk factors of worse oncological outcomes.

RESULTS

In this period, n = 123 patients underwent video-assisted thoracoscopic segmentectomy for non-small-cell lung cancer: we performed n = 65 simple and n = 58 complex video-assisted thoracoscopic segmentectomy; n = 99 (80.5%) had a solid appearance on computed tomography scan and n = 78 (63.4%) a moderate-to-high [18F]-2-fluoro-2-deoxy-D-glucose (FDG)-positron emission tomographic computed tomography scan avidity. Mortality was 0%, and complications occurred in n = 14 (21.5%) and 9 (15.5%) patients. The median follow-up was 24 (range: 6-60) months and the 5-year overall survival was 96% without difference between video-assisted thoracoscopic segmentectomies (p = 0.16). Local recurrence developed in n = 2 (3.1%) and n = 3 (5.2%) patients; regional in n = 2 (3.1%) and 1 (1.8%) and distant in 8 (12.3%) and 2 (3.4%), without difference between video-assisted thoracoscopic segmentectomies (p = 0.51). The overall 5-year disease-free survival rate was 78%. Pathological upstaging was observed in n = 13 patients (nodal in n = 6, tumour in n = 7) and it was the only significant factor for worse disease-free survival at the multivariable analysis (hazard ratio: 2.43, 95% CI: 1.04-8.68, p = 0.049), value confirmed also in the group of intended video-assisted thoracoscopic segmentectomy (p = 0.047).

CONCLUSIONS

Pathological upstaging after simple or complex video-assisted thoracoscopic segmentectomy is a risk factor for recurrence and then video-assisted thoracoscopic segmentectomy should be considered an appropriate therapeutic option for selected stage IA non-small-cell lung cancer patients.

Lobectomy Demonstrates Superior Survival Than Segmentectomy for High-Grade Non-Small Cell Lung Cancer: The National Cancer Database Analysis

BACKGROUND

Current recommendations for segmentectomy for non-small cell lung cancer (NSCLC) include size ≤2 cm, margins ≥ 2 cm, and no nodal involvement. This study further stratifies the selection criteria for segmentectomy using the National Cancer Database (NCDB).

METHODS

The NCDB was queried for patients with high-grade (poorly/undifferentiated) T1a/b peripheral NSCLC (tumor size ≤2 cm), who underwent either lobectomy or segmentectomy. Patients with pathologic node-positive disease or who received neoadjuvant/adjuvant treatments were excluded. Propensity score analysis was used to adjust for differences in pretreatment characteristics.

RESULTS

11 091 patients were included with 10 413 patients (93.9%) treated with lobectomy and 678 patients (6.1%) underwent segmentectomy. In a propensity matched pair analysis of 1282 patients, lobectomy showed significantly improved median survival of 88.48 months vs 68.30 months for segmentectomy, P = .004. On multivariate Cox regression, lobectomy was associated with significantly improved survival (hazard ratio (HR): .81, 95% CI .72-.92, P = .001). Subgroup analysis of propensity score matched patients with a Charlson-Deyo comorbidity score (CDCC) of 0 also demonstrated a trend of improved survival with lobectomy.

DISCUSSION

Lobectomy may confer significant survival advantage over segmentectomy for high-grade NSCLC (≤2 cm). More work is needed to further stratify various NSCLC histologies with their respective grades allowing more comprehensive selection criteria for segmentectomy.

Impact of segmentectomy and lobectomy on non-lung cancer death in early-stage lung cancer patients

OBJECTIVES

This study aimed to analyse the risk of death from non-lung cancer after segmentectomy or lobectomy for early-stage lung cancer.

METHODS

A total of 1385 patients underwent lobectomy or segmentectomy for clinical stage 0-I primary lung cancer, with no evidence of recurrence after surgery, between January 2008 and December 2018. Risk factors for non-lung cancer deaths (NLCD) were analysed using multivariable logistic regression analysis. The overall survival (OS) of patients with low and high comorbidities who underwent lobectomy and segmentectomy was compared using a log-rank test.

RESULTS

Patients with NLCD (n = 126) were more likely to have undergone lobectomy than patients with non-recurrence survival (n = 1259). Multivariable analysis revealed that age (≥65 years), smoking index (≥600), body mass index (≤18.5 kg/m2), interstitial pneumonia, values for percentage of predicted vital capacity (≤9.4%) and lobectomy were risk factors for NLCD. Patients who underwent segmentectomy had significantly better 5-year OS than those who underwent lobectomy, after propensity score matching (94.6% vs 90.4%, P = 0.027). Patients with high comorbidities (patients with ≥2 of the following risks: age ≥65 years, smoking index ≥600, body mass index ≤18.5 kg/m2, Charlson Comorbidity Index ≥1, values for percentage of predicted vital capacity ≤96.4%) who underwent segmentectomy had a better 5-year OS than those who underwent lobectomy (92.8% vs 87.8%, P = 0.016). However, there was no difference in 5-year OS between segmentectomy and lobectomy in patients with low comorbidities (98.5% vs 97.4%, P = 0.867).

CONCLUSIONS

The impact of lobectomy and segmentectomy on NLCD depends on the extent of the patients' comorbidities.

[Research Progress in the Effect of Consolidation Tumor Ratio on the Diagnosis and Treatment of Early-stage Peripheral Lung Cancer]

Consolidation tumor ratio (CTR) is a hot issue in lung cancer imaging studies in recent years. It is defined as the proportion of the maximum consolidation diameter divided by the maximum tumor diameter in the lung window scanned by high resolution computed tomography (HRCT). Many studies have also confirmed that it can be used as an indicator to identify whether a lung tumor is benign or malignant at the early stage, the main basis on which to decide whether sublobectomy can be performed, and is an independent factor for the recurrence and prognosis of early-stage lung cancer. Especially after tumor size and CTR results of JCOG0804 and JCOG0802 trials in Japan were published, a breakthrough in the treatment method upends the conventional surgical approach, which benefits patients with early-stage lung cancer. But insufficient research data on CTR leads to the fact that an evaluation system to measure CTR is yet to be built. This paper discusses the research progress in CTR prediction of benign or malignancy of pulmonary nodules, how to choose a surgical approach, lymph node dissection, spread through air spaces (STAS) and other hot issues. It also investigates the possible indicators to predict efficacy based on CTR, summarizes and analyzes the development trend of surgical methods to treat early-stage peripheral lung cancer and challenges, to provide new ideas for clinical application.
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Uniportal video-assisted thoracic surgery basal segmentectomy: a single-center retrospective cohort study

BACKGROUND

Uniportal video-assisted thoracic surgery (VATS) basal segmentectomy is technically challenging and requires a deep understanding of the segmental anatomy of the lung. This report describes the uniportal VATS segmentectomy of basal segments using a single-direction approach.

METHODS

A total of 49 patients who underwent uniportal VATS basal segmentectomy between April 2019 and April 2021 were included in this retrospective study. All the surgeries were conducted using a single-direction approach. The resections of segments 7-8 were mainly performed using the interlobar fissure approach, while the resections of segments 9-10 were performed using the inferior pulmonary ligament approach.

RESULTS

A total of 33 patients underwent a single basal segmentectomy and 16 patients underwent combined basal segmentectomy/sub-segmentectomy. The median operative time was 120 min (range, 60-180 min), and the median blood loss was 20 mL (range, 10-100 mL). The median chest tube duration was 2 days (range, 1-5 days), and the median hospital stay after surgery was 4 days (range, 2-15 days). The morbidity rate after surgery was 6.1% (3/49). There were no perioperative deaths. The pathological examinations revealed 3 cases of adenocarcinoma in situ (AIS), 33 cases of minimally invasive adenocarcinoma, and 13 cases of lepidic-predominant invasive adenocarcinoma. No recrudescence or mortality was reported during the median follow-up time of 7 months (range, 2-25 months).

CONCLUSIONS

Uniportal VATS basal segmentectomy is a feasible and reliable technique based on our experience. This single-direction method allows the uniportal VATS basal segmentectomy to be performed in an easy manner with the targeted segmental bronchi and vessels exposed from superficial to deep in order of their appearance while avoiding the repeated turnover of the lung.

Progress in three-dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy

The number of minimally invasive surgeries, such as video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery, has increased enormously in recent years. More and more relevant studies report that anatomic pulmonary segmentectomy has the same effect as traditional lobectomy in the surgical treatment of early stage non-small cell lung cancer (diameter less than 2.0 cm). Segmentectomy requires sufficient knowledge of the location of the pulmonary nodules, as well as the anatomy of the target segments, blood vessels, and bronchi. With the rapid development of imaging technology and three-dimensional technology, three-dimensional reconstruction has been widely used in the medical field. It can effectively assess the vascular branching patterns, discover the anatomic variations of the blood vessels and bronchi, determine the location of the lesion, and clarify the division of the segments. Therefore, it is helpful for preoperative positioning, surgical planning, preoperative simulation and intraoperative navigation, and provides a reference for formulating an individualized surgical plan. It therefore plays a positive role in anatomic pulmonary segmentectomy. This study reviews the progress made in three-dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy.

Lobectomy versus segmentectomy: a propensity score-matched comparison of postoperative complications, pulmonary function and prognosis

OBJECTIVES

To demonstrate the differences in clinical outcomes between lobectomy and segmentectomy for non-small cell lung cancer using propensity score matching.

METHODS

A single-centre, retrospective, matched cohort study was conducted in clinical T1N0M0 non-small cell lung cancer patients treated by surgery between 2012 and 2019. Differences in freedom from recurrence, overall survival, postoperative complications, chest drainage and preservation of pulmonary function between lobectomy and segmentectomy were evaluated using the propensity score model. Matched variables of patients were age, sex, comorbidity index and pulmonary function. Matched variables of tumours were tumour size, T-stage, fluorodeoxyglucose uptake on positron emission tomography, histopathology, lobe site and tumour distance ratio from the hilum.

RESULTS

Of the 112 patients treated by lobectomy and 233 patients treated by segmentectomy, 93 patients each from both groups were selected after the matching. The median tumour distance ratio from hilum was 0.7 in lobectomy and 0.8 in segmentectomy group (P = 0.59), i.e. almost outer third tumour location. There were no significant differences in freedom from recurrence (P = 0.38), overall survival (P = 0.51), postoperative complications (P = 0.94), drainage period (P = 0.53) and prolonged air leakage (P = 0.82) between the two. Median preservation of pulmonary function was 93.2% after segmentectomy, which was significantly higher than 85.9% after lobectomy (P < 0.001).

CONCLUSIONS

Freedom from recurrence, overall survival, postoperative complications and chest drainage were similar between segmentectomy and lobectomy. Segmentectomy could be one of the options for clinical T1N0M0 non-small cell lung cancer located outer third as well as being able to preserve pulmonary function better than lobectomy.

CLINICAL TRIAL REGISTRATION

Risk analysis in peripheral clinical T1 non-small cell lung cancer correlations between tumor-to-blood standardized uptake ratio on 18F-FDG PET-CT and primary tumor pathological invasiveness: a real-world observational study

BACKGROUND

Sublobar resection is not suitable for patients with pathological invasiveness [including lymph node metastasis (LNM), visceral pleural invasion (VPI), and lymphovascular invasion (LVI)] of peripheral clinical T1 (cT1) non-small cell lung cancer (NSCLC), while primary tumor maximum standardized uptake value (SUV_max) on ¹⁸F-FDG PET-CT is related to pathological invasiveness, the significance differed among different institutions is still challenging. This study explored the relationship between the tumor-to-blood standardized uptake ratio (SUR) of ¹⁸F-FDG PET-CT and primary tumor pathological invasiveness in peripheral cT1 NSCLC patients.

METHODS

This retrospective study included 174 patients with suspected lung neoplasms who underwent preoperative ¹⁸F-FDG PET-CT. We compared the differences of the clinicopathological variables, metabolic and morphological parameters in the pathological invasiveness and less-invasiveness group. We performed a trend test for these parameters based on the tertiles of SUR. The relationship between SUR and pathological invasiveness was evaluated by univariate and multivariate logistics regression models (included unadjusted, simple adjusted, and fully adjusted models), odds ratios (ORs), and 95% confidence intervals (95% CIs) were calculated. A smooth fitting curve between SUR and pathological invasiveness was produced by the generalized additive model (GAM).

RESULTS

Thirty-eight point five percent of patients had pathological invasiveness and tended to have a higher SUR value than the less-invasiveness group [6.50 (4.82-11.16) vs. 4.12 (2.04-6.61), P<0.001]. The trend of SUV_max, mean standardized uptake value (SUV_mean), metabolic tumor volume (MTV), total lesion glycolysis (TLG), mean CT value (CT_mean), size of the primary tumor, neuron-specific enolase (NSE), the incidence of LNM, adenocarcinoma (AC), and poor differentiation in the tertiles of SUR value were statistically significant (P were <0.001, <0.001, 0.010, <0.001, <0.001, 0.002, 0.033, <0.001, 0.002, and <0.001, respectively). Univariate analysis showed that the risk of pathological invasiveness increased significantly with increasing SUR [OR: 1.13 (95% CI: 1.06-1.21), P<0.001], and multivariate analysis demonstrated SUR, as a continuous variable, was still significantly related to pathological invasiveness [OR: 1.09 (95% CI: 1.01-1.18), P=0.032] after adjusting for confounding covariates. GAM revealed that SUR tended to be linearly and positively associated with pathological invasiveness and E-value analysis suggested robustness to unmeasured confounding.

CONCLUSIONS

SUR is linearly and positively associated with primary tumor pathological invasiveness independent of confounding covariates in peripheral cT1 NSCLC patients and could be used as a supplementary risk maker to assess the risk of pathological invasiveness.

Preoperative 18F-FDG SUVmax >6.3 or Size >2.3 cm of primary lesions predict lymph nodes metastasis with higher negative predictive value in peripheral cT1 non-small-cell lung cancer

BACKGROUND

Sublobar resection is suitable for peripheral cT1N0M0 non-small-cell lung cancer (NSCLC). The traditional PET-CT criterion (lymph node size ≥1.0 cm or SUVmax ≥2.5) for predicting lymph nodes metastasis (LNM) has unsatisfactory performance.

OBJECTIVE

We explore the clinical role of preoperative SUVmax and the size of the primary lesions for predicting peripheral cT1 NSCLC LNM.

METHODS

We retrospectively analyzed 174 peripheral cT1 NSCLC patients underwent preoperative 18F-FDG PET-CT and divided into the LNM and non-LNM group by pathology. We compared the differences of primary lesions' baseline characteristics between the two groups. The risk factors of LNM were determined by univariate and multivariate analysis, and we assessed the diagnostic efficacy with the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value (NPV).

RESULTS

Of the enrolled cases, the incidence of LNM was 24.7%. The preoperative SUVmax >6.3 or size >2.3 cm of the primary lesions were independent risk factors of peripheral cT1 NSCLC LNM (ORs, 95% CIs were 6.18 (2.40-15.92) and 3.03 (1.35-6.81). The sensitivity, NPV of SUVmax >6.3 or size >2.3 cm of the primary lesions were higher than the traditional PET-CT criterion for predicting LNM (100.0 vs. 86.0%, 100.0 vs. 89.7%). A Hosmer-Lemeshow test showed a goodness-of-fit (P = 0.479).

CONCLUSIONS

The excellent sensitivity and NPV of preoperative of the SUVmax >6.3 or size >2.3 cm of the primary lesions based on 18F-FDG PET-CT might identify the patients at low-risk LNM in peripheral cT1 NSCLC.

Segmentectomy for inner location small-sized non-small-cell lung cancer: Is it feasible?

BACKGROUND

The efficacy of segmentectomy for inner small-sized non-small-cell lung cancer (NSCLC) remains unknown. We aimed to elucidate whether segmentectomy for inner small-sized NSCLC, defined using novel three-dimensional measuring method, yields feasible oncological outcomes compared to segmentectomy for outer lesions.

METHODS

We retrospectively analyzed patients with small-sized (<2cm) cN0 NSCLC who underwent segmentectomy between January 2007 and December 2020. Tumor centrality ratio, which was measured by using three dimensional reconstruction software, was evaluated, with the location of tumor origin confirmed pathologically. Cases with a ratio below and above 2/3 were allocated to the 'Inner group' and 'Outer group', respectively. Oncological outcomes were compared between the two groups.

RESULTS

Our cohort was divided into the 'Inner group' (n=75) and 'Outer group' (n=127). The proximal distance from a tumor exceeded 20 mm in all cases. Tumor centrality ratio was associated with the pathological origin of a tumor. The rate of unforeseen positive lymph node metastasis was significantly higher in the 'Inner group' (p=0.04). There were no significant differences in the 5-year recurrence free survival (RFS; 91% versus 87%, p=0.67). Univariate analysis identified age, consolidation/tumor ratio, the presence of ground-glass-opacity (GGO) and lymphovascular invasion, but not tumor centrality, as significant prognostic factors for RFS. In the multivariate analysis, the presence of GGO and lymphovascular invasion remained significant.

CONCLUSIONS

Regarding oncological outcomes, segmentectomy with a safety proximal distance could be feasible, even for inner small-sized NSCLC. Tumor invasiveness, not tumor centrality, may influence tumor recurrence. (242 words).

Prognosis of segmentectomy and lobectomy for radiologically aggressive small-sized lung cancer

OBJECTIVES

The purpose of this study was to determine the radiological characteristics of aggressive small-sized lung cancer and to compare the outcomes between segmentectomy and lobectomy in patients with these lung cancers.

METHODS

A series of 1046 patients with clinical stage IA1-IA2 lung cancer who underwent lobectomy or segmentectomy at 3 institutions was retrospectively evaluated to identify radiologically aggressive small-sized (solid tumour size ≤ 2 cm) lung cancers. Prognosis of segmentectomy was compared with that of lobectomy in 522 patients with radiologically aggressive small-sized lung cancer using propensity score matching.

RESULTS

Multivariable analysis showed that increasing consolidation-to-tumour ratio on preoperative high-resolution computed tomography (CT) (P = 0.037) and maximum standardized uptake on 18 fluoro-2-deoxyglucose positron emission tomography/CT (P = 0.029) was independently associated with worse recurrence-free survival. Based on analysis of the receiver operating characteristic curve, radiologically aggressive lung cancer was defined as a radiologically solid (consolidation-to-tumour ratio ≥ 0.8) or highly metabolic (maximum standardized uptake ≥ 2.5) tumour. Among patients with radiologically aggressive lung cancer, no significant statistical differences in 5-year recurrence-free (81% vs 90%; P = 0.33) and overall (88% vs 93%; P = 0.76) survival comparing lobectomy (n = 392) to segmentectomy (n = 130) were observed. Among 115 propensity-matched pairs, 5-year recurrence-free survival and overall survival were similar between patients who underwent lobectomy and those who underwent segmentectomy (83.3% and 88.3% vs 90.9% and 94.5%, respectively).

CONCLUSIONS

Difference in survival was not identified with segmentectomy and lobectomy in patients with radiologically aggressive small-sized lung cancer with high risk of recurrence.

Clinical significance of intrapulmonary lymph node dissection in pathological stage IA non-small cell lung cancer: A propensity score matching analysis

Background

This study aimed to investigate the prognostic impact of intrapulmonary lymph node (ILN, stations 13–14) dissection on disease‐free survival (DFS) in stage IA non‐small cell lung cancer (NSCLC) patients in order to facilitate a more suitable determination of surgical strategies for early‐stage cases.

Methods

We retrospectively analyzed 416 patients with pathological stage IA NSCLC from February 2016 to November 2019. The patients were divided into a group with ILN dissection (ILN^D+ group) and a group without ILN dissection (ILN^D‐ group). DFS was compared using the Kaplan–Meier method and compared statistically using the log‐rank test before and after propensity score matching (PSM). Subgroup analysis of DFS stratified based on tumor size was also calculated.

Results

Both before and after PSM, the four‐year DFS of the ILN^D+ group was greatly increased compared to that of ILN^D‐ group (90.1% vs. 79.7%, p = 0.003; 95.5% vs. 80.6%, p = 0.003, respectively) and multivariable cox regression analysis revealed ILN dissection was an independent factor favoring DFS in stage IA NSCLC (p = 0.016 and p = 0.015, respectively). Subgroup analysis revealed the four‐year DFS was comparable between the ILN ^D+ and ILN^D‐ groups with regard to tumor size ≤1.5 cm (90.6% vs. 92.7%, p = 0.715). However, the ILN ^D+ group was found to have a better oncological outcome compared with the ILN^D‐ group with regard to tumor size >1.5 cm (90.0% vs. 73.8%, p = 0.003).

Conclusions

The prognostic impact of ILN dissection on patients with stage IA NSCLC appears to be significantly influenced by tumor size, and this should be taken into account when choosing the most appropriate therapeutic modality.

Positron Emission Tomography in Segmentectomy for cT1N0M0 Nonsmall Cell Lung Cancer

BACKGROUND

This study was aimed to examine the significance of fluorodeoxyglucose positron emission tomography in predicting prognosis after segmentectomy in lung cancer.

METHODS

This was a retrospective cohort study, including 227 patients with cT1N0M0 nonsmall cell lung cancer who underwent positron emission tomography followed by segmentectomy between 2012 and 2019. Significance of tumor histology, T-stage, tumor size, and standardized uptake value on positron emission tomography in relation to recurrence-free survival were examined using Cox's proportional hazard analysis. Median follow-up period was 56 months (range: 1-95 months).

RESULTS

Tumor stages were Tis in 25 patients, T1mi/T1a in 51, T1b in 98, and T1c in 53. Twenty-six patients (11%) experienced recurrences, including local (n = 8) and distant (n = 18). Multivariate analysis showed that the significant variables for recurrence-free survival were T-stage and standardized uptake value (p = 0.002 and 0.015, respectively), whereas tumor histology and tumor size were not significant (p = 0.28 and 0.44, respectively). When tumor size was divided into ≤2 cm and >2 cm for analysis, it was not significant again (p = 0.49), whereas standardized uptake value remained significant (p = 0.008). While standardized uptake value of tumors with recurrences was significantly higher than those without (4.9-2.8 and 2.6-2.5, respectively, p < 0.001), there was no significant difference between local and distant recurrences (p = 0.32). Cut-off value of standardized uptake value for recurrences was 3.2. Five-year recurrence-free survival rates in tumors with standardized uptake value <3.2 and ≥3.2 were 86 and 65%, respectively (p < 0.001).

CONCLUSION

Positron emission tomography could predict the prognosis after segmentectomy better than tumor size.

Extent of Segmentectomy That Achieves Greater Lung Preservation Than Lobectomy

BACKGROUND

This study sought to clarify the extent of segmentectomy that achieves greater lung preservation than lobectomy.

METHODS

This was a single-center retrospective cohort study involving 374 patients with lung cancer who were treated with either lobectomy or segmentectomy between 2013 and 2018. The percentage of preserved pulmonary function (%PPF) after surgery was compared among patients who underwent lobectomy (n = 164), segmentectomy of 2 or more segments (Seg ≥2S; n = 42), and segmentectomy of less than 2 segments (Seg <2S; n = 168). Using perfusion scintigraphy, forced expiratory volume in 1 second of the preserved target lobe was measured to examine its effect on the %PPF. The number of resected subsegments (SSs) in segmentectomy that made the %PPF higher than that observed with lobectomy was also examined.

RESULTS

Mean %PPF was lowest in those patients who underwent lobectomy (86%), followed by Seg ≥2S (89%) and Seg <2S (95%) (P < .001), but the difference between the lobectomy and Seg ≥2S was not significant (P = .21). The forced expiratory volume in 1 second of the preserved target lobe was significantly lower in the Seg ≥2S group than in the Seg <2S group (P < .001). The number of resected SSs was 6 to 12 in lobectomy, 4 to 7 in Seg ≥2S, and 1 to 4 in Seg <2S. Although the %PPF after segmentectomy of less than 5 SSs (Seg <5SS) was significantly higher than that after lobectomy (P < .001), the %PPF after segmentectomy of 5 or more SSs (Seg ≥5SS) was not significantly different from that after lobectomy (P = .68).

CONCLUSIONS

Both the Seg ≥2S and Seg ≥5SS groups did not differ from lobectomy in %PPF because of the low function of preserved target lobe.

[Progress in Survival Prognosis of Segmentectomy for Early-stage Non-small Cell Lung Cancer]

Surgery is currently the most appropriate treatment for early-stage non-small cell lung cancer (NSCLC). Increasing unilateral or bilateral multiple primary lung cancer being found, segmentectomy has attracted wide attention for its unique advantages in the treatment for such tumors. Ground glass opacity dominant early-stage NSCLC is associated with a good prognosis and can be cured by segmentectomy, however, the treatment of solid-dominant NSCLC remains controversial owing to the invasive nature. With the in-depth study on the lymph node metastasis pathway, radiological characteristics and molecular biology of NSCLC, a large part of solid nodules with certain characteristics can also be cured by segmentectomy. This paper reviews the research status and progress about the indication of segmentectomy.
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Comparing Segmentectomy and Lobectomy for Clinical Stage IA Solid-dominant Lung Cancer Measuring 2.1 to 3 cm

INTRODUCTION

We aimed to determine the feasibility of segmentectomy for radiologically solid-dominant clinical stage IA lung cancer measuring 2.1 to 3 cm (whole tumor size).

PATIENTS AND METHODS

Data from 197 patients with radiologically solid-dominant clinical stage IA lung cancer measuring 2.1 to 3 cm who underwent lobectomy (n = 154) or segmentectomy (n = 43) were retrospectively analyzed. Recurrence-free survival (RFS) and overall survival (OS) at 5 years were assessed. Finally, propensity score matching was performed by age, gender, radiologic whole tumor size, consolidation to maximum tumor ratio, tumor location, maximum standardized uptake value, and preoperative forced expiratory volume in 1 second (FEV1) and vital capacity (VC).

RESULTS

Only 2 (4.7%) patients in the segmentectomy group were converted to lobectomy because of lymph node metastasis or inadequate surgical margins. Postoperative reductions in VC and FEV1 at 12 months were significantly less in the segmentectomy group (VC, 7.4%; FEV1, 6.9%) than in the lobectomy group (VC, 17.6%; FEV1, 14.4%). RFS was comparable between patients who underwent lobectomy and segmentectomy in both the unmatched (73.4% and 82.7%, respectively; P = .30) and the 37 propensity-matched (79.5% and 80.1%, respectively) patients. Similarly, OS was comparable between patients who underwent lobectomy and segmentectomy in the unmatched (80.0% and 90.6%, respectively; P = .42) and matched (82.9% and 89.3%, respectively) patients.

CONCLUSIONS

Segmentectomy can be feasible in patients with radiologically solid-dominant clinical stage IA lung cancers measuring 2.1 to 3 cm when patients are appropriately selected.

Surgeons' preference sublobar resection for stage I NSCLC less than 3 cm

Background

This study aimed to compare survival between standard lobectomy and surgeons' preference sublobar resection among patients with stage I non‐small cell lung cancer (NSCLC).

Methods

Medical records of patients undergoing pulmonary resection between 2006 and 2016 were reviewed retrospectively. Differences in disease‐free survival (DFS) and DFS‐associated factors between patients receiving lobectomy and surgeons' preference sublobar resection were analyzed after 1‐1 propensity score‐matching (n = 119 per group).

Results

In total, 1064 pathological stage I NSCLC patients were identified, including 816 (76.7%) who underwent lobectomy, 111 (10.4%) who underwent sublobar resection as a compromised procedure (medically unfit), and 137 (12.9%) who underwent surgeons' preference sublobar resection. Rates of five‐year DFS for patients undergoing lobectomy, medically unfit, and surgeons' preference sublobar resection were 88.7%, 71.0%, and 93.4%, respectively (P < 0.001). Multivariable Cox regression analysis demonstrated that radiological solid‐appearance (adjusted hazard [aHR] = 2.908, P = 0.003), PL2 invasion (aHR = 1.970, P = 0.024), and angiolymphatic invasion (aHR = 2.202, P = 0.005) were significantly associated with lower DFS after adjusting for surgeons' preference sublobar resection (aH = 1.031, P = 0.939). Subgroup analysis of all 403 solid‐dominant patients demonstrated equivalent five‐year DFS between surgeons' preference sublobar resection and lobectomy (87.7% and 84.1%, respectively, P = 0.721). Propensity‐matched analysis showed no differences in five‐year DFS in stage I NSCLC patients undergoing lobectomy or surgeons' preference sublobar resection (90.5% vs. 93.4% P = 0.510), and DFS for surgeons' preference sublobar resection remained an insignificant factor (aHR = 0.894, P = 0.834).

Conclusions

Carefully selected patients who have undergone surgeons' preference sublobar resection have comparable outcomes to those receiving lobectomy for stage I NSCLC <3 cm.

Key points

Significant findings of the study Intended sublobar resection has a good outcome. What this study adds Sublobar resection is applicable for stage I NSCLC <3 cm.

Single-direction thoracoscopic basal segmentectomy

OBJECTIVE

Thoracoscopic anatomic single or combined basal segmentectomy is technically challenging because of the variation and deep location of vessels and bronchi in the parenchyma. This study aimed to describe thoracoscopic segmentectomy of basal segments using a single-direction method.

METHODS

This retrospective study included 137 patients who underwent single or combined thoracoscopic basal segmentectomy between April 2015 and August 2019. All procedures were performed via the preferred inferior pulmonary ligament approach or an interlobar fissure approach following a single-direction strategy.

RESULTS

Ninety patients underwent single basal segmentectomy, and 47 patients underwent combined basal segmentectomy. Median operative time was 125 minutes (range, 52-237 minutes), and median blood loss was 30 mL (range, 5-250 mL). Median chest tube duration was 2 days (range, 1-22 days), and median postoperative hospital stay was 4 days (range, 2-24 days). The postoperative morbidity rate was 5.1% (7/137). No perioperative deaths were identified. Pathological examination revealed 133 cases of lung cancer, 2 cases of metastasis, and 2 cases of benign tumors. No recurrence or mortality was observed during the median follow-up period of 15 months (range, 1-53 months).

CONCLUSIONS

The single-direction method for thoracoscopic single or combined basal segmentectomy was feasible and safe in our experience. This method exposes the targeted vessels and bronchi from superficial to deep in order of their appearance and enables anatomic resection of a single segment or combined basal segments to be performed in a simple manner while avoiding dissection of a hypoplastic fissure or inessential splitting of the lung parenchyma.