Propensity-matched Comparison of VATS Left Upper Tri-segmentectomy and Lobectomy

Left upper division segmentectomy is not a simple procedure: experience from two high-volume centers

BACKGROUND

Whether left upper division segmentectomy (LUDS) is a simple procedure remains controversial. This study aimed to compare the outcomes of LUDS with those of simple segmentectomy (SS) (excluding LUDS) and complex segmentectomy (CS) at two high-volume centers.

METHODS

We retrospectively reviewed 1565 patients who underwent thoracoscopic segmentectomy for early-stage lung cancer between February 2015 and February 2020. Patients were categorized into three groups: LUDS (n = 189), SS (n = 317), and CS (n = 1059). The primary endpoint was defined as the occurrence of any following events: intraoperative complications, postoperative complications, 30-day readmission, and local recurrence.

RESULTS

The rate of the primary endpoint was significantly higher in the LUDS group (14.3%) than in the SS group (7.6%) (P = 0.046) but was comparable between the LUDS and CS groups (14.4%) (P = 1.000). The median operative time in the LUDS group was 135 min, compared to 120 min in the SS group (P < 0.001) and 140 min in the CS group (P = 0.180). The median blood loss and rate of vascular injury in the LUDS group were significantly higher than those in the SS and CS groups (all P < 0.05). Subgroup analysis of the LUDS group demonstrated that the high-experience group had lower rates of primary endpoint and vascular injury, shorter operative time, and reduced blood loss.

CONCLUSIONS

LUDS is an efficient but complex procedure characterized by a long operative time, considerable blood loss, and a potential risk of vascular injury. Performance by experienced surgeons should be considered, as surgical expertise tends to result in improved outcomes.

Comparison of survival between lobectomy and trisegmentectomy for clinical stage T1c-2aN0M0 non-small cell lung cancer in the left upper segment of the lung

Left upper trisegmentectomy is expected to be as curative as lobectomy for lung cancer because the left upper lobe is anatomically the same as the combined upper and middle lobes of the right lung and the procedure can provide a sufficient surgical margin. In the present multicenter study, we compared the results of trisegmentectomy and lobectomy in patients with clinical stage T1c-2aN0M0 left upper lung cancer. We retrospectively analyzed the outcomes of patients with clinical stage T1c-2aN0M0 lung cancer in the left upper segment who underwent lobectomy or trisegmentectomy between January 2006 and June 2022. The trisegmentectomy group (S group) and lobectomy group (L group) comprised 33 and 132 patients, respectively. Comparisons of postoperative survival revealed no significant differences in overall survival (p = 0.761) or disease-free survival (p = 0.508) between the two groups. There were also no significant differences in survival after adjustment for clinical factors by Cox proportional hazards models and propensity score matching. Local recurrence was significantly more predominant in the S group than in the L group (p = 0.006). The S group had a worse postoperative survival than the L group when the tumor was located in anterior segment. Trisegmentectomy can provide an equivalent postoperative survive to lobectomy in patients with clinical stage T1c-2aN0M0 left upper segment lung cancer except in patients with tumor in anterior segment.

Left Upper Lobectomy vs Trisegmentectomy for Lung Cancer: A Propensity Score-Matched Comparison

BACKGROUND

The left upper division (segments I-III) and the lingula (segments IV and V) are analogous to the right upper and middle lobes, respectively. Whereas bilobectomy for right upper lobe tumors is rare, left upper division tumors are often resected by left upper lobectomy (LUL) rather than by left upper trisegmentectomy (LU3S). To assess safety and oncologic efficacy of LUL vs LU3S, we compared short- and long-term outcomes after both procedures.

METHODS

Patients undergoing LUL or LU3S for clinical stage IA-IIA non-small cell lung cancer in the left upper division from January 2006 to December 2020 were identified from an institutional database. Propensity score matching was used to control for clinical differences.

RESULTS

We identified 229 cases meeting inclusion criteria: 131 (57.2%) LUL, 98 LU3S. After matching, 83 cases were included in each group. Median clinical tumor size was similar for LUL vs LU3S (2.2 cm [interquartile range, 1.6-3.0 cm] vs 2.1 cm [interquartile range, 1.7-2.9 cm]; P = .80). Total lymph nodes sampled did not differ between LUL and LU3S (median, 7 vs 6; P = .36), nor did patterns of N2 sampling (P = .11). Odds of postoperative complications did not differ after LUL vs LU3S (odds ratio, 0.75; 95% CI, 0.39-1.46). No 30-day death was observed. Median follow-up was 72 months. There was no statistically significant difference in 5-year overall survival (75.9% vs 82.1%; P = .28) or locoregional recurrence-free survival (73.7% vs 80.0%; P = .23) after LUL vs LU3S.

CONCLUSIONS

Our findings suggest that LU3S and LUL have equivalent short- and long-term outcomes in patients with clinical stage IA-IIA non-small cell lung cancer in the left upper division.

Long-Term Results of Segmentectomy vs. Lobectomy for c-Stage IA Lung Cancer: A Real-Life Study with a Propensity Score Analysis Based on a National Cohort

Background/Objectives: The objective was to compare the results of segmentectomy and lobectomy in the treatment of c-stage IA lung cancer in terms of tumor recurrence and 5-year survival. Methods: An observational study was performed using 3533 patients included in the registry of the Spanish VATS Group (GEVATS) of the Spanish Society of Thoracic Surgery (SECT) between 2016 and 2018. A total of 1004 lobectomies and 83 segmentectomies in c-stage IA were selected. Two comparable groups were selected through 2:1 propensity score matching with patient-, tumor- and surgery-related variables, leaving 166 lobectomies and 83 segmentectomies. Tumor recurrence was analyzed by Fisher's test and overall, cancer-specific, recurrence-free and disease-free survival by Kaplan-Meier and Log-rank tests. Results: Overall recurrence was 23.7% in both groups, with a predominance of locoregional recurrence in segmentectomy (16.2% vs. 11.2%) and distant recurrence in lobectomy (12.5% vs. 7.5%). There was no difference between the two groups in any of the survival types. Overall survival at 5 years was 73.5% (95% CI: 65.5-82.4%) in the lobectomy group vs. 73.1% (95% CI: 60.1-88.9%) in the segmentectomy group. Conclusions: Anatomic segmentectomy may be a valid option in the treatment of c-stage IA lung cancer since the recurrence and long-term survival outcomes compared to lobectomy are equivalent.

Propensity matching analysis of left upper tri-segmentectomy versus lobectomy for stage I non-small cell lung cancer

BACKGROUND

The equivalence between left upper lobectomy (LUL) and left upper tri-segmentectomy (LUTS) for stage I left upper non-small cell lung cancer (NSCLC) remains unclear. This study compares the perioperative and oncological outcomes of LUL and LUTS in this patient population.

METHODS

This study included patients who underwent LUL or LUTS at West China Hospital of Sichuan University and Sichuan ShangJin Hospital between August 2018 and November 2023. Patients with tumors located at least 2 cm from the lingular segment were included. Propensity score matching (PSM) addressed baseline imbalances between groups. Perioperative outcomes, overall survival (OS), recurrence-free survival (RFS), lung cancer-specific survival (LCSS), and subgroup analyses were assessed.

RESULTS

A total of 1019 patients were included (LUL: 524; LUTS: 495) with a median follow-up of 4.8 years (IQR: 2.5-8.1). Compared to LUL, LUTS was associated with significantly shorter operative times (103 vs. 120 min, p = 0.001), reduced postoperative drainage volume at 3 days (335 vs. 485 ml, p = 0.001) and total (360 vs. 530 ml, p = 0.001), lower conversion to thoracotomy rates (1.0% vs. 3.4%, p = 0.009), and fewer postoperative complications (9.9% vs. 14.9%, p = 0.016). No significant differences were observed in 5-year OS (86.7% vs. 85.4%, HR: 0.96; 95% CI: 0.66-1.39; p = 0.821), 5-year RFS (78.4% vs. 75.3%, HR: 0.85; 95% CI: 0.63-1.13; p = 0.258), or 5-year LCSS (90.2% vs. 91.3%, HR: 0.99; 95% CI: 0.62-1.57; p = 0.956) between the two groups.

CONCLUSION

For stage I left upper NSCLC, LUTS, while preserving adequate surgical margins, achieves superior perioperative and comparable oncological outcomes to LUL.

Comparison of 5-Year Survival and Disease Recurrence After Trisegmentectomy or Left Upper Lobectomy: A Propensity Score Analysis of the National GEVATS Database

INTRODUCTION

Trisegmentectomy, or resection of the upper subdivision of the left upper lobe with preservation of the lingula, is considered by some authors to be equivalent to right upper lobectomy with middle lobe preservation. Our objective was to compare survival and recurrence after trisegmentectomy versus left upper lobectomy procedures registered in the Spanish Video-Assisted Thoracic Surgery group (GEVATS) database.

METHODS

We compared mortality, survival and recurrence in patients with left upper lobectomy or trisegmentectomy after propensity score matching for the following variables: age, smoking habit, tumor size, histologic type, radiological density of tumor, surgical access, forced expiratory volume in one second, diffusing capacity of the lungs for carbon monoxide, hypertension, chronic heart failure, ischemic heart disease, arrhythmia, stroke, peripheral vascular disease, diabetes and pre-surgery nodal status by positron emission tomography/computed tomography.

RESULTS

A total of 540 left upper lobectomies and 83 trisegmentectomies were registered in the GEVATS database. After propensity score matching, 134 left upper lobectomies and 67 trisegmentectomies were selected. Survival outcomes were similar, but differences were found for recurrence (21.5% for trisegmentectomies vs. 35.4% for left upper lobectomies, p=0.05). Moreover, the recurrence patterns differed, with the lobectomy group showing a greater tendency to distant dissemination.

CONCLUSIONS

Trisegmentectomy and left upper lobectomy show similar 5-year survival rates. In our database, recurrence after trisegmentectomy was lower than after left upper lobectomy, while the recurrence pattern differed among the 2 surgical approaches, with a greater tendency to distant metastasis after left upper lobectomy.

Clinical outcomes of left upper segmentectomy vs. lobectomy for early non-small-cell lung cancer: a nationwide database study in Japan

PURPOSE

Given that left upper lobe and right upper and middle lobes share a similar anatomy, segmentectomy, such as upper division and lingulectomy, should yield identical oncological clearance to left upper lobectomy. We compared the prognosis of segmentectomy with that of lobectomy for early stage non-small-cell lung cancer (NSCLC) in the left upper lobe.

METHODS

We retrospectively examined 2115 patients who underwent segmentectomy or lobectomy for c-stage I (TNM 8th edition) NSCLC in the left upper lobe in 2010. We compared the oncological outcomes of segmentectomy (n = 483) and lobectomy (n = 483) using a propensity score matching analysis.

RESULTS

The 5-year recurrence-free and overall survival rates in the segmentectomy and lobectomy groups were comparable, irrespective of c-stage IA or IB. Subset analyses according to radiological tumor findings showed that segmentectomy yielded oncological outcomes comparable to those of lobectomy for non-pure solid tumors. In cases where the solid tumor exceeded 20 mm, segmentectomy showed a recurrence-free survival inferior to that of lobectomy (p = 0.028), despite an equivalent overall survival (p = 0.38).

CONCLUSION

Segmentectomy may be an acceptable alternative to lobectomy with regard to the overall survival of patients with c-stage I NSCLC in the left upper lobe.

High-risk characteristics of pathological stage I lung adenocarcinoma after resection: patients for whom adjuvant chemotherapy should be performed

BACKGROUND

The objective of the present study was to identify patients with pathologic stage I lung adenocarcinoma (LUAD) who are at high risk of recurrence and assess the efficacy of adjuvant chemotherapy (ACT) in these individuals.

METHODS

A retrospective study was conducted on 1504 patients with pathologic stage I LUAD who underwent surgical resection at Shanghai Pulmonary Hospital and Sun Yat-sen University Cancer Center. Cox proportional hazard regression analyses were performed to identify indicators associated with a high risk of recurrence, while the Kaplan-Meier method and Log-rank test were employed to compare recurrence-free survival (RFS) and overall survival (OS) between patients with ACT and those without it.

RESULTS

Four independent indicators, including age (≥62 years), visceral pleural invasion (VPI), predominant pattern (micropapillary/solid), and lymphovascular invasion (LVI), were identified to be significantly related with RFS. Subsequently, patients were classified into high-risk and low-risk groups by LVI, VPI, and predominant pattern. The administration of ACT significantly increased both RFS (P < 0.001) and OS (P = 0.03) in the high-risk group (n = 250). Conversely, no significant difference was observed in either RFS (P = 0.45) or OS (P = 0.063) between ACT and non-ACT patients in the low-risk group (n = 1254).

CONCLUSIONS

Postoperative patients with stage I LUAD with factors such as LVI, VPI, and micropapillary/solid predominant pattern may benefit from ACT.

Uniportal left S1 + 2 segmentectomy

The left upper lobe is one of the largest lobes of the lung; left upper segmentectomy is well established among thoracic surgeons. In uniportal left S1 + 2 segmentectomy, dissection of the vasculature, bronchus, and intersegmental plane can be performed anteriorly. Given that the fissureless technique is commonly used in uniportal video-assisted thoracoscopic surgery, S1 + 2 segmentectomy exhibits high affinity with the unidirectional approach. We have frequently performed left S1 + 2 segmentectomy for early non-small cell lung cancer located in the apical segment, since this procedure has the potential to preserve pulmonary function over tri-segmentectomy. Herein, we introduce our approach to uniportal left S1 + 2 segmentectomy as a minimally invasive alternative for preserving lung function.

Left Upper Lobe Multi-Segmentectomy Vs Lobectomy for Early-Stage Lung Cancer: A Meta-Analysis

INTRODUCTION

The left upper lobe (LUL) has unique hilar anatomy, and LUL multi-segmentectomy (apical trisegmentectomy and lingulectomy) may result in different outcomes than both single anatomical segmentectomy and left upper lobectomy in the management of early-stage primary lung cancer; however no meta-analyses have been performed. The aim of this meta-analysis is to determine if LUL multi-segmentectomy is non-inferior to left upper lobectomy for long-term survival outcomes, or superior for in-hospital outcomes.

METHODS

Electronic databases searches were performed on PubMed, Embase, and the Cochrane Library to identify studies comparing outcomes in LUL multi-segmentectomy vs left upper lobectomy in early-stage lung cancer (clinical stage T2 N0 or less). Long-term postoperative overall and disease-free survival were assessed via reconstruction of Kaplan-Meier survival curves. In-hospital complications and length of stay, as well as long term recurrence were analysed via random effects models.

RESULTS

Five relevant studies were identified, including 1,196 patients. Overall survival did not differ at 5 years (multi-segmentectomy 92.6% vs lobectomy 89.3%, P=0.188), but patients undergoing LUL multi-segmentectomy had better disease-free survival at 5 years (93.1% vs 88.4%, P=0.041). Patients undergoing LUL multi-segmentectomy had a shorter mean length of hospital stay (mean difference -0.26 days, 95% CI; -0.39 to 0.14, P<0.01, I²=0.00%). There was no difference in combined in-hospital complications (P=0.14), local recurrence (P=0.35), distant recurrence (P=0.23), or overall recurrence (P=0.39).

CONCLUSION

LUL multi-segmentectomy is associated with reduced hospital length of stay, but no difference in long-term overall survival compared with left upper lobectomy in the management of early-stage primary lung cancer.

A Novel Systematic Oxidative Stress Score Predicts the Survival of Patients with Early-Stage Lung Adenocarcinoma

This study aimed to construct an effective nomogram based on the clinical and oxidative stress-related characteristics to predict the prognosis of stage I lung adenocarcinoma (LUAD). A retrospective study was performed on 955 eligible patients with stage I LUAD after surgery at our hospital. The relationship between systematic-oxidative-stress biomarkers and the prognosis was analyzed. The systematic oxidative stress score (SOS) was established based on three biochemical indicators, including serum creatinine (CRE), lactate dehydrogenase (LDH), and uric acid (UA). SOS was an independent prognostic factor for stage I LUADs, and the nomogram based on SOS and clinical characteristics could accurately predict the prognosis of these patients. The nomogram had a high concordance index (C-index) (0.684, 95% CI, 0.656-0.712), and the calibration curves for recurrence-free survival (RFS) probabilities showed a strong agreement between the nomogram prediction and actual observation. Additionally, the patients were divided into two groups according to the cut-off value of risk points based on the nomogram, and a significant difference in RFS was observed between the high-risk and low-risk groups (p < 0.0001). SOS is an independent prognostic indicator for stage I LUAD. These things considered, the constructed nomogram based on SOS could accurately predict the survival of those patients.

Comparison of oncological outcomes between trisegmentectomy and lobectomy for non-small cell lung cancer in the left upper division

Background

The left upper lobe is one of the largest lobes in the lungs and is divided into two anatomical units: the upper division (segments 1+2 and segment 3) and lingula (segments 4 and 5). This anatomical classification is similar to that used for the right upper and middle lobes. Although bilobectomy is not recommended for right upper or middle lobe tumors close to the interlobar plane, lobectomy is often performed for tumors located close to the intersegmental plane in the left upper division. To aid in establishing trisegmentectomy as a standard treatment for clinical N0 non-small cell lung cancer (NSCLC) in the left upper lobe, we aimed to re-assess its feasibility based on oncological outcomes according to tumor location.

Methods

We retrospectively analyzed the data of patients with clinical N0 NSCLC in the left upper division who underwent left upper lobectomy or trisegmentectomy between April 2006 and December 2020. After propensity score matching, oncological outcomes were compared between the trisegmentectomy and lobectomy groups. To verify whether trisegmentectomy was indicated regardless of tumor distance from the intersegmental plane, we compared the recurrence-free survival (RFS) rates following trisegmentectomy between patients with tumors ≤20 and >20 mm from the intersegmental plane.

Results

After propensity score matching, 46 patients were included in each group. There was no significant difference in the 5-year RFS rate between the lobectomy and trisegmentectomy groups (75.5% vs. 84.0%, P=0.41). In the trisegmentectomy cohort, the 5-year RFS rate did not significantly differ according to tumor distance from the intersegmental plane (≤20 or >20 mm) measured using three-dimensional computed tomography (79.4% vs. 81.2%, P=0.69). Multivariate analysis indicated that tumor distance from the intersegmental plane was not a significant predictor of RFS (hazard ratio: 1.75, 95% confidence interval: 0.52-5.91, P=0.37).

Conclusions

Our analysis suggests that oncological outcomes (i.e., RFS rates) following trisegmentectomy for clinical N0 NSCLC in the left upper division are not significantly inferior to those following lobectomy, even if the tumor is located close to the intersegmental plane.