Eur J Cardiothorac Surg 1999;16:S61-S63
© 1999 Elsevier Science NL
Sublobar resection for lung cancer
Hani Shennib
The Montreal General Hospital, Division Of Cardio-thoracic Surgery, McGill University, 1650 Cedar Avenue, Montreal, Quebec, Canada
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Abstract
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The role of limited lung resection ‘segmentectomy and wedge resection' in the treatment of lung cancer has been reviewed. Survival for patients with stage I lung cancer and lesions less than 2 cm is comparable to that of major resections such as lobectomy. The theoretical advantage of limited resection is the simplicity of the procedure and the potential for performing it through lesser invasive techniques. The major drawback at this time which should render it a compromise rather than a choice operation is the increased risk of locoregional recurrence. Until properly conducted clinical trials validate its efficacy in peripheral T1 lung cancer with or without adjuvent therapy, sublobar resection should be limited to patients that are at poor risk of tolerating major lung resection. Sublobar resections however may also play a useful role in treatment of metachronous or synchronous lung cancer.
Key Words: Limited lung resection • Survival • Stage I lung cancer
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1. Introduction
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It is agreed upon that lung resection when possible is the best therapeutic option for stage I lung cancer. Approximately 40 years ago, the debate on the appropriateness of lobectomy as opposed to a pneumonectomy as the resection of choice for lung cancer raged and settled on the conclusion that a more limited resection at that time (lobectomy) was adequate and more preserving of lung function. Approximately 15 years ago, several retrospective reviews of a variety of sublobar lung resections for lung cancer made its way to the literature and raised the point that wedge resection or segmentectomy alone or in combination with radiotherapy can be effective in offering 5-year survival that is similar to ones reported with lobectomy [1–8]. Subsequently, one prospective randomised study was performed by the lung cancer study group which compared limited resection with lobectomy for stage I lung cancer. Results of this study indicate that at 5 years, survival was similar in the two groups, however that the limited resection group had a higher incidence of locoregional recurrence [9]. This led to the conclusion that limited resection should be considered a compromised procedure and should be offered in a selective group of patients who would not tolerate a major lung resection. This review addresses the above issues and attempts to re identify the role of limited resection in the treatment of lung cancer today.
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2. The evidence that limited resection works
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There is no question that the surgical team at the Rush Presbyterian St. Luke's Medical Centre were the champions of conservative lung resection [1,4,5,10–12] Jensik and co-workers repeatedly presented evidence that sparing the whole lung by performing a sleeve lobectomy was advantageous to the patients and did not compromise long-term survival [10]. Similarly his 15-year experience on the outcome of segmental resection for lung cancer was the subject of a classic article describing the technique, its indications and its applicability in the treatment of lung cancer for a selected group of patients [1,4]. Hoffmen et al. performed one of the first comparison of lobectomy with wedge resection for the treatment of lung cancer [13]. Despite not being a randomized perspective trial it gave an insight on the potential for treating peripheral lesions with a rather simple wedge resection technique.
In 1985 Errett and co-workers from McGill proposed that wedge resection could be considered an alternative procedure for peripheral lung cancer patients who are of poor risk for major resections [2]. In the mid 1980s Ginsberg and co-workers from the Lung Cancer Study Group proposed a prospective randomized comparative trial of lobectomy versus limited resection for the treatment of stage I T1 non-small cell lung cancer. The results of this study revealed five year survival which was similar in both groups. There was however, a more than two-fold increase in the incidence of loco-regional recurrence in the limited resection patients particularly those who received wedge resection as opposed to segmentecomy [9]. There was an important difference in pulmonary functions measured at 3 months to the advantage of patients with limited resection which dissipated at a follow up of 1 year [14]. One can conclude from such an important prospective trial that limited resection should be considered a compromised operation in patients with poor lung functions as wedge resection alone can not confer the same advantage as that of lobectomy in regards to local recurrence. Whether adjuvant radiotherapy may reduce such risk has not yet been determined.
Another classic article which addresses the specific issue of limited anatomic resection ‘segmentectomy' compared to lobectomy for stage I lung cancer was published by Warren and Faber in 1994 [12]. In this study 173 patients with stage I non-small cell lung cancer underwent either segmentectomy or lobectomy. The age, and gender were similar. The segmental resection group had 67% incidence of adenocarcinoma as opposed to 51% in the lobectomy group. This perhaps is a reflection that the segmentectomy group had more peripheral lesions than the lobectomy group. The 5-year survival overall was higher in the lobectomy group (80%) when compared to the segmentectomy group (48%) (P=0.035). However on further analysis, lesions less than 2 cm in diameter had a 5-year survival which was similar between the two groups. The local recurrence again was higher in the segmentectomy group (22% segmentectomy vs. 5% lobectomy). Of interest however, was that the size of the tumor had no bearing what so ever on the risk of loco-regional recurrence in the segmentectomy group.
Kodama et al. [15] published a single institutional study where limited resection was intentionally performed for a selected group of patients with T1 non-small cell lung cancer. The analyses was stratified into 2 groups: a group which received ‘limited resection' regardless of there pulmonary functional status and another ‘limited compromised group' which consisted of patients who would not tolerate major resection because of there poor pulmonary functions. These two group of patients were compared with a conventional lobectomy group. As the limited compromised resection group was smaller in size, had an older mean age, had a different distribution of type of cancer and started with a poorer pulmonary function status as compared to the other group, a meaningful comparison could not be made. The 5-year survival for this group was 48%. On the other hand the intentional limited resection and lobectomy group analysis yielded some interesting findings. First, the survival for limited resection was 93% as compared to 88% for lobectomy. Second, that while the locoregional recurrence was slightly higher in the limited resection group as compared to the lobectomy, three out of the four patients had their recurrence occur in the mediastinum rather than lung. This suggests that a more aggressive approach towards lymph node staging and dissection must be considered an important addition to segmentectomy. It is important to recognize that the inclusion criteria for the ‘intentional limited segmentectomy' group of patients by Dr. Kodama were rather rigorous and all tumors were less than 2 cm, had well-defined margins and the periphery of the nodule had no strong spicula on pre-operative computed tomographic scan. The segmentectomy itself was performed with the assistance of ND-YAG laser dissection and a safety margin of about 3 cm from the tumor edge was consistently attempted at resection.
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3. Anatomic consideration against limited resection
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Middle lobe cancer lends itself to a full lobectomy rather than a segmentectomy because the lobes are often small and a safety margin could not be achieved without compromising lobar function. Similarly, an anatomical segmentectomy is difficult to perform in the medial, lateral and posterior basal segments of the lower lobe. The relation of the bronchovascular structures of the basal segments render a clean segmentectomy for these specific segments rather difficult and may compromise the function of the remaining segments. Furthermore, when other adjacent undeterminant nodules exist, resection of lung cancer nodules may necessitate either a wider resection or leaving the indeterminate nodules and (leaving another lung cancer untreated). A wider resection may ultimately become of a size that warrants a lobectomy rather than several wedge resections or segmentectomies.
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4. Extending the indications for sublobar resection
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It is clear from reviewing the literature and the recent updated studies of patient cohorts that segmentectomy and wedge resection is ideal for patients with limited pulmonary functions, or those who are considered at high risk for tolerating major resections. This advantage is particularly true in decreasing morbidity and mortality around the time of resection and in preserving lung functions in the short but not long term. Limited lung resection may indeed be an acceptable operation for patients with small peripheral lung cancer (<2 cm) provided aggressive interoperative pathological lymph node staging is routinely done and a wide resection margin is obtained. However because of the increased risk of local recurrence with limited resection techniques, it is recommended that an extended segmentectomy, as recommended by the Japanese ‘extended segmentectomy for small lung tumours group,' be performed [16].
A limited resection should also be considered when dealing with operative situations which may result in significantly added risk of major lung resection. For example, when concomitant complex cardiovascular procedures are contemplated, wedge resection of small peripheral lung cancer may be expeditious and effective. In situations where synchronous or matachronous lung cancer appear, and provided the anatomy and the nature of the cancer permit limited resection, there may be merit in performing two limited resections or a major lung resection on one side and sublobar resection on the opposite or ipsilateral side. One however should make an effort to differentiate between two separate primary cancers and metastatic nodules.
Furthermore, in view of recent evidence of a high incidence of lung cancer in patients who are investigated prior to performing lung volume reduction surgery, resection of incidental lung cancer nodules as part of the lung volume reduction in surgery is warranted.
Finally patients with poor lung reserve must be recognized to have a substantially lower 5-year survival secondary to their emphysema [15,17]. This consideration should be incorporated when designing a strategy for resection of a severe COPD patients with lung cancer. Despite anecdotal reports of lobectomy being tolerated by patients with limited cardiopulmonary reserve, there is only one prospective study which reports the true morbidity and mortality in a cohort of high risk patients subjected to major resection [18]. Until further studies warrant otherwise, limited resection should seriously be considered in this group of patients. The role of radiotherapy to minimize the incidence of locoregional recurrence is currently under investigation and several retrospective studies have suggested that it may be advantageous. The Cancer and Leukemia Group B study number 9335 addresses the role of video assisted wedge resection with adjunct radiotherapy for the treatment of T1 lung cancer in patients with limited cardiopulmonary reserve. This study is near completion and will likely shed light on the true morbidity and mortality of thoracoscopic wedge resection, its technical feasibility, and the ability to combine radiotherapy with surgery in this frail population.
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Footnotes
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Presented at the 2nd MITSIG International Symposium: Controversies in Cardiothoracic Surgery, Hong Kong, November 20–21, 1998.
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References
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- Jensik RJ, Faber LP, Milloy FJ, Monson DO. Segmental resection for lung carcinoma. J Thorac Cardiovasc Surg 1973;66:563-572.[Medline]
- Errett LE, Wilson J, Chiu R. C-J. Munro, DD. Wedge resection as an alternative procedure for peripheral bronchogenic carcinoma in poor-risk patients. J Thorac Cardiovasc Surg 1985;90:656-661.
- Shields TW, Higgins GA. Minimal pulmonary resection in treatment of carcinoma of the lung. Arch Surg 1974;108:420-422.[Abstract/Free Full Text]
- Jensik RJ. Miniresection of small peripheral carcinomas of the lung. Surg Clin North Am 1987;67:951-958.[Medline]
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- Ginsberg RT, Rubinstein LV. Lung Cancer Study Group. Randomized trial of lobectomy versus resection for T1N0 non-small cell lung cancer. Ann Thorac Surg 1995;60:615-623.
- Jensik RJ, Faber LP, Kittle CF. Sleeve lobectomy for bronchogenic carcinoma: the Rush-Presbyterian-St Luke's Medical Center experience. Int Surg 1986;71:207-210.[Medline]
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- Tsubota N, Ayabe K, Doi O, Mori T, Namikawa S, Taki T, Yo W. for the Study Group of Extended Segmentectomy for Small Lung Tumor. Ongoing prospective study of segmentectomy for small lung tumors. Ann Thorac Surg 1998;66:1787-1790.
- Landreneau RJ, Sugarbaker DJ, Mack MJ, Fetterman L, Liptay M, Bartley S, Boley T, Keenan R, Ferson P, Weyant R, Naunheim K. Wedge resection versus lobectomy for stage I (T1N0M0) non-small-cell lung cancer. J Thorac Cardiovasc Surg 1997;113:691-700.[Abstract/Free Full Text]
- Unpublished report on cancer and leukemia group B 9238 (chairman Greg Lowen)..
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Abstract
1. Introduction
