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Ann Thorac Surg 1998;66:1787-1790
© 1998 The Society of Thoracic Surgeons

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Original articles: general thoracic

Ongoing prospective study of segmentectomy for small lung tumors

^a General Thoracic Surgery, Hyogo Medical Center, Hyogo, Japan

Accepted for publication May 29, 1998.

Address reprint requests to Dr Tsubota, Hyogo Medical Center for General Thoracic Surgery, 13-70 Kitaoji, Akashi, Hyogo, 675 Japan
e-mail: (n-tsubo{at}sanynet.or.jp)

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Study group... References

 
Background. Lesser resection for small lung tumors remains an unresolved problem. This study was conducted to see whether this type of operation is acceptable or not.

Methods. From 1992 to 1994, 55 patients were enrolled in a multicenter trial of limited surgical resection for peripheral tumors of less than 2 cm diameter. The procedure consisted of segmentectomy with exploration of lymph nodes by examining frozen sections. The operation was modified if the report was positive. The intersegmental plane was identified by keeping the resected segments inflated and the preserved segments collapsed. To divide the plane, stapling or electrocauterization on the edge of the collapsed area was used. In this way the resection line was delivered beyond the burdened segment; this was called extended segmentectomy.

Results. There were no perioperative deaths, but there were eight postoperative deaths. In 1 patient who died because of local recurrence, it had been known that the margin to the lesion had been narrow (15 mm); 1 had bilateral intrapulmonary nodules, 1 had nodules in the side that was not operated on, and another succumbed to a second neoplasm of small cell lung cancer 4 years after the first operation. The remaining 4 died of nonpulmonary diseases. Almost all other patients are alive and free from recurrence, except for 1 in whom N2 disease was not detected intraoperatively but was confirmed after the operation.

Conclusions. The interim results suggest that extended segmentectomy is applicable in patients with a small peripheral lung cancer. However, a wide margin and aggressive intraoperative pathologic examinations are mandatory.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Study group... References

 
With the advent of new diagnostic techniques, small lung tumors have become more often diagnosed and operated on. However, limited resection remains controversial. After many studies concerning lesser resection of the lung [1–3], the Lung Cancer Study Group has recently reported a very influential study against it [4]. Although they reported that lobectomy was the surgical procedure of choice for patients with peripheral T1 N0 non–small cell lung cancer, we think that the report contains some questions to be discussed about the method used and that no conclusion has been drawn as yet.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Study group... References

 
Patient eligibility
The study was started in January 1992 and finished in December 1994. Patients suspected of having a lung tumor were initially registered for entry into this study of extended segmentectomy with lymph node exploration if they had a peripheral tumor of 2 cm or less on the chest x-ray film and no evidence of metastatic lesions through routine examinations. Peripheral tumor was defined as a tumor located close to the visceral or interlobar pleura on computed tomographic film. All patients were in physical conditions that allowed them to tolerate a lobectomy. If the surgeon detected any other pathologic lesions that did not allow the segmentectomy, the operation was changed to another type of procedure and the patient was not included in this study.

Surgical technique
All vessels and bronchi going into the resected segments are isolated and severed at the hilum. The lymph nodes around the hilum and those obtained by mediastinal dissection or sampling are pathologically examined. The intersegmental plane is detected as follows. After the segmental bronchus is isolated, the burdened lobe, which is collapsed, is temporarily inflated. The bronchus is first tied to keep the gas inside and then severed at a point proximal to the tie. While the bronchus is being closed, the segments to be preserved start losing gas and the line that forms between the inflated and the collapsed lung indicates the intersegmental plane. This is opposite to the conventional technique. The intersegmental plane around the hilum is entered along the pulmonary artery and vein. However at the peripheral portion of the lung, stapling or electrocauterization is used on the edge of the collapsed area, so that the resection line is placed on the adjacent segment beyond the affected one. We named this type of resection plus lymph node exploration "extended segmentectomy."

Pathologic assessment
During the operation, lymph nodes from around the hilum and mediastinum are sent to the pathologist. If there are any findings suggesting segmentectomy is not indicated, the operation is modified accordingly. After the operation, all specimens were examined in the same fashion as for routine lobectomy.

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Study group... References

 
Patients
Of the 73 patients preregistered during the study period, 18 were not subjected to this trial for various reasons (Table 1). The characteristics of the 55 patients subjected to extended segmentectomy are summarized in Table 2. Eighteen patients underwent extended segmentectomy in the right upper lobe, 9 in the right lower, 20 in the left upper lobe, and 8 in the left lower lobe. Stapling at the peripheral region was most commonly used to divide the intersegmental plane; yttrium-aluminum garnet laser and manual methods were used less frequently.

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Study group... References

 
There have been several studies in favor of and against limited operation for lung cancer. Martini and colleagues [5] were of the opinion that any resection less extensive than lobectomy places the patient at an increased risk of local recurrence and decreases the chances of long-term survival. On the other hand, Jensik and associates [6] reported that the evidence, after consideration of all factors, supported a philosophy of conservative resection.

In 1995, the Lung Cancer Study Group reported the results of a randomized trial of lobectomy versus limited resection for non–small cell lung cancer and concluded that because of the higher death rate and locoregional recurrence rate associated with limited resection, lobectomy still must be considered the surgical procedure of choice for patients with peripheral T1 N0 non–small cell lung cancer [4]. Although the report was very influential because this was a randomized study and had been performed by the Lung Cancer Study Group, it also contained several questions that must be discussed. Besides the statements made by invited commentators, there were surprising and objectionable methods in the report: namely, wedge resection was chosen for about 30% of the enrolled patients who were in good physical condition and could tolerate a lobectomy. Generally, an appropriate lymph node exploration around the hilum cannot be performed with a wedge resection. Moreover, mediastinal dissection might be of little significance in those patients. Thus, as the authors themselves properly stated regarding the conclusion, "Longer follow-up would be necessary for a final assessment of survival difference" [4]. Warren and Faber [7] concluded from their studies on segmentectomy versus lobectomy in patients with stage I pulmonary carcinoma that lobectomy was the preferred operative procedure for patients with stage I tumors larger than 3.0 cm in diameter. Landreneau and coworkers [8] concluded based on the results of their multicenter study that wedge resection was indicated only for stage I non–small cell lung cancer in patients with physiologic impairment. On the other hand, Kodama and associates [9] reported an excellent outcome concerning intentional limited operation for selected patients with T1 N0 M0 non–small cell lung cancer.

Before beginning the trial, we had investigated patients subjected to lobectomy and lymph nodes dissection [10]. Because of the relatively high incidence of skipping or overlooking lymph node metastases, especially in patients with a small tumor, we decided to perform a trial in which wedge resection would not be used and exploration of lymph nodes should meet the criteria employed for standard procedures.

At the interim point, we had 1 patient with local recurrence. This was disappointing but not surprising. The surgeon had noticed immediately after the operation that although the line of the incision was free from tumor invasion as confirmed by frozen section examination, the safety margin was only 15 mm away from the tumor. Thus, it was no wonder that this patient had local recurrence, as the margin was not wide enough. Regarding the 2 other patients in whom pulmonary nodules developed, 1 bilaterally and 1 contralaterally, it is unknown whether this was related to the limited operation. As for the remaining 5 patients, the cause of death was clearly unrelated to the initial lung tumor and they were free from recurrence at the time of death. To calculate the survival in this type of study, we could be allowed to exclude these 5 patients, in whom the procedure was not responsible for their death. Presently, even if the 2 patients with pulmonary nodules are included, the 5-year survival is 91% with a mean follow-up period of 47.2 ± 11 months (Fig 1). We compared this rate with the 5-year survival rate for patients with stage I tumor who underwent lobectomy at Hyogo Medical Center for General Thoracic Surgery. From June 1984 to December 1991, 27 patients with small lung tumors less than 2 cm in size and negative lymph nodes were operated on and their 5-year survival rate was 89%. Flehinger and colleagues [11] reported a 5-year survival rate of 70% for the effect of surgical therapy on survival from stage I lung cancer. Comparing these data [12], we are satisfied with the interim results.

View larger version (9K): [in this window] [in a new window]   Fig 1. Five-year survival rate for patients who underwent an extended segmentectomy for small lung tumors. The follow-up period was 47.2 ± 11 months (mean ± SD). In the 3 patients who died, the first site of recurrence was an adjacent segment (1), bilateral pulmonary nodules (2), and contralateral pulmonary nodules (3).

With use of this technique the intersegmental line appears more clearly, and moreover, it has the advantage that stapling on the edge of the collapsed area displaces the resection line across beyond the border of the burdened segment. We have named this operation extended segmentectomy.

In conclusion, the interim results support the philosophy of conservative resection; however, a wide margin to the tumor and exploration of the lymph nodes of the upper mediastinum for an upper lobe tumor and of the carinal nodes for a lower lobe tumor, accompanied by examination around the hilum and segmental bronchi, are mandatory.

	Acknowledgments

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Study group... References

 
We thank the members of the study group for referring their patients to us.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Study group... References

 
^* The members of the study group are listed in Appendix 1.

	Appendix 1. Study group of extended segmentectomy for small lung tumors

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Study group... References

 
Dr Motokazu Suyama, Division of Chest Surgery, Aichi Cancer Center, Nagoya; Dr Ken Nakagawa, Division of Chest Surgery, Cancer Institute Hospital, Tokyo; Dr Noboru Ishii, Department of Emergency, Kobe University, School of Medicine, Kobe; Drs Takero Mizuno and Hiroshi Niwa, Respiratory Disease Center, Division of Thoracic Surgery, Seirei Mikatahara General Hospital, Hamamatsu; Dr Tsutomu Yasumitsu, Surgery, Habikino Prefectural Hospital, Osaka; and Dr Shinichiro Miyoshi, Department of Surgery, Osaka University, School of Medicine, Osaka.

	References

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Study group... References

 

1. Bates M. Segmental resection for bronchogenic carcinoma. Thorax 1975;30:234-235.[Free Full Text]
2. Bennet W.F., Smith R.A. Segmental resection for bronchogenic carcinoma: surgical alternative for the compromised patient. Ann Thorac Surg 1979;27:168-172.
3. Hoffman T.H., Randsell H.T. Comparison of lobectomy and wedge resection for carcinoma of the lung. J Thorac Cardiovasc Surg 1980;79:211-217.[Abstract]
4. Lung Cancer Study Group (prepared by Robert J. Ginsberg and Lawrence V. Rubinstein). Randomized trial of lobectomy versus limited resection for T1 N0 non–small cell lung cancer. Ann Thorac Surg 1995;60:615-623.[Abstract/Free Full Text]
5. Martini N., McCaughan B.C., McCormack P.M., et al. The extent of resection for localized lung cancer: lobectomy. In: Kittle C.F., ed. Current controversies in thoracic surgery. Philadelphia: Saunders, 1986:171-175.
6. Jensik R.J., Faber L.P., Kittle C.F. Sleeve lobectomy for bronchogenic carcinoma: the Rush-Presbyterian-St Luke’s Medical Center experience. Int Surg 1986;71:207-210.[Medline]
7. Warren W.H., Faber P.F. Segmentectomy versus lobectomy in patients with stage I pulmonary carcinoma. Five-year survival and patterns of intrathoracic recurrence. J Thorac Cardiovasc Surg 1994;107:1087-1094.[Abstract/Free Full Text]
8. Landreneau R.J., Sugarbaker D.J., Mack M.J., et al. Wedge resection versus lobectomy for stage I (T1 N0 M0) non–small-cell lung cancer. J Thorac Cardiovasc Surg 1997;113:691-700.[Abstract/Free Full Text]
9. Kodama K., Doi O., Higashiyama M., et al. Intentional limited operation for selected patients with T1 N0 M0 non–small-cell lung cancer: a single-institution study. J Thorac Cardiovasc Surg 1997;114:347-353.[Abstract/Free Full Text]
10. Tsubota N., Yoshimura M. Skip metastasis and hidden N2 disease in lung cancer: how successful is mediastinal dissection?. Surg Today 1996;26:169-172.[Medline]
11. Flehinger B.J., Kimmel M., Melamed M.R. The effect of surgical therapy on survival from early lung cancer. Chest 1992;101:1013-1018.[Abstract/Free Full Text]
12. Mountain C.F. Revisions in the international system for staging lung cancer. Chest 1997;111:1710-1717.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Noriaki Tsubota Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Tsubota, N. Articles by Watanabe, Y. Search for Related Content PubMed PubMed Citation Articles by Tsubota, N. Articles by Watanabe, Y.