Prognostic Predictors in Non-Small Cell Lung Cancer Patients Undergoing Intentional Segmentectomy

doi:10.1016/j.athoracsur.2012.02.093

The Annals of Thoracic Surgery

Volume 93, Issue 6, June 2012, Pages 1788-1794

https://doi.org/10.1016/j.athoracsur.2012.02.093 Get rights and content

Background

Despite recent studies reporting on the results of prospective intentional sublobar resection for patients with small non-small cell lung cancer (NSCLC), few studies have investigated predictors for prognosis or recurrence exclusively in patients undergoing intentional sublobar resection.

Methods

We retrospectively reviewed 223 patients with small (2 cm or less) peripheral NSCLC who underwent intentional segmentectomy at the Niigata Cancer Center Hospital between 1992 and 2009. The significant demographic, clinical, and pathologic factors identified with the log rank test in univariate analyses were analyzed with the Cox proportional hazards regression model to examine independent predictors for prognosis and recurrence in multivariate analysis.

Results

The 5-year and 10-year overall survival rates were 89.6% and 81.0%, respectively, and the 5-year and 10-year recurrence-free probabilities were 91.1% and 91.1%, respectively. Eight patients had locoregional recurrence, and 12 had distant recurrence. Multivariate analyses revealed that age more than 70 years (hazard ratio [HR] 2.389), male (HR 2.750), more than 75% consolidation/tumor ratio on high-resolution computed tomography (HR 2.750), and lymphatic permeation (HR 5.618) were independent poor prognostic factors, and lymphatic permeation (HR 16.257) was an independent predictor for recurrence.

Conclusions

The factors related to upstaging on pathologic diagnosis were not identified as independent predictors; therefore, the current patient selection criterion seems reasonable. If lymphatic permeation is present on pathologic findings, careful follow-up is recommended. The predictors identified in this study will support assessment and interpretation of the results of ongoing prospective randomized trials of lobar versus sublobar resection in patients with small peripheral NSCLC.

Section snippets

Patients

We conducted the prospective study of intentional sublobar resection for small peripheral NSCLC and started enrolling patients in 1992 [7]. The patients in this prospective study met all of the following criteria: (1) cT1a N0 M0 peripheral NSCLC (diagnosed according to the 7th edition of the TNM classification); (2) maximum tumor diameter of 2 cm or less on preoperative radiologic findings; (3) no history of previous treatment; (4) general condition and respiratory function adequate for

Results

Of the 223 patients eligible for this study, 108 were male and 115 were female. The median age was 65 years (range, 42 to 81), and the most dominant histological subtype of the tumor was adenocarcinoma (n = 206, 92.4%). Tumor histology other than adenocarcinoma or squamous cell carcinoma was adenosquamous carcinoma (n = 1) and pulmonary blastoma (n = 1) (data not shown). Intraoperatively, surgical margin lavage cytology by washing a staple cartridge or the pleural surface was performed in 89

Comment

In the present study, the independent poor prognostic factors we identified were age more than 70 years, male, more than 75% of consolidation/tumor size ratio on HRCT, and lymphatic permeation; and lymphatic permeation was identified as an independent risk factor for recurrence in the patients with small (≤2 cm) peripheral NSCLC who underwent intentional segmentectomy. The 5-year and 10-year overall survival rates were 89.6% and 81.0%, respectively; and the 5-year and 10-year recurrence-free

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Cited by (45)

History of pulmonary segmentectomy and subsegmentectomy
2023, Atlas of Thoracoscopic Anatomical Pulmonary Subsegmentectomy
The evolution of our understanding of pulmonary anatomy and physiology, improvements in early diagnosis of lung cancer, advancements in medical imaging, and the use of thoracoscopic technique have all contributed to the transformation of lung surgery from pneumonectomy and lobectomy to segmentectomy and subsegmentectomy. These advances have brought about changes in surgical concepts, better results, and less suffering for patients. However, the advances will not stop here, as new aspects of lung surgery, robotic surgery, and mixed reality guided surgery, among others, are just around the corner.
Oncologic Outcomes of Surgery Versus SBRT for Non–Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis
2021, Clinical Lung Cancer
The optimal treatment of stage I non–small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).
A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.
A total of 100 studies with patients treated for clinical stage I non–small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.
Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non–small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.
Survival and Resected Lymph Node Number During Sublobar Resection for N0 Non-Small Cell Lung Cancer 2 cm or Less
2019, Annals of Thoracic Surgery
Citation Excerpt :
Zhang and colleagues [21] identified 31 eligible studies for meta-analysis and discovered that lobectomy conferred survival advantage over segmentectomy except in the subgroup with systematic lymph node dissection [21]. However, Koike and colleagues [22] reviewed retrospectively 223 patients with NSCLC 2 cm or less who underwent intentional segmentectomy. The result suggested that the extent of lymph node resection (sampling or systematic dissection) was not a statistically significant predictor for both recurrence and poor OS.
We investigated the association between survival and the number of examined lymph nodes after sublobar resection for node-negative non-small cell lung cancer with size of 2 cm or less.
The Surveillance, Epidemiology, and End Results database was used to identify patients diagnosed with non-small cell lung cancer 2 cm or less from 2004 to 2014 and underwent wedge resection or segmentectomy. Patients were stratified by the procedure (wedge resection, segmentectomy), the size of tumors (≤1 cm, 1 to 2 cm), and the number of lymph nodes examined (0, 1 to 3, 4 to 9, ≥10). The relationship between the number of resected lymph nodes and overall survival (OS)/lung cancer-specific survival (LCSS) was analyzed.
A total of 2,298 patients with wedge resection and 566 patients with segmentectomy were identified. Segmentectomy was performed for bigger tumors (1.43 cm versus 1.38 cm) and was associated with more lymph nodes resected (median number: 3 versus 1). Multivariable analysis after propensity score matching revealed that lymph node resection improved survival for patients undergoing wedge resection while not for patients undergoing segmentectomy. In the wedge resection group, 1 to 3 nodes resected improved OS and 4 to 9 nodes improved OS and LCSS compared with patients without nodes evaluated for lesions 1 cm or less. No survival benefit was observed when 10 or more nodes were resected. For lesions 1 to 2 cm, incremental improvement in survival appeared with the increase of examined lymph node number. More than 16 nodes resected conferred no additional survival benefit compared with patients with 10 to 16 nodes resected.
In wedge resection, 4 to 9 and 10 to 16 lymph nodes should be examined for lesions 1 cm or less and 1 to 2 cm, respectively. In segmentectomy, lymph node resection did not confer survival benefits for lesions 2 cm or less.
Prognostic Impact of Margin Distance and Tumor Spread Through Air Spaces in Limited Resection for Primary Lung Cancer
2017, Journal of Thoracic Oncology
The aim of this study was to investigate the relationship between clinicopathological prognostic factors, including surgical margin distance and tumor spread through air spaces (STAS), and recurrence after limited resection for primary lung cancer.
We identified 508 cases of limited resection (12.8%) and examined their clinicopathological features. Using Cox regression analysis, we examined the significant prognostic factors for recurrence of limited resection. Finally, we conducted a histopathological evaluation of tumor STAS.
Multivariate Cox analysis showed that the risk for local recurrence was significantly associated with STAS (hazard ratio = 12.24, p = 0.001) and a tumor margin less than 1.0 cm (hazard ratio = 6.36, p = 0.02). However, the presence of tumor STAS was not significantly associated with distant recurrence (p = 0.98). This lack of association of STAS with distant recurrence may be due to the small number of distant recurrences. In all, 76 cases (15.0%) (60 adenocarcinomas, nine squamous cell carcinomas, and seven others) were positive for STAS. The morphological STAS patterns were 12 single cells, 45 small cell clusters, and 19 large nests. There was no significant relationship between the recurrence rate and morphological STAS pattern. The STAS-positive group was associated with the presence of micropapillary (p = 0.002) and/or solid components (p = 0.008) in patients with adenocarcinoma and with lymphovascular and pleural invasion (p < 0.001).
The presence of STAS and tumor margins less than 1.0 cm are significant risk factors for local recurrence in early-stage lung cancer after limited resection. Thus, the presence of tumor STAS might be a pathological prognostic factor for patients with lung cancer who have undergone limited resection. However, the pathological and molecular significance of STAS remain to be clarified.
Recurrence and Survival After Segmentectomy in Patients With Prior Lung Resection for Early-Stage Non-Small Cell Lung Cancer
2016, Annals of Thoracic Surgery
Lobectomy is the standard of care for patients with early-stage non-small cell lung cancer (NSCLC). However, the treatment of choice for patients with prior lung resection and a second primary NSCLC has not been established. We compared rates and patterns of recurrence and survival in patients with and without prior lung resection treated by segmentectomy and determined predictors of recurrence.
This was a retrospective cohort study of 90 patients who underwent 91 consecutive segmentectomies for early-stage NSCLC between April 2004 and December 2014. Logistic regression was used to determine predictors of recurrence, and Kaplan-Meier curves were used to determine survival.
Of the 91 segmentectomies, 21 (23%) had a prior lung cancer resection and 70 (77%) were primary resections. There were 18 recurrences (20%): 9 of 21 (43%) in those with prior lung resection and 9 of 70 (13%) in those without. The 90-day mortality was 0%. The recurrence-free survival and 5-year survival were 61% and 55% in those with prior lung resection (p = 0.09) and 84% and 65% in those without (p = 0.4). Close parenchymal margin and number of lymph nodes examined were significant modifiable predictors of recurrence.
Segmentectomy is a reasonable option for patients with early-stage NSCLC who have had a prior lung resection. It results in similar survival but trends toward lower recurrence-free survival compared with patients undergoing primary resection.
Lobectomy Versus Segmentectomy in Radiologically Pure Solid Small-Sized Non-Small Cell Lung Cancer Presented at the Ninety-fifth Annual Meeting of the American Association for Thoracic Surgery, Seattle, WA, April 25-29, 2015.
2016, Annals of Thoracic Surgery
Citation Excerpt :
In contrast, the indication of limited resection for radiologically pure solid tumors is still controversial even though tumor size is small, because these tumors imply invasive characteristics [7, 8]. In small-sized NSCLC, an unfavorable postoperative prognosis for patients with pure solid lesions was suggested [7], and a low proportion of GGO on CT was a significant predictor of poor survival after segmentectomy [18]. Furthermore, the association between radiologically pure solid tumors and increased frequency of lymph node metastasis was reported [8].
The indication for limited resection of radiologically pure solid non-small cell lung cancer (NSCLC) is controversial owing to its invasive pathologic characteristics. This study was performed to compare the outcomes after lobectomy and segmentectomy in these NSCLC patients.
We retrospectively reviewed 251 patients with radiologically pure solid cT1a N0 M0 NSCLC who underwent lobectomy or segmentectomy, and the preoperative characteristics of the patients treated with the two operative techniques were matched using propensity score methods. Overall survival (OS) and disease-free survival (DFS) curves were compared using the log rank test, and differences in survival were also evaluated by the McNemar test. The preoperative factors and surgical procedure were analyzed with the multivariate Cox proportional hazards regression model to identify independent predictors of poor OS and DFS.
In the propensity score matched lobectomy and segmentectomy groups (87 patients per group), the 5-year and 10-year OS rates were 85% versus 84% and 66% versus 63%, respectively; and the 5-year and 10-year DFS rates were 80% versus 77% and 64% versus 58%, respectively. There were no significant differences between the two groups in OS or DFS by the log rank test, and also no significant differences in 3-year, 5-year, or 7-year OS or DFS by the McNemar test. Although age, smoking status, pulmonary function, and carcinoembryonic antigen were identified as significant predictors of both OS and DFS, the surgical procedure was not identified.
Similar oncologic outcomes after lobectomy and segmentectomy were indicated among patients with radiologically pure solid small-sized NSCLC.

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Original articleGeneral thoracicPrognostic Predictors in Non-Small Cell Lung Cancer Patients Undergoing Intentional Segmentectomy

Background

Methods

Results

Conclusions

Section snippets

Patients

Results

Comment

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Chest

J Thorac Cardiovasc Surg

J Thorac Oncol

Lung Cancer

J Thorac Oncol

Chest

Int J Radiat Oncol Biol Physics

Chest

Original article
General thoracic
Prognostic Predictors in Non-Small Cell Lung Cancer Patients Undergoing Intentional Segmentectomy