Staple Line Thickening After Sublobar Resection: Reaction or Recurrence?

Prospective cohort study of Suture-Line recurrence and clinical outcomes in stage 1A Non-Small cell lung cancer

BACKGROUND

Increased lung cancer screening has made early-stage non-small-cell lung cancer (NSCLC) more common, with lung-sparing surgery as the standard curative treatment. Our study evaluated patients who underwent surgery for pathologic stage 0/1A NSCLC and presented with suture-line recurrences-either isolated or with additional findings-and compared these patients to other types of recurrence.

METHODS

We analyzed 653 patients with pathologic stage 0/1A NSCLC from the IELCART cohort (2016-2023). Recurrences were categorized by the presence or absence of suture line involvement, and survival outcomes were assessed.

FINDINGS

Among 653 patients (median age 69), 44 (6.7 %) experienced recurrences, including 22 suture-line recurrences. Sublobar resections (19/22 vs. 11/22, p = 0.01) and smaller margins (8 mm vs. 20 mm, p < 0.001) were more frequent in patients with suture-line recurrences. Of the 22 suture-line recurrences, 13 were isolated, and 9 had additional findings. Isolated recurrences were diagnosed later (31.0 vs. 14.0 months, p = 0.01) and treated with surgery (6/13) or radiotherapy (7/13), both well-tolerated. Patients with isolated suture-line recurrences demonstrated better survival outcomes compared to all other recurrence types (overall survival: 72.0 % vs. 45.7 %, p = 0.02; lung cancer-specific survival: 90.0 % vs. 76.1 %, p = 0.19).

INTERPRETATION

Recurrences after stage 0/1A lung cancer surgery are rare, with half involving the suture line. Suture-line recurrences arise around two years post-surgery, often following sublobar resections with resection margins under 1 cm. For isolated suture-line recurrences, treatment with either radiotherapy and completion surgery were effective, yielding comparable outcomes and improved survival compared to any other recurrence types.

Pleomorphic Carcinoma Arising at Previous Resection Margins of Ground-Glass Opacities

Pleomorphic carcinoma of the lung is highly malignant and occurs mostly in the upper lobes of smokers; however, no reports exist of new occurrences from the resection margins of the previous ground-glass opacities. In our case, a 73-year-old man underwent an initial partial resection of the left upper lung for ground-glass opacities, with progressive thickening of the resection margin during the following 10 months. Radical resection was performed, resulting in the diagnosis of a newly arising pleomorphic carcinoma from previously resected margins.

Postoperative CT surveillance in the evaluation of local recurrence after sub-lobar resection of neoplastic lesions of the lung

OBJECTIVE

As indications for sub-lobar resections increase, it will become more important to identify risk factors for postsurgical recurrence. We investigated retrospectively the association between local recurrence after sub-lobar resection of neoplastic lung lesions and pre- and post-operative CT imaging and pathologic features.

MATERIALS AND METHODS

We reviewed retrospectively neoplastic lung lesions with postoperative chest CT surveillance of sub-lobar resections in 2006-2016. We defined "suspicious" findings as nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line and/or progression and explored their association with local recurrence. Primary lung cancer stage, tumoral invasion of lymphatics, visceral pleura or large vessels, bronchial and vascular margin distance were also assessed.

RESULTS

Our study group included 45 cases of sub-lobar resection took for either primary (n = 37) or metastatic (n = 8) lung tumors. Local recurrence was observed in 16 of those patients. New nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line on surveillance CT was significantly associated with local recurrence (p = 0.037). Additionally, solid nodule (p = 0.005), age at surgery ≤60 years (p = 0.006), two or more sites of invasion (p < 0.0001) and poor histologic differentiation (p = 0.0001) were also significantly associated with local tumor recurrence. Of 16 patients with surveillance post-surgical PET-CT, 15 had elevated FDG uptake.

CONCLUSION

The postoperative changes along the suture line should follow a predictable time course demonstrating a pattern of stability, thinning or resolution on CT surveillance. New or increasing postoperative nodularity ≥3 mm or soft tissue thickening ≥4 mm along the suture line requires close diagnostic work-up. Surgical pathology characteristics added prognostic value on postoperative recurrence surveillance.

Completion lobectomy after anatomical segmentectomy

OBJECTIVES

Completion lobectomy (CL) after anatomical segmentectomy in the same lobe can be complicated by severe adhesions around the hilar structures and may lead to fatal bleeding and lung injury. Therefore, we aimed to investigate the perioperative outcomes of CL after anatomical segmentectomy.

METHODS

Among 461 patients who underwent anatomical segmentectomy (thoracotomy, 62 patients; thoracoscopic surgery, 399 patients) between January 2005 and December 2019, data of patients who underwent CL after segmentectomy were extracted and analysed in this study.

RESULTS

Eight patients underwent CL after segmentectomy. CL was performed via video-assisted thoracic surgery in 3 patients and thoracotomy in 5 patients. In each case, there were moderate to severe adhesions. Four patients required simultaneous resection of the pulmonary parenchyma and pulmonary artery. Thoracotomy was not required after thoracoscopic surgery in any patient. Two patients experienced complications (air leakage and arrhythmia). The median duration of hospitalization after CL was 6 (range, 5-7) days. No postoperative mortality or recurrence of lung cancer was observed. All the patients with lung cancer were alive and recurrence-free at the time of publication.

CONCLUSIONS

Although individual adhesions render surgery difficult, CL after anatomical segmentectomy shows acceptable perioperative outcomes. However, CL by video-assisted thoracoscopic surgery may be considered on a case-by-case basis depending on the initial surgery.