Systematic review and meta-analysis of segmentectomy vs. lobectomy for stage IA non-small cell lung cancer

Outcomes of Segmentectomy With or Without Preoperative Biopsy in Non-Small Cell Lung Cancer (NSCLC)

BACKGROUND

There is a discussion amongst oncologic societies regarding the necessity of preoperative biopsy prior to resection in lung cancer. We aim to examine outcomes of segmentectomy with or without preoperative biopsy in non-small cell lung cancer (NSCLC) patients.

METHODS

A retrospective cohort study was conducted utilizing the National Cancer Database. Adult patients diagnosed with clinical stage I (N0 M0, tumor size ≤ 2 cm) NSCLC between 2010 and 2019 who underwent segmentectomy were included. Patients with carcinoid tumors or who received neoadjuvant systemic or radiation therapy were excluded. Demographic and clinical variables were analyzed. Propensity score matching (PSM) was performed to adjust for confounders between patients who underwent segmentectomy with versus without preoperative biopsy. Short term outcomes (readmission, 30-day and 90-day survival) and long-term overall survival (OS) were compared between groups.

RESULTS

In total, 6891 patients met inclusion criteria, of which 2287 (33.2%) underwent preoperative biopsy and 4604 (66.8%) did not. There was no significant difference in 30-day readmission (P = .13), 30-day survival (P = .26), and 90-day survival (P = .31). Patients who did not receive preoperative biopsy was associated with a higher 5-year OS (P = .02); however, post-PSM, there was no significant difference between the 2 groups (P = .20).

CONCLUSIONS

After PSM, no significant difference was found in margin positivity, nodal upstaging, 30-day readmission, 30- and 90-day survival, and 5-year OS between cohorts. This demonstrates that segmentectomy without preoperative biopsy remains a safe option for those with early stage, ≤ 2 cm NSCLC.

Pathologic upstaging and survival outcomes for patients undergoing segmentectomy versus lobectomy in clinical stage T1cN0M0 non-small cell lung cancer

Objectives

To assess the impact of the extent of surgical resection on overall survival in patients with clinical T1cN0M0 (cT1cN0M0) non-small cell lung cancer (NSCLC), with and without pathologic nodal upstaging (pN1+).

Methods

The National Cancer Database (NCDB) was queried to identify patients with cT1cN0M0 NSCLC who underwent lobectomy or segmentectomy without receiving neoadjuvant therapy between 2010 and 2021. Bivariate analyses were performed to compare demographic and clinical characteristics across surgical groups. Propensity score matching was used to compare outcomes of segmentectomy versus lobectomy. Cox proportional hazard models and Kaplan-Meier survival estimates were used to assess the association of overall survival on the interaction between extent of resection and pathologic nodal upstaging.

Results

A total of 22,945 patients were analyzed, including 21,875 (95.3%) who underwent lobectomy and 1070 (4.7%) who underwent segmentectomy. Pathologic nodal upstaging to pN1+ occurred in 14.5% of lobectomy cases and in 6.6% of segmentectomy cases. Propensity score-matched analysis revealed that patients undergoing segmentectomy had comparable overall survival to those undergoing lobectomy (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.86-1.16), and those undergoing segmentectomy with pN1+ had comparable overall survival to those undergoing lobectomy with pN1+ (HR, 1.04; 95% CI, 0.65-1.66).

Conclusions

In patients with cT1cN0M0 NSCLC, overall survival outcomes are similar between segmentectomy recipients and lobectomy recipients, including those incidentally found to have pN1+, suggesting a potential role of lobe-preserving approaches. Additionally, completion lobectomy may not offer a survival benefit in cT1cN0M0 patients incidentally discovered to have pathologic N1 nodes.

Completion lobectomy after thoracoscopic segmentectomy on the left side should be approached with thoracotomy

Background

Lung segmentectomy is widely used to treat early-stage non-small cell lung cancer (NSCLC), but the risk of local recurrence in the ipsilateral lobe is increased and the surgical treatment of the local recurrence could be a real challenge. The aim of this study is to report our experience in a consecutive series of patients undergoing completion lobectomy (CL) after thoracoscopic segmentectomy.

Methods

We retrospectively reviewed all the medical charts of the patients who underwent thoracoscopic segmentectomy for early-stage NSCLC (cIA) between January 2015 and December 2023, focusing on patients who had NSCLC recurrence in the ipsilateral lobe treated with CL.

Results

Among the 263 segmentectomies performed, 13 patients (4.9%) experienced local recurrence in the ipsilateral remaining lobe, of whom 9 (3.4%) underwent CL, including 5 in the left upper lobe, with a median interval of 31 months between procedures. All patients underwent CL through thoracotomy with the need of central isolation in 5/9 (55.5%); rupture of the pulmonary artery occurred two patients and vascular sleeve resection was necessary in one. No postoperative deaths were observed, complications occurred in 5/9 patients with major complications, defined as Clavien-Dindo grade >3b, in 2/9 (22.2%) patients. Median hospital stay was 11 days. At the end of follow-up 2 patients had distant recurrence 12 median months after the CL.

Conclusions

CL in the left side could be considered a challenging procedure also after minimally invasive segmentectomy and we consider safe to perform CL with thoracotomy due to a scar tissue formation between the bronco-vascular structures leading the need for extensive hilar dissection and central isolation of the pulmonary artery.

Trends and comparative outcomes between operative approaches for segmentectomy in lung cancer

BACKGROUND

Segmentectomy is increasingly performed for non-small cell lung cancer. However, comparative outcomes data among open, robotic-assisted, and video-assisted thoracoscopic approaches are limited.

METHODS

A retrospective cohort study of non-small cell lung cancer segmentectomy cases (2013-2021) from the Society of Thoracic Surgeons General Thoracic Surgery Database was performed. Baseline characteristics were balanced using inverse probability of treatment weighting and compared by operative approach. Volume trends, outcomes, and nodal upstaging were assessed.

RESULTS

Of 9927 patients who underwent segmentectomy, 84.8% underwent minimally invasive surgery, with robotic-assisted thoracoscopic surgery becoming the most common approach in 2019. Open segmentectomy is more likely to be performed at low-volume centers (P < .0001), whereas robotic-assisted thoracoscopic surgery is more likely to be performed at high-volume centers (P < .0001). Video-assisted thoracoscopic surgery had a higher open conversion rate than robotic-assisted thoracoscopic surgery (odds ratio, 11.8; CI, 7.01-21.6; P < .001). Minimally invasive surgery had less 30-day morbidity compared with open segmentectomy (video-assisted thoracoscopic surgery odds ratio, 0.71; 95% CI, 0.55-0.94; P = .013; robotic-assisted thoracoscopic surgery odds ratio, 0.59; CI, 0.43-0.81; P = .001). The number of nodes and stations harvested were highest for robotic-assisted thoracoscopic surgery; however, N1 upstaging was more likely in open compared with robotic-assisted thoracoscopic surgery (odds ratio, 0.63; CI, 0.45-0.89; P < .007) and video-assisted thoracoscopic surgery (odds ratio, 0.61; CI, 0.46-0.83; P = .001).

CONCLUSIONS

Segmentectomy volume has increased considerably, with robotic-assisted thoracoscopic surgery becoming the most common approach. Minimally invasive surgery has less major morbidity compared with open segmentectomy, with no difference between video-assisted thoracoscopic surgery and robotic-assisted thoracoscopic surgery. However, risk of open conversion is higher with video-assisted thoracoscopic surgery. Robotic-assisted thoracoscopic surgery had increased nodal harvest, whereas hilar nodal upstaging was highest with thoracotomy. This study reveals significant differences in outcomes exist between segmentectomy operative approach; the impact of approach on survival merits further investigation.

Comparing survival outcomes of localized tumor destruction, sublobar resection, and pulmonary lobectomy in stage IA non-small cell lung cancer: a study from the SEER database

PURPOSE

A large-scale comparative analysis was performed with the aim of comparing local tumor destruction (LTD), sublobar resection (SR), and pulmonary lobectomy (PL) for cancer-specific survival (CSS) and overall survival (OS) in stage IA non-small cell lung cancer (NSCLC).

METHODS

In the Surveillance, Epidemiology, and End Results (SEER) database (2000-2021), we included patients with pathologically confirmed stage IA non-small cell lung cancer who were treated with LTD, SR, or PL. Comparison between groups was performed separately after 1:1 proportional propensity score matching (PSM) with a caliper value of 0.1. Kaplan-Meier analysis was performed to compare survival outcomes between groups.

RESULTS

In the total cohort of 4437 LTD patients, 2425 SR patients, and 6386 PL patients, 84.18% of LTD-treated patients were older than 65 years, whereas 68.95% of SR-treated patients and 62.82% of PL-treated patients were older than 65 years. The CSS (HR = 0.756, 95% CI 0.398 ~ 1.436, P = 0.393) and OS (HR = 0.46, 95% CI 0.553 ~ 1.295, P = 0.442) of LTD were consistent with SR. Whereas LTD demonstrated lower CSS (HR = 0.603, 95% CI 0.378 ~ 0.940, P = 0.024) and OS (HR = 0.590, 95% CI 0.432 ~ 0.805, P < 0.001) than PL, but were consistent when the tumor size was ≤ 1 cm. The CSS (HR = 1.215, 95% CI 0.872 ~ 1.693, P = 0.249) of SR was consistent with PL, but OS (HR = 1.347, 95% CI 1.079 ~ 1.681, P = 0.008) was higher than PL, but were consistent when the tumor size was 1.1-3 cm.

CONCLUSIONS

In patients with stage IA non-small cell lung cancer, the CSS and OS of LTD were no worse than those of SR. Compared with PL, the CSS and OS of LTD were lower, but when the tumor size was ≤ 1 cm, the CSS and OS of LTD were no worse than those of PL.

Impact of Triple Inhaler Therapy on COPD Patients with Non-Small Cell Lung Cancer After Radical Surgery: A Single-Centre Retrospective Analysis

Background: Chronic obstructive pulmonary disease (COPD) is among the most relevant comorbidity associated with lung cancer. The advent of innovative triple treatment approaches for COPD has significantly improved patients' quality of life and outcomes. Few data are available regarding the impact of triple inhaler therapy on patients featuring COPD and lung cancer. Methods: We retrospectively evaluated the impact of triple inhale bronchodilators in a cohort of 56 patients with treated COPD who underwent lung surgery for primary cancer. Results: Triple bronchodilation can help to relieve the symptoms of the disease and improve lung function, allowing people with lung cancer to reduce the risk of serious exacerbations and improve their quality of life. Conclusions: Within the limits of the study, it should be underlined that bronchodilators can effectively affect the outcome and performance status after thoracic surgery.

Lobectomy versus segmentectomy in patients with T1N2 non-small cell lung cancer: An analysis of the National Cancer Database

Objective

To assess survival outcomes for patients with stage IIIA (T1N2M0) non-small cell lung cancer (NSCLC) using the National Cancer Database (NCDB).

Methods

Patients with T1N2M0 NSCLC undergoing lobectomy or segmentectomy were identified in the NCDB from 2004 to 2019. Patient characteristics were compared using χ2 and Fisher exact tests. Overall survival was evaluated using the Kaplan-Meier method and the Cox proportional hazard analysis adjusting for type of resection, age, sex, and margin positivity, Charlson comorbidity index, number of lymph nodes examined, number of positive lymph nodes, and tumor size.

Results

In total, 2883 patients with T1N2 NSCLC undergoing segmentectomy or lobectomy were identified. The majority (96.5%) of patients received lobectomy and 100 (3.5%) patients received segmentectomy. Patients undergoing segmentectomy were older (P = .001) and had tumors in the lower lobe of the lung (P = .001) versus patients undergoing lobectomy. Fewer patients who received segmentectomy underwent radiation (P = .015) and neoadjuvant chemotherapy (P = .041). Fewer patients undergoing segmentectomy had >10 lymph nodes examined and >5 positive nodes compared with patients receiving lobectomy (both P < .001). Although 30-day readmission rates were similar (P = .27), 30-day mortality was lower in the segmentectomy cohort (P = .047). There was a significantly lower risk of death among patients undergoing lobectomy versus segmentectomy (hazard ratio, 0.96; 95% confidence interval, 0.94-0.98; P = .001).

Conclusions

In this NCDB analysis, lobectomy was more commonly performed for T1N2 NSCLC compared with segmentectomy. Lobectomy offered a significant survival advantage over segmentectomy, even when adjusting for risk factors. Thus, these findings suggest that lobectomy may be a superior resection of choice for patients with T1N2 disease.

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.

Lung Resection for Non-Small Cell Lung Cancer following Bronchoscopic Lung Volume Reduction for Heterogenous Emphysema

Bronchoscopic lung volume reduction (BLVR) is a minimally invasive treatment for emphysema. Lung cancer may be associated with emphysema due to common risk factors. Thus, a growing number of patients undergoing BLVR may develop lung cancer. Herein, we evaluated the effects of lung resection for non-small cell lung cancer in patients undergoing BLVR. The clinical data of patients undergoing BLVR followed by lung resection for NSCLC were retrospectively reviewed. For each patient, surgical and oncological outcomes were recorded to define the effects of this strategy. Eight patients were included in our series. In all cases but one, emphysema was localized within upper lobes; the tumor was detected during routine follow-up following BLVR and it did not involve the treated lobe. The comparison of pre- and post-BLVR data showed a significant improvement in FEV1 (29.7 ± 4.9 vs. 33.7 ± 6.7, p = 0.01); in FVC (28.5 ± 6.6 vs. 32.4 ± 6.1, p = 0.01); in DLCO (31.5 ± 4.9 vs. 38.7 ± 5.7, p = 0.02); in 6MWT (237 ± 14 m vs. 271 ± 15 m, p = 0.01); and a reduction in RV (198 ± 11 vs. 143 ± 9.8, p = 0.01). Surgical resection of lung cancer included wedge resection (n = 6); lobectomy (n = 1); and segmentectomy (n = 1). No major complications were observed and the comparison of pre- and post-operative data showed no significant reduction in FEV1% (33.7 ± 6.7 vs. 31.5 ± 5.3; p = 0.15) and in DLCO (38.7 ± 5.7 vs. 36.1 ± 5.4; p = 0.15). Median survival was 35 months and no cancer relapses were observed. The improved lung function obtained with BLVR allowed nonsurgical candidates to undergo lung resection for lung cancer.