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

1、Segmentectomy versus lobectomy in patients with stage I pulmonary carcinomaFiveyear survivalofJ Thorac Cardiovasc Surg 1994;107:1087-1094 1994 Mosby, Inc. GENERAL THORACIC SURGERYSegmentectomy versus lobectomy in patients with stage I pulmonary carcinoma:Five-year survival and patterns of intrathora

2、cic recurrence William H. Warren, MD, L. Penfield Faber, MD Chicago, Ill.Supported in part by the John and June Antalek Foundation, the Kole Foundation, and contributors to the Thoracic Disease Research Fund. Address for reprints: William H. Warren, MD, Suite 218, 1725 West Harrison St., Chicago, IL

3、 60612. Abstract One hundred seventy-three patients with stage I (T1 N0, T2 N0) non-small-cell lung cancer underwent either a segmental pulmonary resection (n = 68) or lobectomy (n = 105) from 1980 to 1988. Four patients were lost to follow-up, but the remaining 169 patients were followed up for 5 y

4、ears. Survival and the prevalence of local/regional recurrence were assessed. Although no survival advantage of lobectomy over segmental resection was noted for patients with tumors 3.0 cm in diameter or smaller, a survival advantage was apparent for patients undergoing lobectomy for tumors larger t

5、han 3.0 cm. The rate of local/regional recurrence was 22.7% (15/66) after segmental resection versus 4.9% (5/103) after lobectomy. A review of histologic tumor type, original tumor diameter, and segment resected revealed no risk factors that were predictive of recurrence. An additional resection for

6、 recurrence was performed in four patients. Lobectomy is the preferred operative procedure for patients with stage I tumors larger than 3.0 cm. Because the rate of local/regional recurrence was high after segmental resections, diligent follow-up of these patients is mandatory. (J THORAC CARDIOVASC S

7、URG 1994;107:1087-94) Over the past 30 years, considerable controversy has arisen over the role of segmental resections in the management of stage I (T1 N0, T2 N0) lung carcinoma. Although segmental lung resection has been described as a reasonable option for patients with compromised pulmonary rese

8、rve, 1-3 others have advocated it for patientsbelieved to be able to tolerate a lobectomy. 4-9 The appropriateness of segmental pulmonary resections must be measured by the perioperative morbidity and mortality, the 5-year survival, and the prevalence of locally recurrent disease. Despite guidelines

9、 suggested to distinguish a local recurrence from a second primary pulmonary carcinoma or a solitary pulmonary metastasis, 10,11 problems of interpretation persist. For the purposes of this clinical retrospective study, we defined a local/regional recurrence as the development of an additional carci

10、noma in the ipsilateral hemithorax (lung and mediastinum) within 5 years of the resection, regardless of the histologic assessment and the exact location within the hemithorax. Although this definition is entirely arbitrary and does not attempt to distinguish incompletely resected tumors from solita

11、ry metastases or second primary carcinomas, it is, nevertheless, objective and unambiguous. The prevalence of local/regional recurrence was also compared with the prevalence of carcinoma developing in the contralateral hemithorax. The purposes of this clinical review were (1) to evaluate survival af

12、ter segmentectomy and standard lobectomy in the management of stage I pulmonary carcinomas, (2) to determine the prevalence of local/regional and contralateral recurrence, and (3) to identify prognostic factors relating to survival and to the development of local/ regional recurrence. METHODS AND PA

13、TIENTS In this retrospective, nonrandomized study, the clinical and pathology files from 1980 to 1988 were reviewed for patients who had undergone either a standard lobectomy or a segmental resection (defined as the resection of one or more anatomic segments of a single lobe but less than a lobe) fo

14、r a pathologic stage I (T1 N0, T2 N0) non-small-cell carcinoma. The choice of the operation was at the discretion of the surgeon. Patients believed to be able to tolerate a lobectomy underwent a segmentectomy if the tumor was small and peripheral. Anatomic segmental resections were performed. These

15、operations involved dissecting out the hilar structures and securing the branches of the pulmonary artery, pulmonary vein, and segmental bronchus individually as previously described 1; patients having nonanatomic wedge resections were not eligible. All tumors were limited to one lobe and patients w

16、ith tumor at the resection margin were excluded. All patients had a regional nodal dissection. Patients having a segmentectomy were included in group I and those having a lobectomy in group II. Patients were excluded if they had synchronous tumors, had had a previous malignant tumor at any site, or

17、had received preoperative or postoperative adjuvant therapy. All other patients were eligible irrespective of their operative risk factors, pulmonary function, or cardiac status. Patients were seen and examined at regular intervals, and chest radiographs were routinely obtained. Whenever possible, p

18、athologic confirmation of recurrent tumor was done before treatment. The prevalence of local/regional recurrence was compared with the prevalence of carcinoma developing in the contralateral lung in both groups in the 5 years of follow-up. Tumors that recurred as simultaneous bilateral carcinomas we

19、re recorded separately. Tumors that recurred simultaneously both in the ipsilateral hemithorax and distantly were considered to be distant recurrences. No attempt was made to assess operative risk factors of these patients. It is acknowledged that some of the group I patients had limited cardiopulmo

20、nary reserve and were poor candidates for a lobectomy. The survival statistics and the prevalence of local/regional recurrence of the two groups were analyzed with respect to tumor diameter as measured by the pathologist, histologic examination, time interval between resection and appearance of the

21、recurrence, and management of the recurrent carcinoma. Because tumor diameter was considered to be potentially significant, results were analyzed by tumor size: 2.0 cm or smaller, 2.1 cm to 3.0 cm, and larger than 3.0 cm. To compare the frequencies of the various categorical outcomes in the two grou

22、ps, we used 2 tests when all expected cell counts were five or more and Fishers exact test otherwise. To compare the tumor size distributions of the two groups, we used the two-sample t test. To examine the effects of single variables on survival, on time-until-recurrence, and on disease-free interv

23、al, we used log rank tests. To check for multivariate effects on these same event times, we performed stepwise fitting of Cox proportional hazards models on the following prognostic variables: age, sex, maximum tumor diameter, histologic type, and location of the tumor (upper, middle, lower lobes) (

24、right versus left). For all statistical tests, the significance level was 0.05. The plots show Kaplan-Meier estimates of the proportion in each group alive as a function of time after the operation. All statistical analyses were performed in the SAS statistical package (SAS Institute, Inc., SAS Lang

25、uage and Procedures: Usage, Version 6, 1st ed., Cary, N.C., SAS Institute Inc., 1989). RESULTS Case histories of 173 patients were reviewed. Four patients were lost to follow-up. Of the remaining 169 patients, 66 had undergone a segmentectomy (group I) and 103 had undergone a lobectomy (group II). T

26、he ages of group I patients ranged from 36 to 81 years (mean 63.9 + 9.8 years); 66.7% were male. The ages of group II patients ranged from 31 to 87 years (mean 63.8 + 9.9 years); 65.0% were male. Tumors in group I were classified histologically as adenocarcinoma (44 cases), squamous carcinoma (15 ca

27、ses), mixed phenotypes (5 cases), and large cell carcinoma (2 cases). Tumors in group II were assessed to be adenocarcinoma (53 cases), squamous carcinoma (35 cases), mixed phenotypes (6 cases), and large cell carcinoma (9 cases) (Table I). The composition of the two groups was not statistically sig

28、nificantly different with respect to histologic type (p = 0.16, Fishers exact test). Table I. Histologic description of tumors Tumor typeGroup I (segmentectomy)Group II (lobectomy)No.%No.%Adenocarcinoma44/666753/10351Squamous carcinoma15/662335/10334Mixed phenotypes5/6686/1036Large cell carcinoma2/6

29、639/1039Overall, carcinomas in group I were smaller than those in group II (p 0.0001, Students two-tailed two-sample t test) (Table II). Of the 66 carcinomas in group I, 38 were 2.0 cm or smaller, 13 were 2.1 to 3.0 cm, and 15 were larger than 3.0 cm in diameter (3.1 to 6.5 cm). Of the 103 carcinoma

30、s in group II tumors, 34 were 2.0 cm or smaller, 10 were 2.1 to 3.0 cm, and 59 were larger than 3.0 in diameter (3.1 to 16.0 cm). Table II. Distribution of carcinomas according to diameter Tumor size(cm)Group I(segmentectomy)Group II(lobectomy)TotalsNo.%No.%3.015/662359/1035774Totals66103169Mean2.23

31、 cm3.28 cmStandard deviation0.971.71Three patients (2 lobectomy, 1 segmentectomy) died in the perioperative period of pulmonary embolus (n = 1), myocardial infarction (n = 1), or adult respiratory distress syndrome (n = 1). At 5 years, considering tumors of all diameters, patients undergoing lobecto

32、my (group II) have a statistically significant survival advantage over patients undergoing segmentectomy (group I) (p = 0.035) (Fig. 1). However, a comparison of patients with tumors 2.0 cm or smaller and patients with tumors 2.1 to 3.0 cm in diameter showed no statistically significant difference between groups I and II (p = 0.24 and 0