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Ann Thorac Surg 2005;80:2041-2045
© 2005 The Society of Thoracic Surgeons

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Original article: General thoracic

Functional Advantage After Radical Segmentectomy Versus Lobectomy for Lung Cancer

Department of Thoracic Surgery, Hyogo Medical Center for Adults, Akashi, Japan

Accepted for publication June 7, 2005.

^_* Address correspondence to Dr Okada, Department of Thoracic Surgery, Hyogo Medical Center for Adults, Kitaohji-cho 13-70, Akashi City 673-8558, Hyogo, Japan (Email: morihito1217jp{at}aol.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
BACKGROUND: Although several reports have recently demonstrated that segmentectomy for small-sized N0 lung cancer leads to recurrence and survival rates equivalent to those associated with lobectomy, controversy regarding the postoperative functional advantage in the former over the latter still persists. The purpose of this study was to evaluate the degree of postoperative functional loss in patients undergoing segmentectomy or lobectomy for lung cancer.

METHODS: We analyzed patients able to tolerate lobectomy, who underwent radical segmentectomy (n = 38) or lobectomy (n = 45) for non–small-cell lung cancer. Functional testing included forced vital capacity, forced expiratory volume in 1 second, and anaerobic threshold measured preoperatively and at 2 and 6 months after surgery.

RESULTS: Preoperative function tests showed no differences between segmentectomy and lobectomy patients. A positive and significant correlation was found between the number of resected segments versus loss of forced vital capacity (r = 0.518, p < 0.0001 at 2 months; r = 0.604, p < 0.0001 at 6 months) and loss of forced expiratory volume in 1 second (r = 0.492, p < 0.0001 at 2 months; r = 0.512, p < 0.0001 at 6 months). The postoperative reduction of forced vital capacity (p = 0.0006) and forced expiratory volume in 1 second (p = 0.0007) was significantly less in the segmentectomy group; however, a marginally significant benefit was observed in this group for anaerobic threshold (p = 0.0616).

CONCLUSIONS: The extent of removed lung parenchyma directly affected that of postoperative functional loss even at 6 months after surgery, and segmentectomy offered significantly better functional preservation compared with lobectomy. These results indicate the importance of segmentectomy for early staged lung cancer.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
As a result of the development of imaging tools such as high-resolution computed tomography, small-sized lung tumors are being detected with increasing frequency. Although lobectomy is still considered as the standard surgical procedure for any primary non–small-cell lung cancer, an increasing number of surgeons have doubts as to whether lobectomy is a must for such small lesions. The only randomized trial done so far comparing lobectomy with limited resection indicated an increased risk of local recurrence and reduced prognosis for patients undergoing the latter, and has led to greater general support for the former as the procedure of choice [1]. Recently, these results have been inspected, and there is an increasing body of evidence demonstrating that segmentectomy for small-sized stage I lung cancers can yield outcomes equivalent to lobectomy even in noncompromised patients [2–7]. Also, several studies demonstrated that the frequency of local recurrence after sublobar resection was the same as that after lobectomy when the indication was limited to stage IA tumors up to 2 cm, and segmentectomy not wedge resection was predominantly used as the lesser resection [4–6].

Theoretically, segmentectomy has an anatomic functional advantage over lobectomy as some segments of lung tissue that would be removed by the latter could be preserved. However, the above-mentioned randomized trial concluded that there were no significant differences in postoperative pulmonary function between lobectomy and limited resection patients. We therefore conducted the present study to assess the extent of postoperative functional loss including exercise tests useful in measuring quality of life [8] in patients who underwent segmentectomy or lobectomy.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
The study group consisted of 83 patients: 45 of them underwent lobectomy and the other 38 underwent segmentectomy. This study was conducted with the approval of the institutional ethics board and informed consent was obtained from all patients. No specific preoperative and postoperative rehabilitation programs were established.

The eligibility criteria for segmentectomy in this study were as follows: patients who had a cT1N0M0 non–small-cell lung cancer 2 cm or smaller in all dimensions on thin-sliced computed tomography and were considered to be able to tolerate a lobectomy through preoperative general examinations [2–4]. Patients were prospectively (not randomly) chosen, and when informed consent for lesser resection was obtained from the patients, we performed anatomic segmentectomy through video-assisted approach with minithoracotomy. The essential points of the surgical technique were to remove the adjacent segment or subsegment together with the affected segments to keep an adequate surgical margin, and to explore hilar and segmental lymph nodes as well as mediastinal lymph nodes to intraoperatively confirm N0 disease. We performed segmentectomy if the patient consented to the sublobar resection, and lobectomy if the consent to sublobar resection was not obtained.

All the study patients were subjected to spirometry and a standard Bruce protocol [9] treadmill (MAT-6000C; Fukuda Electron, Osaka, Japan) test before surgery, and 2 and 6 months after surgery. The patients' heart rate and electrocardiographic findings were monitored during the exercise study. Inspired and expired gases were analyzed by a computerized online breath-by-breath system (Aeromonitor AE-300S; Minato Medical Science, Osaka, Japan). Maximum oxygen consumption was defined as the highest oxygen consumption achieved during the exercise test. Subsequently, the anaerobic threshold was determined by the V-slope method [10]. The exercise test was continued until development of limiting symptoms (dyspnea, chest pain, general fatigue, or leg fatigue), achievement of maximal predicted heart rate defined by the formula 220 – age [11], or presentation of marked and progressive abnormalities on the electrocardiogram. In this study, about half of the studied patients could not continue the exercise tests until the maximal predicted heart rate; therefore, we placed great importance on the anaerobic threshold value, generally considered to be a more objective determinant than maximum oxygen consumption [12].

The statistical significance of differences among clinical preoperative variables was analyzed by Mann-Whitney U test. Also we examined the correlation of the number of removed lung segments with postoperative functional loss on the basis of the correlation coefficient. Comparison of functional changes after segmentectomy or lobectomy was made by repeated-measures analysis of variance.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
The clinical preoperative characteristics and average number of resected segments in the lobectomy and the segmentectomy groups are shown in Table 1. There were no significant differences in preoperative functional factors between the two groups, confirming that the patients with segmentectomy included in this study could tolerate a lobectomy. The number of segments actually removed was halved in the case of segmentectomy (1.9 ± 0.9 versus 3.9 ± 1.1). The cell type of the tumor was adenocarcinoma in all patients, 70% of which contained bronchioloalveolar features. The locations of burdened lung are demonstrated in Table 2. No major postoperative complications occurred, and all patients made a quick recovery.

View larger version (48K): [in this window] [in a new window]   Fig 1. Logistic regression analyses showing the correlation between the extent of segments removed by segmentectomy (n = 38, circle) or lobectomy (n = 45, triangle) and pulmonary function loss. (A) Loss of forced vital capacity (FVC) at 2 months after surgery. (B) Loss of forced vital capacity at 6 months after surgery. (C) Loss of forced expiratory volume in 1 second (FEV1.0 ) at 2 months after surgery. (D) Loss of forced expiratory volume in 1 second at 6 months after surgery.

View larger version (25K): [in this window] [in a new window]   Fig 2. Forced vital capacity (FVC; A), forced expiratory volume in 1 second (FEV1.0 ; B), and anaerobic threshold (C) before surgery, and at 2 and 6 months after surgery in patients undergoing segmentectomy (n = 38) and lobectomy (n = 45). The y axis shows the ratio of the postoperative value to the preoperative one (post-op/pre-op). Values are presented as the mean ± standard error of the mean.

View larger version (24K): [in this window] [in a new window]   Fig 3. Forced vital capacity (FVC; A), forced expiratory volume in 1 second (FEV1.0 ; B), and anaerobic threshold (C) before surgery, and at 2 and 6 months after surgery in patients undergoing segmentectomy (n = 32) and lobectomy (n = 25) for lower lobe or left upper lobe tumors. The y axis shows the ratio of the postoperative value to the preoperative one (post-op/pre-op). Values are presented as the mean ± standard error of the mean.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

The present study demonstrated that segmentectomy offers a functional advantage over lobectomy. Recently, some other authors reached a similar conclusion [3, 7]. Yoshikawa and coworkers [3] in a prospective multiinstitution study showed postoperative functional loss, measured 1 year after surgery, was 11.3% in FVC and 13.4% in FEV_1.0, the values of which were equivalent to those of removing two segments according to the formula for predicting postoperative pulmonary function. In our series, a significantly positive association was clearly found between the extent of the removed segment and the postoperative reduction of FVC and FEV_1.0.

We added an exercise test to the present study because it has been shown to be important in measuring quality of life in a practical way [8]. Treadmill data as well as spirometric data in our series demonstrated that segmentectomy had a postoperative functional advantage over lobectomy. Exercise capacity was regained 6 months after segmentectomy in contrast to approximately a 10% loss after lobectomy.

Why should it be necessary to take away a large part of unaffected healthy lung parenchyma for a small-sized peripheral tumor when trained surgeons can judge N0 disease after sufficient intraoperative pathologic examination? We have advocated that segmentectomy be considered the procedure of choice for patients with a clinical and surgical N0 lesion of 2 cm in diameter or smaller, which has been supported by a large body of current evidence [2–7]. Furthermore, the lesser resection can provide another surgical chance in the future for metachronous lung tumor, which may be much more frequently detected thanks to the continuous development of imaging tools [14], because surgical outcome for lung cancer is improving [15] and the patients after surviving a first disease have a higher risk of a second disease. The present debate concerning the optimal resection for such a disease could be resolved by a prospective randomized trial. Such a trial must be appropriately constructed. The Lung Cancer Study Group trial was very influential, but actually it had several flaws, the most important of which was that wedge resection was chosen for approximately 30% of the enrolled patients. Future trials should be limited to segmentectomy as the only lesser resection. Also, the margin from the tumor that is secured by resecting the adjacent segment or subsegment, if needed, should concentrate our attention to avoid local recurrence, and intraoperative lymph node evaluation would be needed to randomize patients with N0 disease.

	References

Top Abstract Introduction Patients and Methods Results Comment References

 

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