|Year : 2013 | Volume
| Issue : 5 | Page : 106-109
Comparative study of the anatomic segmentectomy versus lobectomy for clinical stage I A peripheral lung cancer by video assistant thoracoscopic surgery
Lin Zhang, Wei Ma, Yun Li, Yuanzhu Jiang, Guoyuan Ma, Guanghui Wang
Department of General Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
|Date of Web Publication||30-Sep-2013|
Department of General Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021
Source of Support: None, Conflict of Interest: None
Objective: The objective of this study was to compare the completely thoracoscopic anatomic segmentectomy with lobectomy to treat stage I A peripheral lung cancer <2 cm.
Materials and Methods: A retrospective study was performed that 54 cases stage I A peripheral lung cancer patients were selected, including 26 cases of segmentectomy and 28 cases of lobectomy. We observed the operative time, blood loss, number of lymphadenectomy, post-operative chest drainage, hospital days, post-operative complications and mortality, post-operative recurrence and 3-year survival rate.
Results: There was no significant difference about complications such as post-operative atelectasis, severe pneumonia, arrhythmia and cardiovascular/cerebrovascular in two groups (P > 0.05). The local recurrence rate was not significant different in two groups (P > 0.05). Two groups of operative time, blood loss and number of dissected lymph nodes was not statistically significant (P > 0.05), However, the difference was statistically significant in average chest drainage and less decreased pulmonary function, which led to patients received segmentectomy recovered faster and hospitalized less time (P < 0.05). We also found there was no significant difference on survival rate with 1 and 3 year follow-up of two groups (log-rank Chi-square = 0.028, P > 0.05).
Conclusions: For stage I A peripheral lung cancer, the thoracoscopic anatomic segmentectomy was safe and effective just as thoracoscopic lobectomy, and furthermore with faster post-operative recovery.
Keywords: Lobectomy, lung cancer, lymphadenectomy, segmentectomy, thoracoscopes
|How to cite this article:|
Zhang L, Ma W, Li Y, Jiang Y, Ma G, Wang G. Comparative study of the anatomic segmentectomy versus lobectomy for clinical stage I A peripheral lung cancer by video assistant thoracoscopic surgery. J Can Res Ther 2013;9, Suppl S1:106-9
|How to cite this URL:|
Zhang L, Ma W, Li Y, Jiang Y, Ma G, Wang G. Comparative study of the anatomic segmentectomy versus lobectomy for clinical stage I A peripheral lung cancer by video assistant thoracoscopic surgery. J Can Res Ther [serial online] 2013 [cited 2020 Mar 29];9:106-9. Available from: http://www.cancerjournal.net/text.asp?2013/9/5/106/119121
| > Introduction|| |
As is all known, regardless of traditional thoracotomy or video assistant thoracoscopic surgery (VATS), the standard lobectomy resection plus system lymph node dissection surgery were considered as classic formula. Now, lobectomy by VATS has been widely used to treat early-stage non-small cell lung cancer and basically become a standard approach, as its safe, minimally invasive and radical characteristics. Nevertheless, for stage I A peripheral lung cancer that was less than 2 cm, lobectomy followed with post-operative complications often caused much harm especially for those who combined with cardiovascular or chronic obstructive pulmonary disease, in recent years, some scholars have proposed anatomic segmentectomy plus lymph node dissection by VATS for stage I A peripheral lung cancer was more minimally invasive and had equal efficiency compared with lobectomy. This retrospective study, which included 26 cases of thoracoscopic anatomic segmentectomy and 28 cases of thoracoscopic lobectomy for stage I A peripheral lung cancer, was observed the operating and post-operative effectiveness, safety and survival rate etc.
| > Materials and Methods|| |
We collected 54 in-patients of stage I A lung cancer from February 2009 to July 2010, who were admitted in General Thoracic Surgery Department of Shandong Provincial Hospital Affiliated to Shandong University and treated by a completely thoracoscopic resection surgery procedure. One group included 26 cases treated by segmentectomy, including 18 cases of male patients and eight female patients, average age 63 years, four cases of hypertension, five patients with chronic bronchitis, three cases of diabetes, three cases of coronary heart disease, one case of cardiac stents implantation, one case of breast cancer patient; The other group included 28 cases treated by lobectomy, including 22 cases of male patients and six female patients, average age 62 years, seven cases of hypertension, four cases of chronic bronchitis, five cases of diabetes, five patients with coronary heart disease, two cases of coronary stenting. Both two groups of patients underwent routine examination including pre-operative blood, urine, liver and kidney function, blood coagulation function, tumor markers, cranial magnetic resonance imaging, chest plus abdominal enhanced computed tomography (ECT), ECT bone scan etc., all which had excluded distant metastasis.
Double-lumen endotracheal intubation anesthesia was used to all patients and VATS was the procedure by usual three incisions (the intersection of 7 th or 8 th intercostal and midaxillary line as the mirror source hole, the intersection of 3 rd or 4 th intercostal and anterior axillary line-clavicular line midpoint as the based operation hole, the intersection of 8 th or 9 th intercostals and infrascapular line as the vice operation hole). Segmentectomy group included three cases of the left apical posterior segment combined anterior segment (i.e., inherent segment) resection, six cases of lingular segment, four cases of the left superior segment, four cases of the left basal segmental; one case of the right apical-anterior-posterior segment, four cases of the right superior segment, two cases of the right basal segmental. And lobectomy group included eight cases of the left upper lobectomy, five cases of the left lower, six cases of the right upper, three cases of the right middle and six cases of the right lower.
The listed below including operative time, blood loss, number of dissected lymph nodes, post-operative chest tube drainage, hospital days, post-operative complications and mortality, recurrence rate and 3-year follow-up survival rate were observed. Local recurrence was defined as the tumor reoccurred in the ipsilateral lung and mediastinum. All patients were followed-up at 3-month intervals for the first 2 years and 6-month intervals subsequently.
The statistical package for the social sciences 17.0 software package was used to all statistical analyses and P = 0.05 was the threshold of statistical significance. One-factor analysis of variance was used to analyze. Survival curves were estimated using the Kaplan-Meier method and significance was determined by the one-sided log-rank test. The Pearson Chi-square (χ2 ) test was used for comparison of 1 and 3 year survival rates and recurrence rates.
| > Results|| |
Post-operative general conditions
All the 54 patients were expected to be completed the full thoracoscopic surgery well without conversion to thoracotomy or secondary surgical procedures. There was no perioperative death in both groups. There was no significant difference about complications such as post-operative atelectasis, severe pneumonia, arrhythmia and cardiovascular/cerebrovascular in two groups (P > 0.05). The local recurrence rate was not significant different in two groups (P > 0.05). Two groups of operative time, blood loss, number of dissected lymph nodes and 1-and 3-year survival rate was not statistically significant (P > 0.05). However, the difference was statistically significant in average chest drainage and less decreased pulmonary function, which led to patients, received segmentectomy recovered faster and hospitalized less time (P < 0.05). We also found there was no significant difference on survival rate with 12-36 months follow-up of two groups (log-rank χ2 = 0.028, P > 0.05) [Table 1] and [Table 2] [Figure 1].
| > Discussion|| |
The technology of VATS lobectomy for lung cancer has been adopted by American National Comprehensive Cancer Network guidelines, completely thoracoscopic lobectomy have been carried out as a standard approach in recent 10s years. However, the extent of surgery dissection the lung would affect much on post-operative pulmonary function and post-operative recovery. Furthermore, with ECT and positron emission tomography-CT is widely used, a growing number of early stage lung cancer was detected,  for those whose tumor located peripherally with the size < 2 cm and those who need to the secondary surgery later with the cardiovascular system diseases or poor pre-operative lung function especially in elderly patients, once excessive lobectomy resection consist of normal lung tissue was performed, post-operative cardiopulmonary complications increased significantly. Although pulmonary wedge resection was seemed to be a not bad choice for those above mentioned as is a non-anatomical resection, and the limited range of resection in a segment or between two lung segments may cause residues or positive margins that led to tumor recurrence, on the other hand, blind wedge resection may be greater, which would induce the residual lung tissue ventilation/perfusion ratio imbalance leading to inadequate blood vessels, bronchioles distortions.  In 1993, Raviaro et al. of Milan University Hospital  reported the world's segmentectomy surgery by first small incision assisted thoracoscope. In general, completely thoracoscopic anatomic segmentectomy indications are considered as followed: (1) Pre-operative clinical T 1 N 0 M 0 non-small cell lung cancer; (2) tumor located in the peripheral region 1/3 of the lung or the central of lung segment with the diameter ≤ 2 cm; (3) intra-operative lymph node biopsy was negative; (4) the cutting edge should be distant > 2 cm from the tumor or the resection margin distance from the tumor/the tumor maximum diameter ratio > 1; (5) those patients cannot tolerate lobectomy including whose age > 75 years or combined with cardiopulmonary functional limitations or/and need to secondary lung surgery.
Anatomic segmentectomy by VATS could bring out less trauma, less pain, quicker recovery, preservation and good remanent lung function, which could save the patient the maximum extent of normal lung tissue and reduce lung function loss and help patients recovery.  Overseas studies have found that for stage I A non-small cell lung cancer, totally thoracoscopic anatomic segmentectomy had the similar efficacy to lobectomy by comparison with lymphadenectomy number, local recurrence rates and survival rates, ,,, and also found that segmentectomy could ensure adequate margins, lymphadenectomy numbers, the local recurrence rate, 5-year survival rate better than that of pulmonary wedge resection. , In 2004, Keenan et al. studied low pre-operative pulmonary function became more poor 1 year later after lobectomy with the representation that forced expiratory volume in 1 s and forced vital capacity value and carbon monoxide diffusing capacity (DLCO) significantly decreased while segmentectomy group showed just DLCO decreased.  The frequent common post-operative complications of VATS segmentectomy, similar to endoscopic lobectomy, includes bleeding, persistent air leak, hemoptysis, atelectasis, post-operative arrhythmia. From this study, we found there was no intraoperative bleeding leading to conversion to thoracotomy in both two groups, there was no significant difference at the mean intraoperative blood loss and operating duration and the numbers of dissected lymph nodes, However, segmentectomy patients had faster post-operative recovery and post-operative placement duration of chest tube and the average tube drainage was significantly less than lobectomy group, shortening the patient's hospital stay and increasing bed turnover rate and utilization rates. Followed-up to now, there was no recurrence and death. Thus, for the treatment of early peripheral lung cancer, thoracoscopic anatomic segmentectomy can saved the advantages of lobectomy by VATS (minimally invasive, safe, radical), but also has less post-operative chest drainage, decreased the average post-operative extubation days and shortened mean post-operative hospital stay, etc., meanwhile saving the maximum extent of the normal lung tissue, namely, achieving a true sense of the minimally invasive surgery. We suggested totally thoracoscopic anatomic segmentectomy was referred to early stage peripheral lung cancer patients especially for those in elderly or whose cardiopulmonary dysfunction cannot tolerate thoracotomy lobectomy. This method can replace lobectomy. Nothing, but better technologies and skills were demanded to complete for thoracic surgeon.
From our research experience, for stage I A peripheral lung cancer, we considered VATS anatomic segmentectomy plus systemic lymph node dissection be suitable for any patients and any ages and we believe that lymph node sampling may increase the operation time and the risk of false negative so that we recommend that anatomic segmentectomy plus systemic lymph node dissection be performed for clinical stage clinical I A peripheral lung cancer. Whereas, due to the small sample research we studied, some deviation may take place. Internationally, in 2008, 2009, the United States and Japan respectively conducted two Phase III clinical multi-center prospective randomized study (CALGB140503,  JCOG0802/WJOG4607,  ) compared to tumor size ≤ 2 cm in non-small cell lung cancer by VATS lobectomy and segmentectomy, we look forward to the data of evidence-based medicine with a large number of cases.
| > References|| |
|1.||Kim SK, Allen-Auerbach M, Goldin J, Fueger BJ, Dahlbom M, Brown M, et al. Accuracy of PET/CT in characterization of solitary pulmonary lesions. J Nucl Med 2007;48:214-20. |
|2.||Landreneau RJ, Hazelrigg SR, Mack MJ, Dowling RD, Burke D, Gavlick J, et al. Postoperative pain-related morbidity: Video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56:1285-9. |
|3.||Roviaro GC, Rebuffat C, Varoli F, Vergani C, Maciocco M, Grignani F, et al. Videoendoscopic thoracic surgery. Int Surg 1993;78:4-9. |
|4.||Zeng G, Shao W, Ren Y, He J. Mini-invasive surgery in lung cancer: Current status and future considerations. Thorac Cancer 2012;3:88-90. |
|5.||Tschernko EM, Hofer S, Bieglmayer C, Wisser W, Haider W. Early postoperative stress: Video-assisted wedge resection/lobectomy vs conventional axillary thoracotomy. Chest 1996;109:1636-42. |
|6.||Demmy TL, Curtis JJ. Minimally invasive lobectomy directed toward frail and high-risk patients: A case-control study. Ann Thorac Surg 1999;68:194-200. |
|7.||Schuchert MJ, Pettiford BL, Keeley S, D'Amato TA, Kilic A, Close J, et al. Anatomic segmentectomy in the treatment of stage I non-small cell lung cancer. Ann Thorac Surg 2007;84:926-32. |
|8.||Mei J, Pu Q, Liao H, Liu L. Initial experience of video-assisted thoracic surgery left upper sleeve lobectomy for lung cancer: Case report and literature review. Thorac Cancer 2012;3:348-52. |
|9.||Okada M, Nishio W, Sakamoto T, Uchino K, Yuki T, Nakagawa A, et al. Effect of tumor size on prognosis in patients with non-small cell lung cancer: The role of segmentectomy as a type of lesser resection. J Thorac Cardiovasc Surg 2005;129:87-93. |
|10.||Pettiford BL, Schuchert MJ, Santos R, Landreneau RJ. Role of sublobar resection (segmentectomy and wedge resection) in the surgical management of non-small cell lung cancer. Thorac Surg Clin 2007;17:175-90. |
|11.||Keenan RJ, Landreneau RJ, Maley RH Jr, Singh D, Macherey R, Bartley S, et al. Segmental resection spares pulmonary function in patients with stage I lung cancer. Ann Thorac Surg 2004;78:228-33. |
|12.||Detterbeck FC. Sublobar resection: Are the answers different or is it the questions? J Thorac Oncol 2010;5:1500-1. |
|13.||Nakamura K, Saji H, Nakajima R, Okada M, Asamura H, Shibata T, et al. A phase III randomized trial of lobectomy versus limited resection for small-sized peripheral n`on-small cell lung cancer (JCOG0802/WJOG4607L). Jpn J Clin Oncol 2010;40:271-4. |
[Table 1], [Table 2]