Comparison of perioperative and oncological outcomes between video-assisted segmentectomy and lobectomy for patients with clinical stage IA non-small cell lung cancer: a propensity score matching study

Segmentectomy vs. Lobectomy in stage IA non-small cell lung cancer: A systematic review and meta-analysis of perioperative and survival outcomes

While recent randomized controlled trials (RCT) have suggested superior overall survival (OS) outcomes with segmentectomy over lobectomy, questions remain regarding the comparability of these surgical procedures for treating early-stage non-small cell lung cancer (NSCLC). This systematic review and meta-analysis aimed to synthetize existing evidence and to compare the survival outcomes observed for stage IA NSCLC following segmentectomy or lobectomy. 40 studies (38 observational, 2 RCTs) encompassing 103,926 patients were analyzed. Primary outcomes included overall survival (OS), disease-free survival (DFS), local recurrences, harvested lymph nodes, postoperative morbidity, and length of hospital stay. Risk of bias was assessed using established tools, and evidence certainty was evaluated using GRADE. Non-RCTs showed an OS HR of 1.10 (95 % CI: 0.94-1.30, p = 0.24) with low certainty, contrasting with RCTs' HR of 0.82 (95 % CI: 0.66-1.02, p = 0.7) with moderate certainty. Local recurrences exhibited OR 1.40 (95 % CI: 0.94-2.08, p = 0.09) in non-RCTs with low certainty, and RR 1.61 (95 % CI: 1.12-2.31, p = 0.01) in RCTs with low certainty. Non-RCTs showed DFS HR 1.13 (95 % CI: 0.95-1.34, p = 0.18) with low certainty, while RCTs yielded HR 1.00 (95 % CI: 0.85-1.18, p = 0.97) with moderate certainty. Lobectomy resulted in more harvested lymph nodes. Postoperative morbidity and length of hospital stay did not differ significantly. While definitive evidence for OS, DFS, and postoperative outcomes differences was inconclusive, a potential increase in local recurrences following lobectomy was noted. Further well-designed studies are warranted to enhance evidence and inform clinical practice in stage I lung cancer surgery.

Survival and pulmonary function in stage IA non-small cell lung cancer after sublobar resection versus lobectomy: An updated meta-analysis

Traditionally, lobectomy was standard for stage IA non-small-cell lung cancer (NSCLC). Recent RCTs suggest sublobar resection's comparable outcomes. Our meta-analysis, incorporating 30 studies (including four RCTs), assessed sublobar resection's efficacy. Employing a random-effects model and I2 statistics for heterogeneity, we found sublobar resection reduced DFS (HR 1.31, p < 0.01) and OS (HR 1.27, p < 0.01) overall. However, RCT subgroup analysis showed no significant differences in DFS (p = 0.28) or OS (p = 0.62). Sublobar resection is a viable option for well-selected patients.

Long term outcomes after lobar versus sublobar resection for patients with Non-Small cell lung Cancer: Systematic review and individual patient data Meta-Analysis

OBJECTIVES

Surgical resection remains the primary treatment for early-stage non-small cell lung cancer (NSCLC), with lobectomy considered the standard approach. However, recent evidence suggests that sublobar resection may be an alternative option for select patients.

MATERIALS AND METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. Randomized controlled trials (RCTs) and propensity-score matched (PSM) cohort studies comparing lobectomy and sublobar resection in NSCLC patients were included. The primary outcome was overall survival (OS), and secondary outcomes included disease-free survival (DFS), 30-day mortality, and cancer recurrence rates. Individual patient data (IPD) were reconstructed from Kaplan-Meier curves, and one-stage and two-stage meta-analyses were performed.

RESULTS

A total of 18 studies involving 6,075 NSCLC patients (3,119 undergoing lobectomy, 2,956 undergoing sublobar resection) were included. Lobectomy was associated with significantly better OS compared to sublobar resection (hazard ratio [HR]: 0.78, 95 % confidence interval [CI]: 0.68-0.89, p < 0.001). However, when sublobar resection was further divided into segmentectomy and wedge resection, no significant difference in OS was observed between lobectomy and segmentectomy (HR:0.92, 95 %CI: 0.75-1.14, p = 0.464) whereas lobar resection was associated with better OS compared to wedge resection (HR:0.52, 95 %CI: 0.41-0.67, p < 0.001). DFS outcomes were similar between lobectomy and sublobar resection (HR:0.98, 95 %CI: 0.84-1.14, p = 0.778).

CONCLUSION

Lobectomy is associated with better overall survival compared to sublobar resection in NSCLC patients. However, when sublobar resection is subdivided, segmentectomy shows comparable outcomes to lobectomy, while wedge resection is inferior. These findings support the consideration of segmentectomy as the surgical option of choice for Stage IA NSCLC patients.

Accurate Selection of Sublobar Resection for Small Non-small Cell Lung Cancer

BACKGROUND

Although sublobar resection (wedge resection [Wed] or segmentectomy [Seg]) has become a standard operative procedure for clinical stages IA1 and IA2 non-small cell lung cancer (NSCLC) in Japan, the impact of this procedure on the prognosis and postoperative complications in real-world clinical practice is unknown.

METHODS

This study retrospectively analyzed risk factors for a poor prognosis and postoperative complications of 470 patients with clinical stage ≤ IA2 NSCLC who underwent surgery from 2012 to 2021.

RESULTS

Among the patients with a consolidation-to-tumor ratio (CTR) higher than 0.5, the 5-year relapse-free survival (RFS) rate was significantly lower in the Wed group (72.1%) than in the Seg (85.8%) and Lob (86.8%) groups (p < 0.01), but the difference between the Seg and Lob groups was not significant. Among patients with a CTR of 0.5 or lower, the 5-year RFS rate did not differ significantly among the three groups. Multivariable analysis of RFS showed that the prognosis was significantly worse in the Wed group than in the Lob group (hazard ratio, 2.83; p < 0.01), but the difference between the Wed and Seg groups or the between Seg and Lob groups was not significant. Multivariable analysis of postoperative complications showed a significantly lower risk in the Wed group than in the Seg group (odds ratio, 0.31; p < 0.01).

CONCLUSIONS

Seg could become the standard operative procedure for clinical stages IA1 and IA2 NSCLC patients. Wed is suggested to be an option for patients with a CTR of 0.5 or lower and has the advantage of avoiding postoperative complications.

Survival outcomes of segmentectomy and lobectomy for early stage non-small cell lung cancer: a systematic review and meta-analysis

BACKGROUND

The question of whether segmentectomy and lobectomy have similar survival outcomes for patients with early-stage non-small cell lung cancer (NSCLC) is a matter of debate.

METHODS

A cohort study and randomized controlled trial were included, comparing segmentectomy and lobectomy, by utilizing computerized access to the Pubmed, Web of Science, and Cochrane Library databases up until July 2022. The Cochrane Collaboration tool was used to evaluate the randomized controlled trials, while the Newcastle-Ottawa Scale (NOS) was used to evaluate the cohort studies. Sensitivity analyses were also carried out.

RESULTS

The analysis incorporated 17 literature studies, including one randomized controlled trial and 16 cohort studies, and was divided into a segmentectomy group (n = 2081) and a lobectomy group (n = 2395) based on the type of surgery the patient underwent. Each study was followed up from 27 months to 130.8 months after surgery. Over survival (OS): HR = 1.14, 95%CI(0.97,1.32), P = 0.10; disease-free survival (DFS): HR = 1.13, 95%CI(0.91,1.41), P = 0.27; recurrence-free survival (RFS): HR = 0.95, 95%CI(0.81,1.12), P = 0.54.

CONCLUSION

The results of the study suggest that the survival outcomes of the segmentectomy group were not inferior to that of the lobectomy group. Segmentectomy should therefore be considered as a treatment option for early stage NSCLC.

Sublobar resection or lobectomy and postoperative respiratory complications in emphysematous lungs

OBJECTIVES

Pulmonary resection in patients with severe emphysema may impact postoperative respiratory complications. Low-attenuation areas evaluated using three-dimensional computed tomography to assess emphysematous changes are strongly associated with postoperative respiratory complications. Herein, we investigated the relationship between low-attenuation area, the surgical procedure and resected lung volume, which has not been explored in previous studies.

METHODS

We retrospectively evaluated patients with primary or metastatic lung cancer who underwent surgical resection. The low-attenuation area percentage (low-attenuation area/total lung area × 100) and resected lung volume were calculated using three-dimensional computed tomography software, and the relationship with postoperative respiratory complications was analysed.

RESULTS

Postoperative respiratory complications occurred in 66 patients (17%) in the total cohort (n = 383). We set the median value of 1.1% as the cut-off value for low-attenuation area percentage to predict postoperative respiratory complications, which occurred in 24% and 10% of patients with low-attenuation area >1.1% and <1.1%, respectively (P < 0.001). Postoperative respiratory complications occurred in approximately one-third of the patients with low-attenuation area >1.1%, whose resected lung volume was ≥15.8% or ≥5 resected subsegments. Multivariable analysis revealed that sublobar resection was associated with a significantly lower risk of postoperative respiratory complications in patients with low-attenuation area >1.1% (odds ratio 0.4, 95% confidence interval 0.183-0.875).

CONCLUSIONS

Emphysema is a risk factor for postoperative respiratory complications, and lobectomy is an independent predictive risk factor. Preserving more lung parenchyma may yield better short-term prognoses in patients with emphysematous lungs.

Predictability and Utility of Contrast-Enhanced CT on Occult Lymph Node Metastasis for Patients with Clinical Stage IA-IIA Lung Adenocarcinoma: A Double-Center Study

RATIONALE AND OBJECTIVES

With the advantage of minimizing damage and preserving more functional lung tissue, limited surgery is considered depend on the lymph node (LN) involvement situation. However, occult lymph node metastasis (OLM) may be ignored by limited surgery and become a risk factor for local recurrence after surgical resection. The aim of this study was to assess the risk factors for OLM based on computed tomography enhanced image in patients with clinical lung adenocarcinoma (ADC).

MATERIALS AND METHODS

From January 2016 to July 2022, 707 patients with clinical stage IA-IIA ADC underwent lobectomy with systematic LN dissection and were divided into training and validation group based on different institution. Univariate analysis followed by multivariable logistic regression were performed to estimate different risk factors of OLM. A predictive model was established with visual nomogram and external validation, and evaluated in terms of accuracy, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC).

RESULTS

Fifty-nine patients were diagnosed with OLM (11.9%), and four independent predictors of LN involvement were identified: larger consolidation diameter (odds ratio [OR], 2.35, 95% confidence interval [CI]: 1.06, 5.22, p = 0.013), bronchovascular bundle thickening (OR, 1.99, 95% CI: 1.00, 3.95, p = 0.049), lobulation (OR, 2.92, 95% CI: 1.22, 6.99, p = 0.016) and obstructive change (OR, 1.69, 95% CI: 1.17, 6.16, p = 0.020). The model showed good calibration (Hosmer-Lemeshow goodness-of-fit, p = 0.816) with an AUC of 0.821 (95% CI: 0.775, 0.853). For the validation group, the AUC was 0.788 (95% CI: 0.732, 0.806).

CONCLUSION

Our predictive model can non-invasively assess the risk of OLM in patients with clinical stage IA-IIA ADC, enable surgeons perform an individualized prediction preoperatively, and assist the clinical decision-making procedure.

Effect of segmental versus lobectomy in minimally invasive surgery on postoperative wound complications in lung cancer patients: A meta-analysis

It is still a matter of debate whether the surgical segmentectomy and lobectomy of lung cancer are comparable in the incidence of perioperative wound complications. An extensive review of the literature through August 2023 was carried out with a critical review of four databases. Following the acceptance and elimination criteria set out in the trial, as well as a qualitative assessment of the literature, this resulted in a review of related research that compared the results of both lobectomy and partial resection in the management of lung cancer. The analysis of the data was performed with the RevMan 5.3 software, and the 95% confidence interval [CI] and odds ratio [OR] were performed with either stationary or random-effect models. It is concluded that the operation time of lobectomy is shorter than that of sectioning in the treatment of segmentectomy (mean difference [MD], -38.62; 95% CI, -41.96, -35.28; p < 0.0001). But the rate of postoperative wound infection (OR, 0.62; 95% CI, 0.18, 2.15; p = 0.45) and intraoperative blood loss (MD, 17.54; 95% CI, -4.19, 39.26; p = 0.11) were not significantly different for them. Thus, for those who have received a pulmonary carcinoma operation, different operative methods might not have an impact on the incidence of postoperative wound infections. The operative procedure appears to have a major impact on the length of the operation in patients.

Minimally Invasive Anatomical Segmentectomy versus Lobectomy in Stage IA Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis

OBJECTIVE

A systematic review and meta-analysis was performed to assess potential differences in perioperative outcomes and disease-free survival (DFS) and overall survival (OS) of patients with pathological stage IA non-small cell lung cancer (NSCLC) who underwent minimally invasive anatomical segmentectomy or lobectomy.

METHODS

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of EMBASE (through Ovid), MEDLINE (via PubMed), and Cochrane CENTRAL was conducted. Two researchers independently reviewed each eligible study that included patients with stage IA NSCLC who underwent minimally invasive anatomical segmentectomy and lobectomy and compared perioperative and/or survival outcomes of patients.

RESULTS

A total of 887 publications were identified. Of these, 10 articles met our eligibility criteria. A significantly higher number of lymph nodes were harvested in lobectomies. The two groups did not significantly differ in postoperative complication rates, DFS, and OS. Patients who underwent segmentectomy had shorter postoperative hospital stays.

CONCLUSIONS

Minimally invasive lobectomy and segmentectomy showed comparable short-term and long-term outcomes in stage IA NSCLC patients. Postoperative complication rates were similar. Minimally invasive lobectomies are associated with a higher number of harvested lymph nodes, although this did not affect the final staging or the survival outcomes.

Preclinical study of peripheral parenchymal lymphatic drainage in lung

Background

This study aims to determine the regularity of sentinel lymph nodes of peripheral lung parenchyma and the lymphatic drainage between adjacent pulmonary segments in experimental animals.

Methods

Thoracotomy was performed on 12 experimental Guizhou miniature pigs, and 1 mL methylene blue was injected into the superior segment of the lower lobe (S6) and the anterior segment of the upper lobe (S3), successively, to observe lymphatic drainage, in sentinel lymph nodes and the lymphatic drainage between adjacent segments.

Results

A total of 161 lymphatic vessels were observed in 48 pulmonary segments, with an average of 3.4 lymphatic vessels per segment: RS6 (superficial 1.0±0.61, deep 2.5±1.00), RS3 (superficial 1.0±0.51, deep 2.0±1.07), LS6 (superficial 3.0±0.42, deep 1.0±0.38), LS3 (superficial 1.0±0.43, deep 2.0±0.62). There were significantly more lymphatic vessels in deep plexus than in superficial (p<0.01). As for sentinel lymph nodes, LS6 drained to the hilar, subcarinal and 4L lymph nodes; RS6 drained to the hilar and subcarinal lymph nodes; LS3 drained to the hilar and 4L lymph nodes; and RS3 drained to the hilar and 4R lymph nodes. In addition, methylene blue could drain from peripheral lung tissue of S3 and S6 directly to mediastinal lymph nodes through superficial plexuses. Lymphatic drainage regularity of S3 and S6 to adjacent pulmonary segments were also observed. The R6 rarely drained to the basal segment, while R3 could possibly drain to the posterior segment.

Conclusion

The regularity of peripheral pulmonary parenchymal lymphatic drainage in experimental animals can provide a basis for the management of lymph nodes in pulmonary segmentectomy in humans, to a certain extent.

Thoracoscopic segmentectomy versus lobectomy: A propensity score–matched analysis

Objectives

The aim of this study is to compare the postoperative complications, perioperative course, and survival among patients from the multicentric Spanish Video-assisted Thoracic Surgery Group database who received video-assisted thoracic surgery lobectomy or video-assisted thoracic surgery anatomic segmentectomy.

Methods

From December 2016 to March 2018, a total of 2250 patients were collected from 33 centers. Overall analysis (video-assisted thoracic surgery lobectomy = 2070; video-assisted thoracic surgery anatomic segmentectomy = 180) and propensity score–matched adjusted analysis (video-assisted thoracic surgery lobectomy = 97; video-assisted thoracic surgery anatomic segmentectomy = 97) were performed to compare postoperative results. Kaplan–Meier and competing risks method were used to compare survival.

Results

In the overall analysis, video-assisted thoracic surgery anatomic segmentectomy showed a lower incidence of respiratory complications (relative risk, 0.56; confidence interval, 0.37-0.83; P = .002), lower postoperative prolonged air leak (relative risk, 0.42; 95% confidence interval, 0.23-0.78; P = .003), and shorter median postoperative stay (4.8 vs 6.2 days; P = .004) than video-assisted thoracic surgery lobectomy. After propensity score–matched analysis, prolonged air leak remained significantly lower in video-assisted thoracic surgery anatomic segmentectomy (relative risk, 0.33; 95% confidence interval, 0.12-0.89; P = .02). Kaplan–Meier and competing risk curves showed no differences during the 3-year follow-up (median follow-up in months: 24.4; interquartile range, 20.8-28.3) in terms of overall survival (hazard ratio, 0.73; 95% confidence interval, 0.45-1.7; P = .2), tumor progression–related mortality (subdistribution hazard ratio, 0.41; 95% confidence interval, 0.11-1.57; P = .2), and disease-free survival (subdistribution hazard ratio, 0.73; 95% confidence interval, 0.35-1.51; P = .4) between groups.

Conclusions

Video-assisted thoracic surgery segmentectomy showed results similar to lobectomy in terms of postoperative outcomes and midterm survival. In addition, a lower incidence of prolonged air leak was found in patients who underwent video-assisted thoracic surgery anatomic segmentectomy.

Comparison Between Wedge Resection and Lobectomy/Segmentectomy for Early-Stage Non-small Cell Lung Cancer: A Bayesian Meta-analysis and Systematic Review

BACKGROUND

Surgery has become an accepted method for the treatment of early-stage non-small cell lung cancer (NSCLC). The purpose of this Bayesian meta-analysis was to compare the overall survival (OS), disease-free survival (DFS), and relapse-free survival (RFS) between wedge resection and lobectomy/segmentectomy for treatment of early-stage NSCLC.

METHODS

Eligible studies were retrieved from Web of Science, PubMed, MEDLINE, Cochrane Library, EMBASE, CNKI, and WanFang up to July 2021 and screened based on established selection criteria. The Bayesian meta-analysis was performed with the combination of the reported survival outcomes of the individual studies using a random-effect model. The OS, DFS, and RFS of the wedge resection group was compared with the lobectomy/segmentectomy group. The hazard ratio (HR) and standard error were extracted or calculated for each study using the Kaplan-Meier method.

RESULTS

This study was registered with PROSPERO (INPLASY202080090).The pooled OS hazard ratio between segmentectomy and lobectomy was 1.1 [95% confidence interval (CI) 0.92-1.4], the pooled HR between lobectomy and wedge resection was 0.71 [95% CI 0.52-0.96], and the pooled HR between segmentectomy and wedge was 0.80 [95% CI 0.56-1.10]. The pooled HR of DFS or RFS was not statistically significant among the three surgical approaches.

CONCLUSIONS

Patients with early-stage NSCLC received lobectomy had the lowest hazard ratio of OS than patients received wedge resection, indicating that the overall survival of patients received lobectomy was higher than patients received wedge resection. However, regarding DFS and RFS, the three surgical approaches showed no significant difference.

Surgical Issues for Operable Early-Stage Non-Small-Cell Lung Cancer

Surgical care for early stage non-small-cell lung cancer continuously evolves with new procedures, techniques and care pathways. The most obvious recent change was the transition to minimally invasive procedures, but numerous other aspects of care have also been refined to improve safety and tolerability. These care advancements are essential as we move into an era with increased early detection as a result of screening and greater indications for the use of adjuvant and neoadjuvant strategies.

Comparison of operative and postoperative characteristics and outcomes between thoracoscopic segmentectomy and lobectomy for non-small-cell lung cancer: a propensity score matching study from the Italian VATS Group Registry

OBJECTIVES

Only few studies compared the surgical morbidity and mortality of thoracoscopic segmentectomy versus lobectomy for non-small-cell lung cancer, in particular, by relating the segmental resections with the corresponding anatomical lobes.

METHODS

We enrolled a total of 7487 patients who underwent VATS lobectomy (7269) or segmentectomy (218) from January 2014 to July 2019. A propensity score matching approach was used to account for potential confounding factors between the 2 groups. After matching, 349 lobectomies and 208 segmentectomies were included in the analysis. We analysed the operative and postoperative outcomes of video-assisted anatomical segmentectomy compared with video-assisted lobectomy and, in details, the results of segmentectomy with its corresponding lobectomy in a large cohort of patients from the Italian VATS Group Registry.

RESULTS

The overall conversion rate to thoracotomy was not statistically different between the groups (27 patients 8% vs 7 patients 3%, P = 0.1). The lobectomy group had a greater number of resected lymph nodes (median 11 vs 8, P = 0.006). No significant differences were detected in 30-day mortality (1.4%, 5 patients vs 0.9%, 2 patients), overall complications (18%, 62 patients vs 14%, 29 patients) and prolonged air leakage (31 patients, 9% vs 12 patients, 6%) between lobectomy and segmentectomy, respectively. No statistical differences were found regarding the median duration of drainage (3.2 days, P = 1) and the overall median length of hospital stay (6.4 days, P = 0.1) between the 2 groups. In the context of segmentectomy versus corresponding lobectomy, the right upper lobectomy compared with right upper segmentectomy showed a higher number of resected lymph nodes (P = 0.027). No statistical differences were reported in terms of conversion rate and postoperative complication and mortality.

CONCLUSIONS

Segmentectomy could be considered a safe procedure without significant differences compared to thoracoscopic lobectomy in terms of postoperative morbidity and mortality.

Bibliometric Analysis of 50 Most Cited Articles Comparing Lobectomy with Sublobar Resection

BACKGROUND

 Recent years have seen an increase in the number of studies of the sublobar resection approach in non-small cell lung cancer (NSCLC) surgery. The purpose of this bibliometric analysis is to assess the significance and impact of articles comparing sublobar resection and lobectomy in NSCLC surgery.

MATERIAL AND METHODS

 The Web of Science database was searched to identify studies comparing sublobar resection and lobectomy in NSCLC surgery published between 2005 and 2020 (accessed: September 11, 2020). The 50 most cited articles were analyzed by years, countries, authors, authors' affiliations, journals, journals' addresses, and impact factors.

RESULTS

 The bibliometric analysis revealed that the most cited article had 443 citations, while the total number of citations of all articles was 2,820. The mean number of citations, in turn, was 56.4 ± 75.62 (1-443) times. The highest number of publications over the past 15 years was in 2016, with eight articles. The Annals of Thoracic Surgery (n = 10; 20%) had the highest number of publications on the list. The articles included in the present study were mostly (n = 35, 70%) published in U.S. journals. While multiple subject matters and analyses were presented by many studies, survival was the topic of greatest interest, with 37 (74%) studies.

CONCLUSION

 This study revealed that interest in studies comparing sublobar resection with lobectomy has increased in recent years. It also presents both quantitative and qualitative analyses of the most cited articles in the literature on this topic. Therefore, it can serve as a guide for researchers.

Comparison of perioperative and survival outcomes between sublobar resection and lobectomy of patients who underwent a second pulmonary resection

Background

Repeat pulmonary resection is widely accepted in clinical practice. This study aimed to compare sublobar resection (segmentectomy or wedge resection) with lobectomy in the treatment of patients who underwent a second pulmonary resection.

Methods

This study retrospectively included patients who underwent lobectomy or sublobar resection for second pulmonary resection. 1:1 propensity score matching (PSM) was performed to balance selection bias. Clinicopathological features, perioperative and survival outcomes of lobectomy and sublobar resection were compared.

Results

A total of 308 patients who underwent second pulmonary resection were identified: 71 (23.1%) who underwent lobectomy and 237 (76.9%) who underwent sublobar resection. After PSM, 58 patients for each group were selected with well‐balanced clinicopathological characteristics. In patients who underwent sublobar resection, significantly shorter chest tube duration (days) (median, 4 vs. 2, p < 0.001) and postoperative hospital stay (days) (median, 6 vs. 4, p < 0.001) were observed. There was no significant difference in overall survival between these two groups after the second and first surgery (p = 0.65, p = 0.98), respectively. Subgroup analysis according to the type of the first resection showed consistent results.

Conclusions

Sublobar resection may be considered as an alternative option for second pulmonary resection due to its perioperative advantages and similar survival outcomes compared with lobectomy.

Outcomes of superior segmentectomy versus lower lobectomy for superior segment Stage I non-small-cell lung cancer are equivalent: An analysis of 196 patients at a single, high volume institution

OBJECTIVES

To determine if superior segmentectomy has equivalent overall (OS), disease-free (DFS), and locoregional-recurrence-free survival (LRFS) to lower lobectomy for early-stage non-small-cell lung cancer (NSCLC) in the superior segment.

METHODS

We retrospectively reviewed all Stage 1 lower lobectomies for superior segment lesions and superior segmentectomies at our hospital from 2000 to 2018. Comparison statistics and Cox hazard modeling were performed to determine differences between groups and attempt to identify risk factors for OS, DFS, and LRFS.

RESULTS

Superior segmentectomy patients, compared with lower lobectomy patients, had more current smokers, worse forced expiratory volume in 1 s percentage, radiologic emphysema scores, clinically and pathologically smaller tumors, and more occurrences of 0 lymph nodes examined. Outcomes for superior segmentectomy compared with lower lobectomy were equivalent for 5-year OS (67.0% vs. 75.1%, p = 0.70), DFS (56.9% vs. 60.4%, p = 0.59), and LRFS (87.9% vs. 91.3%, p = 0.46). Multivariable Cox modeling lacked utility due to no outcome differences.

CONCLUSIONS

In well-selected patients, superior segmentectomies can have equivalent OS, DFS, and LRFS compared with lower lobectomies of superior segment tumors for early stage lung cancer. Further data are needed to provide better risk estimates.

Prognosis of segmentectomy in the treatment of stage IA non-small cell lung cancer

With improvements in detection technology, increasing numbers of patients with non-small cell lung cancer (NSCLC) are being diagnosed at an early stage. In order to treat the illness with minimal invasion and preserve lung function to the greatest possible extent, there has been an increasing tendency towards treating early-stage NSCLC by segmentectomy. However, questions remain regarding whether patients may benefit from this procedure considering the surgical and oncological outcomes. Whether adequate margin distance and lymph node dissection may be achieved is one of the most important issues associated with this procedure. The present study reviews the prognosis of segmentectomy in the treatment of stage IA NSCLC.

Postoperative Short-term Outcomes Between Sublobar Resection and Lobectomy in Patients with Lung Adenocarcinoma

Background

To investigate postoperative temporary consequences of the enrolled patients with lung adenocarcinoma.

Patients and Methods

We analyzed the clinical data of patients with lung adenocarcinoma admitted by the same surgical team of Peking Union Medical College Hospital (PUMCH) from July 2019 to December 2019. Statistical methods including propensity score matching (PSM) analysis was used to analyze the differences among them.

Results

A total of 108 patients were enrolled, including 50 patients with sublobar resection and 58 patients with lobectomy. Before PSM, there were statistically significant differences in age (p=0.015), hospitalization costs (p=0.042), lymphadenectomy (p=0.000), pathological staging (p=0.000), number of lymph nodes removed (p=0.000), number of positive lymph nodes (p=0.034), chest drainage duration (p=0.000), total chest drainage (p=0.000), length of postoperative hospital stays (p=0.000), postoperative D-dimer level (p=0.030) and perioperative lymphocyte margin (LM) (p=0.003) between sublobar resection and lobectomy. After PSM, there were statistical differences in number of lymph nodes removed (p=0.000), chest drainage duration (p=0.031) and total chest drainage (p=0.002) between sublobar resection and lobectomy. Whether with PSM analysis or not, there were no significant differences in other blood test results, such as inflammation indicators, postoperative neutrophil-lymphocyte ratio (NLR), albumin level, perioperative activity of daily living (ADL) scale scoring margin, complications, postoperative admission to intensive care unit (ICU) and readmission within 30 days. NLR was associated with total chest drainage (p=0.000), length of postoperative hospital stays (p=0.000), postoperative D-dimer level (p=0.050) and ADL scale scoring margin (p=0.003) between sublobar resection and lobectomy.

Conclusion

Sublobar resection, including wedge resection and segmentectomy, was as safe and feasible as lobectomy in our study, and they shared similar short-term outcomes. Postoperative NLR could be used to detect the clinical outcomes of patients. Secondary resectability of pulmonary function (SRPF) should be the main purpose of sublobar resection.

Preoperative evaluation of the segmental artery by three-dimensional image reconstruction vs. thin-section multi-detector computed tomography

Background

“Exoview” is a three-dimensional (3D) image reconstruction software developed by our medical team independently. The aim of this retrospective study was to compare the use of 3D image reconstruction, and thin-section multi-detector computed tomography (MDCT) in the preoperative evaluation of the segmental artery (SA).

Methods

From May 2018 to May 2019, 52 patients received anatomical segmentectomy in our department. All patients received computed tomography pulmonary angiography (CTPA) by use of a 64-slice MDCT before operation. Then the 2D CT data were converted into 3D format by use of Exoview. We compared the intraoperative findings of the SA branches with 3D images and thin-section MDCT.

Results

The study cohort of 52 patients included 31 women and 21 men and the operative factors include operation time (148.75±53.56 min), blood loss (57.31±79.68 mL), postoperative hospitalization days (6.42±3.48 days), lymph node sampling (3.00±1.50 stations) and postoperative complications (5 patients, 10%). The adenocarcinoma in situ with microinvasion was the predominant type (25 cases, 48%). There were 7 patients accepted for video-assisted thoracoscopic surgery (VATS) lobectomy with radical lymph nodes dissection because invasive adenocarcinoma was confirmed by intraoperative frozen-section analysis. One other patient was confirmed for conversion from VATS segmentectomy to an open operation because of bleeding of the bronchial artery. According to intraoperative findings, 95.7% (132 of 138) and 100% (138 of 138) of these SA branches were precisely identified on preoperative 3D image reconstruction and thin-section MDCT images. The 6 missed branches were less than 1.4 mm in actual diameter.

Conclusions

Both 3D image reconstruction and thin-section MDCT provided precise preoperative information about SA. The 3D image reconstruction software “Exoview” could visualize SA for surgeons. However, the thin-section MDCT provided a better evaluation of small SA branches.

Systematic review and meta-analysis of video-assisted thoracoscopic surgery segmentectomy versus lobectomy for stage I non-small cell lung cancer

BACKGROUND

Whether video-assisted thoracoscopic surgery (VATS) segmentectomy and VATS lobectomy provide similar perioperative and oncological outcomes in stage I non-small cell lung cancer (NSCLC) is still controversial.

METHODS

Meta-analysis of 12 studies comparing outcomes after VATS lobectomy and VATS segmentectomy for stage I NSCLC. Data were analyzed by the RevMan 5.3 software.

RESULTS

Disease-free survival (HR 1.19, 95% CI 0.89 to 1.33, P = 0.39), overall survival (HR 1.11, 95% CI 0.89 to 1.38, P = 0.36), postoperative complications (OR = 1.10, 95% CI 0.69 to 1.75, P = 0.7), intraoperative blood loss (MD = 3.87, 95% CI - 10.21 to 17.94, P = 0.59), operative time (MD = 10.89, 95% CI - 13.04 to 34.82, P = 0.37), air leak > 5 days (OR = 1.20, 95% CI 0.66 to 2.17, P = 0.55), and in-hospital mortality (OR = 1.67, 95% CI 0.39 to 7.16, P = 0.49) were comparable between the groups. Postoperative hospital stay (MD = - 0.69, 95% CI - 1.19 to - 0.19, P = 0.007) and number of dissected lymph nodes (MD = - 6.44, 95%CI - 9.49 to - 3.40, P < 0.0001) were significantly lower in VATS segmentectomy patients.

CONCLUSIONS

VATS segmentectomy and VATS lobectomy provide similar oncological and perioperative outcomes for stage I NSCLC patients. This systematic review was registered on PROSPERO and can be accessed at http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID = CRD42019133398.

Anatomic Segmentectomy in Nonintubated Video-Assisted Thoracoscopic Surgery

Thoracic surgery has evolved into minimally invasive surgery, in terms of not only surgical approach but also less aggressive anesthesia protocols and lung-sparing resections. Nonintubated anatomic segmentectomies are challenging procedures but can be safely performed if some essentials are considered. Strict selection criteria, previous experience in minor procedures, multidisciplinary cooperation, and the 4 cornerstones (deep sedation, regional analgesia, oxygenation support and vagal blockade) should be followed. Better outcomes in postoperative recovery, including resumption of oral intake, chest tube duration, and hospital stay, and low complication and conversion rates, are encouraging but should be checked in larger multicenter prospective randomized trials.

Comparison of postoperative complications between segmentectomy and lobectomy by video-assisted thoracic surgery: a multicenter study

BACKGROUND

Compared to lobectomy by video-assisted thoracic surgery (VATS), segmentectomy by VATS has a potential higher risk of postoperative atelectasis and air leakage. We compared postoperative complications between these two procedures, and analyzed their risk factors.

METHODS

We reviewed the records of all patients who underwent anatomical pulmonary resections by VATS from January 2014 to March 2018 in two Swiss university hospitals. All complications were reported. A logistic regression model was used to compare the risks of complications for the two interventions. Adjustment for patient characteristics was performed using a propensity score, and by including risk factors separately.

RESULTS

Among 690 patients reviewed, the major indication for lung resection was primary lung cancer (86.4%) followed by metastasis resection (5.8%), benign lesion (3.9%), infection (3.2%) and emphysema (0.7%). Postoperatively, there were 80 instances (33.3%) of complications in 240 segmentectomies, and 171 instances (38.0%) of complications in 450 lobectomies (P = 0.73). After adjustment for the patient's propensity to be treated by segmentectomy rather than lobectomy, the risks of a complication remained comparable for the two techniques (odds ratio for segmentectomy 0.91 (0.61-1.30), p = 0.59). Length of hospital stay and drainage duration were shorter after segmentectomy. On multivariate analysis, an American Society of Anesthesiologists score above 2 and a forced expiratory volume in one second below 80% of predicted value were significantly associated with the occurrence of complications.

CONCLUSIONS

The rate of complications and their grade were similar between segmentectomy and lobectomy by VATS.

Impact of complex segmentectomies by video-assisted thoracic surgery on peri-operative outcomes

Background

Pulmonary segmentectomies are generally classified into simple (tri-segmentectomy or lingulectomy as well as apical or basilar segmentectomy) and complex (individual or bi-segmentectomy of the upper, middle and lower lobes). Complex segmentectomies are technically feasible by video-assisted thoracic surgery (VATS) but remain challenging, and reports on post-operative outcomes are scarce. This study analyzes the differences between simple and complex VATS segmentectomy in terms of peri- and post-operative outcomes.

Methods

We retrospectively reviewed records of all patients who underwent anatomical pulmonary segmentectomy by VATS from 2014 to 2018 in two university hospitals.

Results

A total of 232 patients (114 men; median age 67 years; range, 29-87 years) underwent VATS segmentectomy for primary lung cancer (n=177), metastases (n=26) and benign lesions (n=29). The overall 30-day mortality and morbidity rates were 0.8% and 29.7%, respectively. The re-operation rate was 4.7%. Complex segmentectomy was realized in 111 patients including 86 (77.5%) upper lobe segmentectomies and 44 (39.6%) bi-segmentectomies. There was no statistical difference between complex and simple segmentectomy in terms of operative time (145 vs. 143 min, respectively; P=0.79) and chest tube duration [median: 1 (range, 0-33) vs. 2 (range, 1-19) days, respectively; P=0.95]. Post-operative overall complication rates were similar for both groups (30% vs. 30%, respectively; P=0.99) and were not correlated with the type of segmentectomy. However, complex segmentectomy patients had a shorter length of hospitalization compared to simple segmentectomy patients [median: 5 (range, 1-36) vs. 7 (range, 2-31) days; P=0.026]. Interestingly, complex segmentectomies were realized most frequently 2 years after implementation of VATS segmentectomy (23% vs. 77%; P=0.01).

Conclusions

In comparison with simple segmentectomy, complex segmentectomy by VATS seems to present similar post-operative complication rates. Learning curve and progressive increase in acceptance by surgeons seem to be key elements for successful implementation of complex segmentectomies and could explain the shorter length of stay we observed.

Sublobar resection is associated with decreased survival for patients with early stage large-cell neuroendocrine carcinoma of the lung

OBJECTIVES

Sublobar resection (SLR) for early non-small-cell lung carcinoma (NSCLC) has been shown to have a survival rate similar to that of lobectomy. Large-cell neuroendocrine carcinoma (LCNEC) of the lung, although treated like an NSCLC, has a poor prognosis compared to NSCLC. We sought to determine if outcomes are poor in patients with early stage LCNEC treated with SLR versus lobectomy.

METHODS

We searched for patients with pathological stage I LCNEC ≤3 cm within the National Cancer Database between 2004 and 2014. Propensity score matching was used to compare the 5-year overall survival rate of patients having SLR (wedge or segmentectomy) to that of patients having a lobectomy. Patients were matched for age, node sampling, comorbidity score, tumour size, insurance status and other factors. Patients who received neoadjuvant therapy were excluded. Kaplan-Meier methods were used for analysis.

RESULTS

A total of 1011 patients met the inclusion criteria: 263 were treated with SLR (223 wedges and 40 segmentectomies) and 748 patients, with lobectomy. Patients who received SLR were older, had more comorbidities and smaller tumours. On unadjusted Kaplan-Meier analysis, patients who had SLR had decreased 5-year overall survival compared to those who had a lobectomy (37.9% vs 56.6%, P < 0.001). Propensity score matching (1:1) across 12 demographic and tumour variables yielded 185 patients per group with 34 segmentectomies and 151 wedge resections in the SLR cohort. On Kaplan-Meier analysis of the matched cohort, patients who had SLR had a worse 5-year overall survival rate compared to those who had a lobectomy (41.5% vs 60.3%; P = 0.001).

CONCLUSIONS

SLR for early stage LCNEC is associated with a lower 5-year overall survival rate compared to lobectomy on unadjusted and propensity matched analyses.

[A Review on Comparison of Lobectomy and Segmentectomy in the Treatment of Early Stage Non-small Cell Lung Cancer]

Lung cancer is a worldwide malignancy with high morbidity and mortality in the world. With the application of low-dose spiral computed tomography in the screening and diagnosis of lung cancer, more lung cancers are detected at an early stage and cured by surgical treatment. Anatomical lobectomy has long been the standard procedure for the treatment of early stage non-small cell lung cancer. However, whether intentional segmentectomy can be more used remains controversial. And this paper focuses on the question.
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[Difference of Lung Function Retention after Segmentectomy and Lobectomy]

近年来肺癌发病率和检出率逐渐升高，肺段切除术被越来越普遍应用于治疗早期非小细胞肺癌。有学者认为肺段切除术相比肺叶切除术更有利于术后肺功能的保留，也有研究得出两种手术方式在术后肺功能保留方面差异不大，本文就肺段切除术与肺叶切除术术后肺功能变化的相关研究作一综述。