Segmentectomy versus lobectomy in patients with stage I pulmonary carcinomaFiveyear survivalof.docx

Segmentectomy versus lobectomy in patients with stage I pulmonary carcinomaFiveyear survivalof.docx

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SegmentectomyversuslobectomyinpatientswithstageIpulmonarycarcinomaFiveyearsurvivalof

JThoracCardiovascSurg1994;107:

1087-1094

©1994Mosby,Inc.

GENERALTHORACICSURGERY

SegmentectomyversuslobectomyinpatientswithstageIpulmonarycarcinoma:

Five-yearsurvivalandpatternsofintrathoracicrecurrence

WilliamH.Warren,MD,L.PenfieldFaber,MD

Chicago,Ill.

SupportedinpartbytheJohnandJuneAntalekFoundation,theKoleFoundation,andcontributorstotheThoracicDiseaseResearchFund.

Addressforreprints:

WilliamH.Warren,MD,Suite218,1725WestHarrisonSt.,Chicago,IL60612.

Abstract

Onehundredseventy-threepatientswithstageI（T1N0,T2N0）non-small-celllungcancerunderwenteitherasegmentalpulmonaryresection（n=68）orlobectomy（n=105）from1980to1988.Fourpatientswerelosttofollow-up,buttheremaining169patientswerefollowedupfor5years.Survivalandtheprevalenceoflocal/regionalrecurrencewereassessed.Althoughnosurvivaladvantageoflobectomyoversegmentalresectionwasnotedforpatientswithtumors3.0cmindiameterorsmaller,asurvivaladvantagewasapparentforpatientsundergoinglobectomyfortumorslargerthan3.0cm.Therateoflocal/regionalrecurrencewas22.7%（15/66）aftersegmentalresectionversus4.9%（5/103）afterlobectomy.Areviewofhistologictumortype,originaltumordiameter,andsegmentresectedrevealednoriskfactorsthatwerepredictiveofrecurrence.Anadditionalresectionforrecurrencewasperformedinfourpatients.LobectomyisthepreferredoperativeprocedureforpatientswithstageItumorslargerthan3.0cm.Becausetherateoflocal/regionalrecurrencewashighaftersegmentalresections,diligentfollow-upofthesepatientsismandatory.（JTHORACCARDIOVASCSURG1994;107:

1087-94）

Overthepast30years,considerablecontroversyhasarisenovertheroleofsegmentalresectionsinthemanagementofstageI（T1N0,T2N0）lungcarcinoma.Althoughsegmentallungresectionhasbeendescribedasareasonableoptionforpatientswithcompromisedpulmonaryreserve,

1-3othershaveadvocateditforpatientsbelievedtobeabletotoleratealobectomy.

4-9Theappropriatenessofsegmentalpulmonaryresectionsmustbemeasuredbytheperioperativemorbidityandmortality,the5-yearsurvival,andtheprevalenceoflocallyrecurrentdisease.Despiteguidelinessuggestedtodistinguishalocalrecurrencefromasecondprimarypulmonarycarcinomaorasolitarypulmonarymetastasis,

10,11problemsofinterpretationpersist.

Forthepurposesofthisclinicalretrospectivestudy,wedefinedalocal/regionalrecurrenceasthedevelopmentofanadditionalcarcinomaintheipsilateralhemithorax（lungandmediastinum）within5yearsoftheresection,regardlessofthehistologicassessmentandtheexactlocationwithinthehemithorax.Althoughthisdefinitionisentirelyarbitraryanddoesnotattempttodistinguishincompletelyresectedtumorsfromsolitarymetastasesorsecondprimarycarcinomas,itis,nevertheless,objectiveandunambiguous.Theprevalenceoflocal/regionalrecurrencewasalsocomparedwiththeprevalenceofcarcinomadevelopinginthecontralateralhemithorax.

Thepurposesofthisclinicalreviewwere

（1）toevaluatesurvivalaftersegmentectomyandstandardlobectomyinthemanagementofstageIpulmonarycarcinomas,

（2）todeterminetheprevalenceoflocal/regionalandcontralateralrecurrence,and（3）toidentifyprognosticfactorsrelatingtosurvivalandtothedevelopmentoflocal/regionalrecurrence.

METHODSANDPATIENTS

Inthisretrospective,nonrandomizedstudy,theclinicalandpathologyfilesfrom1980to1988werereviewedforpatientswhohadundergoneeitherastandardlobectomyorasegmentalresection（definedastheresectionofoneormoreanatomicsegmentsofasinglelobebutlessthanalobe）forapathologicstageI（T1N0,T2N0）non-small-cellcarcinoma.Thechoiceoftheoperationwasatthediscretionofthesurgeon.Patientsbelievedtobeabletotoleratealobectomyunderwentasegmentectomyifthetumorwassmallandperipheral.Anatomicsegmentalresectionswereperformed.Theseoperationsinvolveddissectingoutthehilarstructuresandsecuringthebranchesofthepulmonaryartery,pulmonaryvein,andsegmentalbronchusindividuallyaspreviouslydescribed

1;patientshavingnonanatomic"wedge"resectionswerenoteligible.Alltumorswerelimitedtoonelobeandpatientswithtumorattheresectionmarginwereexcluded.Allpatientshadaregionalnodaldissection.PatientshavingasegmentectomywereincludedingroupIandthosehavingalobectomyingroupII.

Patientswereexcludediftheyhadsynchronoustumors,hadhadapreviousmalignanttumoratanysite,orhadreceivedpreoperativeorpostoperativeadjuvanttherapy.Allotherpatientswereeligibleirrespectiveoftheiroperativeriskfactors,pulmonaryfunction,orcardiacstatus.

Patientswereseenandexaminedatregularintervals,andchestradiographswereroutinelyobtained.Wheneverpossible,pathologicconfirmationofrecurrenttumorwasdonebeforetreatment.

Theprevalenceoflocal/regionalrecurrencewascomparedwiththeprevalenceofcarcinomadevelopinginthecontralaterallunginbothgroupsinthe5yearsoffollow-up.Tumorsthatrecurredassimultaneousbilateralcarcinomaswererecordedseparately.Tumorsthatrecurredsimultaneouslybothintheipsilateralhemithoraxanddistantlywereconsideredtobedistantrecurrences.

Noattemptwasmadetoassessoperativeriskfactorsofthesepatients.ItisacknowledgedthatsomeofthegroupIpatientshadlimitedcardiopulmonaryreserveandwerepoorcandidatesforalobectomy.

Thesurvivalstatisticsandtheprevalenceoflocal/regionalrecurrenceofthetwogroupswereanalyzedwithrespecttotumordiameterasmeasuredbythepathologist,histologicexamination,timeintervalbetweenresectionandappearanceoftherecurrence,andmanagementoftherecurrentcarcinoma.Becausetumordiameterwasconsideredtobepotentiallysignificant,resultswereanalyzedbytumorsize:

2.0cmorsmaller,2.1cmto3.0cm,andlargerthan3.0cm.

Tocomparethefrequenciesofthevariouscategoricaloutcomesinthetwogroups,weused

2testswhenallexpectedcellcountswerefiveormoreandFisher'sexacttestotherwise.Tocomparethetumorsizedistributionsofthetwogroups,weusedthetwo-samplettest.Toexaminetheeffectsofsinglevariablesonsurvival,ontime-until-recurrence,andondisease-freeinterval,weusedlogranktests.Tocheckformultivariateeffectsonthesesameeventtimes,weperformedstepwisefittingofCoxproportionalhazardsmodelsonthefollowingprognosticvariables:

age,sex,maximumtumordiameter,histologictype,andlocationofthetumor（upper,middle,lowerlobes）（rightversusleft）.Forallstatisticaltests,thesignificancelevelwas0.05.TheplotsshowKaplan-Meierestimatesoftheproportionineachgroupaliveasafunctionoftimeaftertheoperation.AllstatisticalanalyseswereperformedintheSASstatisticalpackage（SASInstitute,Inc.,SASLanguageandProcedures:

Usage,Version6,1sted.,Cary,N.C.,SASInstituteInc.,1989）.

RESULTS

Casehistoriesof173patientswerereviewed.Fourpatientswerelosttofollow-up.Oftheremaining169patients,66hadundergoneasegmentectomy（groupI）and103hadundergonealobectomy（groupII）.TheagesofgroupIpatientsrangedfrom36to81years（mean63.9+9.8years）;66.7%weremale.TheagesofgroupIIpatientsrangedfrom31to87years（mean63.8+9.9years）;65.0%weremale.

TumorsingroupIwereclassifiedhistologicallyasadenocarcinoma（44cases）,squamouscarcinoma（15cases）,"mixed"phenotypes（5cases）,andlargecellcarcinoma（2cases）.TumorsingroupIIwereassessedtobeadenocarcinoma（53cases）,squamouscarcinoma（35cases）,"mixed"phenotypes（6cases）,andlargecellcarcinoma（9cases）（

TableI）.Thecompositionofthetwogroupswasnotstatisticallysignificantlydifferentwithrespecttohistologictype（p=0.16,Fisher'sexacttest）.

TableI.Histologicdescriptionoftumors

Tumortype

GroupI（segmentectomy）

GroupII（lobectomy）

No.

%

No.

%

Adenocarcinoma

44/66

67

53/103

51

Squamouscarcinoma

15/66

23

35/103

34

"Mixed"phenotypes

5/66

8

6/103

6

Largecellcarcinoma

2/66

3

9/103

9

Overall,carcinomasingroupIweresmallerthanthoseingroupII（p<0.0001,Student'stwo-tailedtwo-samplettest）（

TableII）.Ofthe66carcinomasingroupI,38were2.0cmorsmaller,13were2.1to3.0cm,and15werelargerthan3.0cmindiameter（3.1to6.5cm）.Ofthe103carcinomasingroupIItumors,34were2.0cmorsmaller,10were2.1to3.0cm,and59werelargerthan3.0indiameter（3.1to16.0cm）.

TableII.Distributionofcarcinomasaccordingtodiameter

Tumorsize（cm）

GroupI（segmentectomy）

GroupII（lobectomy）

Totals

No.

%

No.

%

<2.0

38/66

58

34/103

33

72

2.1-3.0

13/66

20

10/103

10

23

>3.0

15/66

23

59/103

57

74

Totals

66

103

169

Mean

2.23cm

3.28cm

Standarddeviation

0.97

1.71

Threepatients（2lobectomy,1segmentectomy）diedintheperioperativeperiodofpulmonaryembolus（n=1）,myocardialinfarction（n=1）,oradultrespiratorydistresssyndrome（n=1）.

At5years,consideringtumorsofalldiameters,patientsundergoinglobectomy（groupII）haveastatisticallysignificantsurvivaladvantageoverpatientsundergoingsegmentectomy（groupI）（p=0.035）（Fig.1）.However,acomparisonofpatientswithtumors2.0cmorsmallerandpatientswithtumors2.1to3.0cmindiametershowednostatisticallysignificantdifferencebetweengroupsIandII（p=0.24and0