Wedge Resection Offers Similar Survival to Segmentectomy for Typical Carcinoid Tumors

Sublobar Resection of Non-Small-Cell Lung Cancer: Wedge Resection vs. Segmentectomy

Lung cancer is the most common cause of cancer death. The mainstay treatment for non-small-cell lung cancer (NSCLC), particularly in the early stages, is surgical resection. Traditionally, lobectomy has been considered the gold-standard technique. Sublobar resection includes segmentectomy and wedge resection. Compared to lobectomy, these procedures have been viewed as a compromise procedure, reserved for those with poor cardiopulmonary function or who are poor surgical candidates for other reasons. However, with the advances in imaging and surgical techniques, the subject of sublobar resection as a curative treatment is being revisited. Many studies have now shown segmentectomy to be equivalent to lobectomy in patients with small (<2.0 cm), peripheral NSCLC. However, there is a mix of evidence when it comes to wedge resection and its suitability as a curative procedure. At this time, until more data can be found, segmentectomy should be considered before wedge resection for patients with early-stage NSCLC.

Comparison of early patient-reported outcomes between uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small-cell lung cancer

BACKGROUND

Analysis of patient-reported outcomes (PROs) offers valuable insights into distinguishing the effects of closely related medical procedures from the patient's perspective. In this study we compared symptom burden in patients undergoing uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small cell lung cancer (NSCLC).

METHODS

This study included patients with peripheral NSCLC from an ongoing longitudinal prospective cohort study (CN-PRO-Lung 3) who underwent segmentectomy or wedge resection with tumor diameter ≤ 2 cm and consolidation tumor ratio (CTR) ≤ 0.5. PROs data were collected using the Perioperative Symptom Assessment for Lung Surgery questionnaire pre-operatively, daily post-surgery up to the fourth hospitalization day, and weekly post-discharge up to the fourth week. Propensity score matching and a generalized estimation equation model were employed to compare symptom severity. In addition, short-term clinical outcomes were compared.

RESULTS

In total, data of 286 patients (82.4%) undergoing segmentectomy and 61 patients (17.6%) undergoing wedge resection were extracted from the cohort. No statistically significant differences were found in the proportion of moderate-to-severe symptoms and mean scores for pain, cough, shortness of breath, disturbed sleep, fatigue, drowsiness, and distress during the 4-day postoperative hospitalization or the 4-week post-discharge period before or after matching (all p > 0.05). Compared with segmentectomy, wedge resection showed better short-term clinical outcomes, including shorter operative time (p = 0.001), less intraoperative bleeding (p = 0.046), and lower total hospital costs (p = 0.002).

CONCLUSIONS

The study findings indicate that uniportal thoracoscopic segmentectomy and wedge resection exert similar early postoperative symptom burden in patients with peripheral NSCLC (tumor diameter ≤ 2 cm and CTR ≤ 0.5).

CLINICAL TRIAL REGISTRATION

Not applicable.

Sublobar Pulmonary Resection in Children With Congenital Lung Abnormalities: A Systematic Review

BACKGROUND

Lobectomy is currently the advised resection for symptomatic congenital lung abnormalities (CLA). Sublobar surgery is suggested as an alternative that enables to conserve healthy lung parenchyma. This systematic review aims to explore the outcomes of sublobar surgery in CLA patients as well as the corresponding surgical terminology and techniques.

METHODS

A systematic literature search was performed in adherence to PRISMA-P guidelines. The target population consists of children undergoing sublobar pulmonary resection for CLA. All studies were independently assessed by two reviewers, and evaluated by a third reviewer in case of disagreement.

RESULTS

The literature search yielded 901 studies of which 18 studies were included, comprising 1167 cases. The median chest tube insertion duration was 3.6 days (range 2.0-6.9 days), the median hospital admission was 4.9 days (range 2.0-14.5 days), and residual disease was diagnosed in 2% - leading to re-operation in 70%. The median incidence of postoperative complications was 15% (range 0-67%). Follow-up imaging was standard-of-care in 2/3 of studies. Due to the absence of standardised terminology, operative details and specification of resection type did not typically relate between studies.

CONCLUSIONS

Sublobar resection of CLA lesions could be a viable alternative to lobectomy in certain cases, with the advantage of conserving healthy lung parenchyma. Peri- and postoperative complications are comparable with those reported for conventional lobectomy. The incidence of residual disease following sublobar surgery appears to be lower than commonly stated. To improve comparability between studies, we recommend reporting perioperative characteristics in a structured format.

LEVEL OF EVIDENCE

Level IV.

Prognosis of Unresected vs Resected Small Pulmonary Carcinoid Tumors

BACKGROUND

Previous studies have shown that overall survival after lung resection for pulmonary carcinoid tumors is favorable. It is unclear what the prognosis is for observation rather than resection for small carcinoid tumors.

METHODS

We queried the National Cancer Database to identify patients presenting with primary pulmonary carcinoid tumors between 2004 and 2017. We included patients with small (<3 cm) primary pulmonary carcinoids, who were observed or underwent a lung resection. To minimize confounding by indication, we used propensity score matching, while accounting for age, sex, race, insurance type, Charlson-Deyo comorbidity score, typical and atypical histology, tumor size, and year of diagnosis. We used Kaplan-Meier survival analyses to compare 5-year overall survival in the matched cohorts.

RESULTS

Of 8435 patients with small pulmonary carcinoids, 783 (9.3%) underwent observation and 7652 (91%) underwent surgical resection. After propensity score matching, surgical resection was associated with improved 5-year overall survival (66% vs 81%, P < .001). No significant difference in overall survival was found between wedge and anatomic resection (88% vs 88%, P = .83). In patients undergoing resection, lymph node sampling at the time of wedge and anatomic resection increased 5-year overall survival (90% vs 86%, P = .0042; 88% vs 82%, P = .04, respectively).

CONCLUSIONS

Surgical resection of small pulmonary carcinoids is associated with improved survival compared with observation. When surgical resection is performed, wedge and anatomic resection result in similar survival, and lymph node sampling improves survival.

A Competing Risk Model Nomogram to Predict the Long-Term Prognosis of Lung Carcinoid

BACKGROUND

The prediction of long-term, cancer-specific survival of lung carcinoid remains controversial. We aimed to build a prognostic model by using competing-risk analysis to predict the long-term, cancer-specific survival of lung carcinoid patients.

METHODS

Patients were retrospectively enrolled from the SEER database, and clinicopathological data were collected. Univariable and multivariable competing-risk analyses were conducted to identify prognostic factors. A competing-risk model and a nomogram were developed by using independent prognostic factors. The model was assessed by using concordance index and calibration curves.

RESULTS

A total of 2496 patients were enrolled, of which 267 (10.7%) died of diagnosed carcinoma; 316 (12.7%) died because of other reasons. The 5-year, 10-year, and 15-year cancer-specific survival of carcinoid patients were 91.35%, 86.60%, and 84.39%, respectively. Multivariable analysis demonstrated that increasing age, male, larger tumor size, higher N stage, M1, atypical carcinoid, and undergoing no surgery were independent risk factors. A competing-risk model based on the risk factors and a corresponding nomogram were developed. Concordance index of the developed model for 5-year, 10-year, and 15-year were 0.891, 0.856, 0.836 respectively in the training cohort and 0.876, 0.841, 0.819 respectively in the validation cohort after bootstrap adjustment. The calibration curves of 5-year, 10-year, and 15-year showed good agreement.

CONCLUSIONS

Increasing age, male, larger tumor size, higher N stage, M1, atypical carcinoid, and undergoing no surgery were independent risk factors. A competing risk model of excellent performance in predicting long-term survival was developed, and a nomogram was established.

The Surgical Management of Lung Neuroendocrine Neoplasms

This review summarizes key recent developments relevant to the surgical management of lung neuroendocrine neoplasms (L-NENs), including typical and atypical carcinoids, large cell neuroendocrine carcinoma, and small cell lung carcinoma. This review includes recent insights into the classification, clinical presentation, diagnostic workup, treatment options, and follow-up. Highlighted topics include general principles of surgery in localized or locally advanced or metastatic L-NENs, lung-sparing surgery for small, peripheral typical carcinoids, adjuvant and systemic therapies for typical and atypical carcinoids, and surgery and adjuvant therapies for large cell neuroendocrine carcinoma and small cell lung carcinoma.

Current Management of Carcinoid Tumor

Bronchopulmonary carcinoid tumors are rare, well-differentiated neuroendocrine neoplasms. They can be categorized as typical or atypical lesions and are low-to-intermediate-grade, respectively. The cornerstone of therapy for carcinoid tumors is surgical resection and current consensus guidelines recommend anatomic resection for stage I to IIIA disease. The renewed interest in sublobar resections for the treatment of lung malignancies has sparked debate over the degree of resection necessary for these indolent lesions. Segmentectomy provides an oncologic resection while preserving as much lung parenchyma as possible, and is a reasonable approach to apply to small, undifferentiated, or typical carcinoid lesions.

Long-term survival analysis of sublobar resection versus lobectomy for older patients with early-stage pulmonary carcinoid tumour: a database-based propensity score-matched study

BACKGROUND

The optimal extent of surgery for older patients with early-stage pulmonary carcinoid tumour (PC) remains controversial.

AIMS

To compare prognostic differences between sublobar resection versus lobectomy in older patients with early-stage PC.

METHODS

The SEER database was searched for stage T1N0M0 PC patients aged ≥ 65 years who underwent lobectomy or sublobar resection from 2000 to 2017. Propensity score matching (PSM) was used to determine intergroup covariate differences. Kaplan-Meier curves and the log-rank test were used for intergroup comparison of overall survival (OS). A Cox proportional hazard model was used to evaluate independent risk factors.

RESULTS

Among 1023 participants, 650 and 373 underwent lobectomy and sublobar resection, respectively. Before PSM, the 5- and 10-year OS in the sublobar resection group were lower than that of the lobectomy group (5-year OS 84.12% vs. 91.16%; 10-year OS 57.43% vs. 64.77%; p = 0.014); after PSM, no significant prognostic difference existed between lobectomy and sublobar resection (5-year OS 88.17% vs. 89.23%; 10-year OS 58.32% vs. 62.75%; p = 0.811). Subgroup analysis included tumour size, age, number of lymph nodes examined and histological type, and showed no statistically significant survival differences between the lobectomy and sublobar resection groups. Multivariable Cox analysis indicated that age ≥ 77 years, male sex, inadequate lymph node assessment (< 7), and atypical carcinoid were associated with reduced OS.

CONCLUSION

Sublobar resection showed a similar long-term survival rate for early-stage PC patients aged ≥ 65 years as with lobectomy, thereby providing a basis for the selection of surgical methods for PC.

Surgical Principles in the Management of Lung Neuroendocrine Tumors: Open Questions and Controversial Technical Issues

OPINION STATEMENT

Primary neuroendocrine tumors (NETs) of the lung represent a heterogeneous group of malignancies arising from the endocrine cells, involving different entities, from well differentiated to highly undifferentiated neoplasms. Because of the predominance of poorly differentiated tumors, advanced disease is observed at diagnosis in more than one third of patients making chemo- or chemoradiotherapy the only possible treatment. Complete surgical resection, as defined as anatomical resection plus systematic lymphadenectomy, becomes a reliable curative option only for that little percentage of patients presenting with stage I (N0) high-grade NETs. On the other hand, complete surgical resection is considered the mainstay treatment for localized low- and intermediate-grade NETs. Therefore, in the era of the mini-invasive surgery, their indolent behavior has suggested that parenchyma-sparing resections could be as adequate as the anatomical ones in terms of oncological outcomes, leading to discuss about the correct extent of resection and about the role of lymphadenectomy when dealing with highly differentiated NETs.