Comparison of pulmonary segmentectomy and lobectomy: Safety results of a randomized trial Suzuki, Kenji; Saji, Hisashi; Aokage, Keiju ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
September 2019, 2019-09-00, 20190901, Letnik:
158, Številka:
3
Journal Article
Recenzirano
Odprti dostop
No definitive comparisons of surgical morbidity between segmentectomy and lobectomy for non–small cell lung cancer have been reported.
We conducted a randomized controlled trial to confirm the ...noninferiority of segmentectomy to lobectomy in regard to prognosis (trial No. JCOG0802/WJOG4607L). Patients with invasive peripheral non–small cell lung cancer tumor of a diameter ≤2 cm were randomized to undergo either lobectomy or segmentectomy. The primary end point was overall survival. Here, we have focused on morbidity and mortality. Predictors of surgical morbidity were evaluated by the mode of surgery. Segmentectomy was categorized into simple and complex. Simple segmentectomy was defined as segmental resection of the right or left segment 6, left superior, or lingular segment. Complex segmentectomy was resection of the other segment. This trial is registered with the University Hospital Medical Information Network--Clinical Trial Registry (UMIN000002317).
Between August 10, 2009, and October 21, 2014, 1106 patients (lobectomy n = 554 and segmentectomy n = 552) were enrolled. No mortality was noted. Complications (grade ≥ 2) occurred in 26.2% and 27.4% in the lobectomy and segmentectomy arms (P = .68), respectively. Fistula/pulmonary-lung (air leak) was detected in 21 (3.8%) and 36 (6.5%) patients in the lobectomy and segmentectomy arms (P = .04), respectively. Multivariable analysis revealed that predictors of pulmonary complications, including air leak and empyema (grade ≥ 2) were complex segmentectomy (vs lobectomy) (odds ratio, 2.07; 95% confidence interval, 1.11-3.88; P = .023), and > 20 pack-years of smoking (odds ratio, 2.61; 95% confidence interval, 1.14-5.97; P = .023).
There was no difference in almost any postoperative measure of intraoperative and postoperative complication in segmentectomy and lobectomy patients, except more air leakage was observed in the segmentectomy arm. Segmentectomy will be a standard treatment if the superior pulmonary function and noninferiority in overall survival are confirmed.
The 2 phase III trials, JCOG0802/WJOG4607L and JCOG0804/WJOG4507L, were based on JCOG0201. Display omitted
Abstract
OBJECTIVES
Although segmentectomy for lung cancer has been widely accepted, complex segmentectomy, which creates several, intricate intersegmental planes, remains controversial. Potential ...arguments include risk of incurability and ‘failure of cancer control’. We compared the outcomes of complex segmentectomy versus lobectomy and evaluated its use in lung cancer treatment.
METHODS
We retrospectively reviewed clinical stage IA lung cancer patients who underwent complex segmentectomy (n = 99) or location-adjusted lobectomy (n = 94) between April 2009 and December 2017. Clinicopathological and postoperative results were compared. Factors affecting survival were assessed by the Kaplan–Meier method and the Cox regression analysis.
RESULTS
No significant differences were detected in 30-day mortality (0% vs 0%), overall complications (26.3% vs 21.3%) and prolonged air leakage (11.1% vs 9.6%) rates between the 2 groups, respectively. Comparable results were obtained for 5-year overall (93.5% vs 96.4%, respectively; P = 0.21) or recurrence-free (92.3% vs 88.5%, respectively; P = 0.82) survivals after complex segmentectomy or lobectomy. There were 2 (2.0%) recurrences after complex segmentectomy and 7 (7.5%) after lobectomy (P = 0.094), with 0 (0%) margin relapses in each group. Multivariable Cox regression analysis revealed that complex segmentectomy and lobectomy had a numerically similar impact on recurrence-free survival (hazard ratio 0.93, 95% confidence interval 0.32–2.69; P = 0.90).
CONCLUSIONS
Complex segmentectomy can provide acceptable short- and long-term outcomes in lung cancer treatment.
In 1995, Ginsberg et al. compared lobectomy with limited resection including segmentectomy and wide-wedge resection for stage I lung cancer in a randomized controlled trial and found that limited ...resection should not be applied to otherwise healthy patients with clinical stage IA lung cancer who can tolerate lobectomy. However, recent advances in diagnostic technology have improved the precision of detecting early-stage and small lung cancers. Therefore, whether radical segmentectomy, anatomical segmentectomy with hilar and mediastinal lymph node dissection (that is more valuable than wedge resection in terms of oncological aspects) and lobectomy are comparable in terms of curative intent for patients with early-stage non-small cell lung cancer (NSCLC) remains controversial. The role of segmentectomy differs according to tumor or patient characteristics. High resolution computed tomography findings of tumor size, location, and the presence or ratio of a ground glass opacity (GGO) component and the maximum of standardized uptake value on fluorine-18-2-deoxy-
d
-glucose positron emission tomography are important for selecting surgical procedures because the malignant potential of even early-stage NSCLC is variable. The ongoing JCOG0802/WJOG4607L, JCOG1211, and CALGB140503 trials will disclose the influence of segmentectomy for patients with early-staged NSCLCs that are small peripheral tumors based on preoperative high-resolution computed tomography findings about preserved pulmonary function and long-term prognosis. Segmentectomy is a key surgical procedure that general thoracic surgeons will need to master considering that it can be converted to lobectomy if the surgical margin is insufficient or lymph node metastasis is intraoperatively confirmed.
As segmentectomy becomes widely used for lung cancer treatment, complex segmentectomy, which makes several, intricate intersegmental planes, remains controversial because of procedural complexity and ...risk of increased complications and incurability. Questions remain about mortality, morbidity, surgical margin, lymph nodes dissection, and postoperative pulmonary function. We evaluated operative and postoperative outcomes of complex compared with simple segmentectomy.
We retrospectively reviewed patients with clinical stage I lung cancer who could tolerate lobectomy and underwent complex or simple segmentectomy between April 2007 and March 2017. Clinicopathologic, operative, and postoperative results of the complex (n = 117) and simple (n = 92) segmentectomy groups were compared.
No statistically significant differences were detected in age, sex, comorbidities, preoperative pulmonary function, tumor histology, and size. Although only median operative time (180 versus 143.5 minutes, p < 0.0001) was significantly longer in the complex group, 30-day mortality (0% versus 0%), overall complications (24.8% versus 22.8%), and prolonged air leakage (11.9% versus 10.9%) were nearly equivalent between the two groups, respectively. The complex group showed comparable results in median surgical margin distance (16.0 versus 17.5 mm) and number of dissected lymph nodes (6.0 versus 7.0 nodes). Margin relapse occurred in 2 patients in the simple group but none occurred in the complex group. Both groups also showed similar postoperative pulmonary functions.
Complex segmentectomy is a safe option in the treatment of lung cancers with adequate operative outcomes.
Purpose
This study compares the sensitivity of dedicated breast positron emission tomography (DbPET) and whole body positron emission tomography (WBPET) in detecting invasive breast cancer based on ...tumor size and biology. Further, we explored the relationship between maximum standardized uptake value (SUVmax) of DbPET and biological features of the tumor.
Methods
A total of 639 invasive breast cancer lesions subjected to both DbPET and WBPET before surgery, between January 2016 and May 2019, were included in the study. The sensitivity of DbPET and WBPET in detection and the biology of the tumor according to the clinicopathological features were retrospectively evaluated.
Results
The overall sensitivity of DbPET was higher than that of WBPET (91.4% vs. 80.3%,
p
< 0.001). Subcentimetric tumors were significant (80.9% vs. 54.3%,
p
< 0.001). Regardless of the nuclear grade, DbPET could detect more lesions than WBPET. The SUVmax was positively correlated with tumor size (
R
= 0.395,
p
< 0.001) and the nuclear grade (
p
< 0.001). Luminal A-like breast cancer had significantly lower SUVmax values than the other subtypes (
p
< 0.001).
Conclusions
DbPET is superior to WBPET in the detection of subcentimetric, low-grade breast cancers. Further, by using SUVmax, DbPET can distinguish luminal A-like breast cancer from the other subtypes.
We performed a validation study to confirm the prognostic importance of the presence of a ground-glass opacity component based on data of the Japan Clinical Oncology Group study, JCOG0201, which was ...a prospective observational study to predict the pathological noninvasiveness of clinical stage IA lung cancer in Japan.
Among the 811 patients registered in JCOG0201, 671 were confirmed eligible by study monitoring and a central review of computed tomography. Registered c-stage IA lung cancer was less than 30 mm in maximum tumor size, which was classified into a with ground-glass opacity group (pure ground-glass opacity and part-solid tumor) or solid group based on the status of a ground-glass opacity component. T staging was reassigned in accordance with the 8th edition of the TNM staging system. To validate the prognostic impact, overall survival was estimated.
Of the cases, 432 (64%) were in the with ground-glass opacity group and 239 (36%) were in the solid group with a median follow-up time of 10.1 years. The 5-year overall survival was significantly different between the with ground-glass opacity group and solid group (95.1% vs 81.1%). The 5-year overall survival was excellent regardless of the solid component size in the with ground-glass opacity group (c-T1a or less: 97.2%, c-T1b: 93.4%, c-T1c: 91.7%). In contrast, prognostic impact of the tumor size was definitive in the solid group (c-T1a: 87.5%, c-T1b: 85.9%, c-T1c: 73.7%).
Favorable prognostic impact of the presence of a ground-glass opacity component was demonstrated in JCOG0201. The presence or absence of a ground-glass opacity should be considered as an important parameter in the next clinical T classification.
This supplemental analysis aimed to confirm the prognostic importance of the presence of a GGO component based on data of the JCOG study, JCOG0201. Among the 671 eligible patients, 432 (64%) were classified in the with GGO group and 239 (36%) were classified in the solid group according to the radiological central review board. The 5-year OS was excellent regardless of the solid component size in the with GGO group, whereas prognostic impact of the tumor size was definitive in the solid group. The presence or absence of a GGO would be considered as an important parameter in the next clinical T classification. GGO, Ground-glass opacity. Display omitted
Objectives The present multicenter study compared the usefulness of the solid tumor size with that of the whole tumor size on preoperative high-resolution computed tomography for predicting ...pathologic high-grade malignancy (positive lymphatic, vascular, or pleural invasion) and the prognosis of clinical stage IA lung adenocarcinoma. Methods We performed high-resolution computed tomography and F-18 fluorodeoxyglucose-positron emission tomography/computed tomography before curative surgical resection in 502 patients with clinical stage IA lung adenocarcinoma. The revised maximum standardized uptake values on F-18 fluorodeoxyglucose-positron emission tomography/computed tomography were used to correct interinstitutional discrepancies. The whole and solid tumor sizes on high-resolution computed tomography were then analyzed in relation to surgical results. Results The mean whole and solid tumor size was 1.97 ± 0.59 cm and 1.20 ± 0.88 cm, respectively. The receiver operating characteristics area under the curve for the whole and solid tumor sizes used to identify high-grade malignancy were 0.590 and 0.829, respectively. Multiple logistic regression analyses demonstrated solid tumor size ( P < .001) and maximum standardized uptake values of the tumor ( P < .001) as independent variables for the prediction of high-grade malignancy. Multivariate Cox analysis of disease-free survival demonstrated the former (hazard ratio, 2.30; 95% confidence interval, 1.46-3.63; P < .001) and latter (hazard ratio, 1.08; 95% confidence interval, 1.00-1.17; P = .05) as independent prognostic factors. Conclusions The solid tumor size on high-resolution computed tomography and maximum standardized uptake values on positron emission tomography/computed tomography have greater predictive value for high-grade malignancy and prognosis in clinical stage IA lung adenocarcinoma than that of whole tumor size.
Background
This study aimed to investigate the efficacy of the Deauville criteria (a 5-point visual scale criteria) in assessing the accumulation of 18F-fluoro-2-deoxy-
d
-glucose (FDG) on ...positron-emission tomography (PET)/computed tomography (CT) for predicting prognosis of early-stage lung adenocarcinoma and selecting candidates for sublobar resection.
Methods
This retrospective study included 648 patients undergoing curative resection for clinical N0 lung adenocarcinoma with a whole tumor size of 3 cm or smaller between April 2007 and March 2019. Accumulations of the FDG on PET/CT scans were scored using the Deauville criteria (Deauville score), and correlations between the Deauville score and prognosis were analyzed.
Results
The recurrence-free survival (RFS) was significantly better for the patients with a Deauville score of 1 or 2 (
n
= 415, 5-year RFS, 92.6%) than for those with a score of 3 (
n
= 82, 5-year RFS, 72.7%;
P
< 0.001) or a score of 4 or 5 (
n
= 151, RFS, 70.8%;
P
< 0.001). The RFS did not differ significantly among the patients with Deauville scores of 1 and 2 who underwent wedge resection (
n
= 102, 5-year RFS, 90.5%), segmentectomy (
n
= 188, RFS, 95.1%;
P
= 0.355), and lobectomy (
n
= 125, RFS, 91.1%;
P
= 0.462).
Conclusion
The 5-point-scale evaluation of FDG accumulation on PET/CT was useful in predicting the prognosis for patients with early-stage lung adenocarcinoma. Lung adenocarcinoma patients with a whole tumor size of 3 cm or smaller and a Deauville score of 1 or 2 can be candidates for sublobar resection.
Since 'radical lobectomy' was reported by Cahan in 1960, the standard surgical care for lung cancer has been lobectomy, in which units of the lobe are excised with their specific regional hilar and ...mediastinal lymphatics. However, pulmonary function-preserving limited resection for lung cancer has gradually become more prevalent in the late 20th century. In 1995, Ginsberg et al. conducted a randomized controlled trial in which limited resection (segmentectomy and wide-wedge resection) and lobectomy for stage I lung cancer were compared and reported that limited resection should not be applied to healthy patients with clinical stage IA lung cancer. The detection of small-sized and early-stage lung cancers has improved with advancement in diagnostic technology. Ground-glass opacity of lung nodules, as recognized on thin-slice computed tomography, has also been widely recognized as being correlated with less-invasive pathological findings of alveolar epithelial cell replacement of cancer cells. The Lung Cancer Surgical Study Group of the Japan Clinical Oncology Group conducted a cohort study of early peripheral lung cancer and investigated the validity thin-slice computed tomography criteria to diagnose non-invasive lung adenocarcinoma for the preoperative prediction of pathological non-invasive cancer. Following this observational study, the on-going JCOG0802/WJOG4607L, JCOG0804/WJOG4507L and JCOG1211 trials were initiated to confirm the validity of limited resection for stage I lung cancer patients stratified according to preoperative thin-slice computed tomography findings; these trials will clarify whether limited resection for lung cancer is not function-preserving but also only curative surgery.
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