Segmentectomy for roentgenographically occult bronchogenic squamous cell carcinoma

Early central airways lung cancer

Early central airways lung cancer accounts for very small percentage of all lung cancers. Given this fact, it is much difficult to carry out a prospective randomized comparative clinical trial. Even retrospective studies can offer important information. Early central airways lung cancer is usually detected by sputum cytology. If sputum cytology shows atypical epithelial cells implying malignancy, the next thing we have to do is bronchoscopy. Both autofluorescence bronchoscopy and white light bronchoscopy were superior to white light bronchoscopy alone in detecting this type of lung cancer. Natural history of this cancer showed about the two-thirds of the patients die from original disease within 10 years. If the tumor length is 10 mm or less, photodynamic therapy is a first-line modality. After photodynamic therapy, a 5-year overall survival of about 80 % and a 10-year overall survival of 70 % can be expected. If a cancer does not meet the criteria for photodynamic therapy, surgical resection is recommended, and 5-year overall survival of about 80 % can be expected. Segmentectomy should be considered because of pulmonary function preservation if a tumor is located at segmental bronchi or beyond it. The frequency of multicentricity is high. Treatment strategy for subsequent primary lung cancer is an important key for the prognosis of patients with treated early central airways lung cancer. Surgical resection is still the most reliable treatment of subsequent primary lung cancer, except for in situ or microinvasive carcinoma located centrally, which could be cured by photodynamic therapy.

Results of long-term follow-up of photodynamic therapy for roentgenographically occult bronchogenic squamous cell carcinoma

BACKGROUND

Photodynamic therapy (PDT) is considered a useful and minimally invasive modality for treating centrally located early lung cancer. To date, there has been limited information on the long-term outcome of patients treated with PDT, especially those who are medically operable.

METHODS

Beginning in 1994, patients with roentgenographically occult bronchogenic squamous cell carcinoma (ROSCC) who met our criteria underwent PDT at Tohoku University Hospital and were followed up through 2006. Our criteria were as follows: (1) ROSCC without distant metastasis; (2) medically operable by means of lobectomy or further resection; (3) longitudinal tumor length of <or= 10 mm; and (4) superficial bronchoscopic tumor findings.

RESULTS

A total of 48 patients with ROSCC underwent PDT. The complete response (CR) rate was 94% (45 of 48 of patients). Nine patients (20%) had local recurrence after CR. A total of 11 deaths was observed, with 6 resulting from multiple primary lung cancer and only 1 from the original ROSCC. The 5-year and 10-year overall survival rates for all 48 patients were 81% and 71%, respectively. The Cox proportional hazard model showed that only metachronous multiple primary lung cancer was an independent poor prognostic factor.

CONCLUSIONS

PDT is thought to be a first-line modality for patients who have ROSCC with a tumor length of <or= 10 mm, even if the tumor is medically operable. Most local recurrence can be cured by active therapy such as surgery, radiotherapy, or PDT. Multiple primary lung cancer subsequent to PDT is an important issue from the viewpoint of survival.

Lobes, fissures, and bronchopulmonary segments

The clinical practice of thoracic surgery requires the surgeon to have intimate knowledge of pulmonary anatomy and of its variations. Attempts to perform thoracic procedures without this knowledge can only result in incomplete operations or technical mishaps. Proper understanding of the anatomy of the pulmonary lobes, segments, and fissures allows the surgeon to correlate imaging, pathologic processes, and possible resectional procedures, thus insuring that each patient gets the best possible operation.

Clinical relevance of sputum cytology and chest X-ray in patients with suspected lung tumors

OBJECTIVE

To review diagnostic procedures, therapeutic modalities, and follow-up methods in patients with suspected lung tumors.

METHODS

We retrospectively examined 70 patients who underwent a complete medical checkup because they had been positive for sputum cytology and had presented no chest X-ray findings for the 10-year period between 1994 and 2004. To make a diagnosis, we conducted the first complete medical checkup that included chest X-ray, sputum cytology, chest computed tomography (CT), and bronchoscopy. In the case that no diagnosis could be made, we repeated the chest X-ray and sputum cytology every 3 to 6 months and additionally conducted chest CT and bronchoscopy according to abnormal findings.

RESULTS

Among 70 patients, there were 36 and 13 who were diagnosed during the first complete medical checkup and follow-up, respectively, 13 who remained undiagnosed, and eight for whom follow-up was discontinued. Among the 49 diagnosed patients, 40, 8, and 1 patient had lung cancer, upper respiratory tract carcinoma (URTC), and esophageal carcinoma (EC), respectively. Among the 40 patients with lung cancer, 34 had a stage 0 or I tumor and 15 were radically treatable by photodynamic therapy and endobronchial irradiation. Nine among 11 patients whose lung cancer was detected during follow-up had a stage 0 or IA tumor.

CONCLUSION

Not only lung cancer but also URTC and EC were successfully detected in patients who were positive for sputum cytology and presented negative chest X-ray. Radical treatment was possible in 38 (76%) of 50 diagnosed patients, thus indicating the importance of follow-up through these procedures.

Extended sleeve pulmonary resection in a patient with synchronous triple bronchogenic squamous cell carcinoma

A 58-year-old male was admitted to our hospital for evaluation of bloody sputum. He was diagnosed as having synchronous triple bronchogenic squamous cell carcinomas in the right upper lobe, from the right B(6) segmental bronchus to the intermediate trunk and the middle lobar bronchus, and in the spur of the left B(1+2)/B(3) segmental bronchus. He underwent sleeve resection of the right upper lobe, right middle lobe, and right S(6) segment, with an anastomosis between the right main and right basal bronchi. This was followed by YAG-laser treatment and external irradiation for the left tumour and the residual right tumour. Postoperatively, chest X-ray revealed adequate expansion of the right basal segment, and pulmonary function testing showed satisfactory results. Recurrence was not detected during an initial 6-month period, however careful follow-up is required.

Effect of tumor size on prognosis in patients with non-small cell lung cancer: the role of segmentectomy as a type of lesser resection

OBJECTIVE

As a result of increasing discovery of small-sized lung cancer in clinical practice, tumor size has come to be considered an important variable affecting planning of treatment. Nevertheless, there have been no reports including large numbers of patients and focusing on tumor size, and controversy remains concerning the surgical management of small-sized tumors. Therefore, we investigated the relationships between tumor dimension and clinical and follow-up data, as well as surgical procedure in particular.

METHODS

We reviewed the records of 1272 consecutive patients who underwent complete resection for non-small cell carcinoma of the lung.

RESULTS

Fifty patients had tumors of 10 mm or less, 273 had tumors of 11 to 20 mm, 368 had tumors of 21 to 30 mm, and 581 had tumors of greater than 30 mm in diameter. The cancer-specific 5-year survivals of patients in these 4 groups were 100%, 83.5%, 76.5%, and 57.9%, respectively. For patients with pathologic stage I disease, they were 100%, 92.6%, 84.1%, and 76.4%, respectively. Multivariate analysis demonstrated that male sex, older age, larger tumor, and advanced pathologic stage adversely affected survival. Lesser resection was performed in 167 (52%) of 323 patients with a tumor of 20 mm or less in diameter but in 156 (16%) of 949 patients with a tumor of greater than 20 mm in diameter. The percentages of lesser resection among all procedures performed were 79%, 56%, 30%, and 15% in patients with pathologic stage I disease with a tumor of 10 mm or less, 11 to 20 mm, 21 to 30 mm, and greater than 30 mm in diameter, respectively. The 5-year cancer-specific survivals of patients with pathologic stage I disease with tumors of 20 mm or less and 21 to 30 mm in diameter were 92.4% and 87.4% after lobectomy, 96.7% and 84.6% after segmentectomy, and 85.7% and 39.4% after wedge resection, respectively. On the other hand, with a tumor of greater than 30 mm in diameter, survivals were 81.3% after lobectomy, 62.9% after segmentectomy, and 0% after wedge resection, respectively.

CONCLUSIONS

Tumor size is an independent and significant prognostic factor and important for planning of surgical treatment. Although lobectomy should be chosen for patients with a tumor of greater than 30 mm in diameter, further investigation is required for tumors of 21 to 30 mm in diameter. Segmentectomy should, as a lesser anatomic resection, be distinguished from wedge resection and might be acceptable for patients with a tumor of 20 mm or less in diameter without nodal involvement.

Sleeve segmentectomy for non–small cell lung carcinoma

OBJECTIVE

Although sleeve segmentectomy for centrally located lung cancers was originally designed for patients unable to tolerate lobectomy, we have tried it in patients with noncompromised function as well. We evaluated the efficiency of this atypical type of bronchoplasty.

METHODS

Of 202 patients for whom we performed bronchoplasty for primary non-small cell lung carcinoma, 16 underwent sleeve segmentectomy.

RESULTS

Sixteen patients were classified into 4 groups according to the mode of bronchial reconstruction: type A, anastomosis between the right intermediate or left main and basal segmental bronchi with removal of the superior segment of the lower lobe (S6; n = 7); type B, anastomosis between the left main and lingular bronchi with removal of the upper division of the left upper lobe (S1+2+3; n = 3); type C, anastomosis between the left main and upper division bronchi with removal of the lingular segments (S4+5; n = 4); and type D, others (n = 2). Nine patients had pulmonary function sufficient to tolerate lobectomy. The tumors were completely resected in all patients. Combined performance of pulmonary angioplasty was carried out in 2 patients. Bronchial reconstruction was successful in all patients, with neither bronchial complications nor local recurrences. Ten patients had stage IA disease, and 6 had more advanced disease. All patients were alive, except 1 who died as a result of distant metastasis and 2 who died of noncancerous causes. Overall 3-year and 5-year survivals were 93.3% and 68.1%, respectively.

CONCLUSIONS

Sleeve segmentectomy, which is technically demanding, should be considered in patients with centrally located and possibly curable early non-small cell lung cancer because the prevalence of small-sized or multiple lung tumors has been increasing and because our findings suggest that this lung-saving operation is safe and useful.

Video-assisted thoracoscopic surgery (VATS) segmentectomy for small peripheral lung cancer tumors: intermediate results

BACKGROUND

We investigated the feasibility and suitability of video-assisted thoracoscopic surgery (VATS) segmentectomy for curing selected non-small cell lung cancer (NSCLC) with this less invasive technique.

METHODS

We performed VATS segmentectomy for small (< 20 mm) peripherally located tumors and pathologically confirmed lobar lymph node-negative disease by frozen-section examination during surgery. Of the 34 patients who underwent this limited resection, 22 were treated with complete hilar and mediastinal lymph node dissection (intentional group), whereas 12 patients who were deemed to be high risk in their toleration for lobectomy underwent VATS segmentectomy with incomplete hilar and mediastinal lymph node dissection (compromised group). The surgical and clinical parameters were evaluated and compared with those of segmentectomy under standard thoracotomy to evaluate the technical feasibility of VATS segmentectomy.

RESULTS

We found that VATS segmentectomy could be performed safely with a nil mortality rate and acceptably low morbidity. The mean period of observation was relatively short at 656.7 +/- 572.1 and 783.4 +/- 535.8 days in the intentional and compromised groups, respectively. At the time of writing, all intentional patients remain alive and free of recurrence. There were two cases of non-cancer-related death in the compromised group. Clinical data indicated that VATS segmentectomy caused the same number or fewer surgical insults compared with segmentectomy under standard thoracotomy.

CONCLUSIONS

The present results are intermediate only; the rate of long-term survival and the advantages of the less invasive procedure still need further investigation. Nevertheless, we believe that VATS segmentectomy with complete lymph node dissection is a reasonable treatment option for selected patients with small peripheral NSCLC.

Pulmonary segmentectomy: results and complications

BACKGROUND

Segmentectomy is an anatomic pulmonary parenchymal-sparing resection performed for certain benign lesions and on selected patients with lung cancer. We reviewed our experience with segmentectomy in this highly select group of patients.

METHODS

We retrospectively reviewed the records of 61 patients (5% of all anatomic resections) undergoing 62 segmentectomies from 1991 to 2001. Wedge resections were excluded. The operative indications were suspected or known lung cancer (43), benign disease (12), and metastatic cancer to the lung (7). Median follow-up for patients with malignancy was 28 months (range 1 to 89 months). Actuarial survival was calculated using the Kaplan-Meier method.

RESULTS

Segmentectomy was performed in 43 lung cancer patients with pathologic stages of Ia-22, Ib-14, IIa-2, IIb-1, IIIa/IIIb-2, and IV-2. All resection margins were negative for malignancy. Segmentectomy for benign diseases included granulomatous disease (5), pulmonary abscess (2), plasmacytoma (1), and others (4). Complications occurred in 39% (24/62) of patients, including atelectasis requiring bronchoscopy (10/62, 16%), pneumonia (9/62, 14%), air leak more than 7 days (5/62, 8%), and supraventricular dysrhythmias (6/62, 10%). In-hospital mortality was 3% (2 patients). Median length of hospital stay was 6 days (range 4 to 66 days). In the lung cancer patients the locoregional recurrence rate was 0% and the distant recurrence rate was 20%. The 4-year actuarial survival for patients with lung cancer was 72%.

CONCLUSIONS

Pulmonary segmentectomy has acceptable morbidity and mortality in selected patients with both benign and malignant lung disease and remains a useful procedure in a thoracic surgeon's armamentarium. Distant, not locoregional recurrence, was responsible for the cancer deaths.

Evaluation of T factor, surgical method, and prognostic factors in central type lung cancer

OBJECTIVE

We report our experience in the diagnosis and surgical treatment of central type lung cancer (CTLC) and discuss the prognostic significance of clinicopathological factors including the T factor.

METHODS

Subjects were 151 patients with CTLC undergoing surgery from 1984 to 1999. Surgical procedures include lobectomy in 111, pneumonectomy in 35, and segmentectomy in 5. Bronchoplasty was done in 44, including sleeve lobectomy in 33, carinal resection in 8, and bronchoplasty without resection of pulmonary parenchyma in 3. Data on CTLC was compared to that on peripheral lung cancer during the same period.

RESULTS

Compared to peripheral tumors, central lung tumors showed a higher ratio in male gender, pN1 in pN factors, squamous cell carcinoma in histology, and pneumonectomy and bronchoplasty in surgery. No statistical differences were seen between groups in surgical outcome, mean age, distribution pattern in pT factors, and extended surgery. The positive predictive cT factor has improved. No significant difference was seen in 5-year survival based on 8 factors--period, cT factors, tumor histology, bronchoplasty, extended surgery, cellular atypia, additional chemotherapy, and radiotherapy. Five-year survival differed significantly for 12 other factors--pT, cN, and pN factors; surgical method; number of resected organs in extended surgery; curability (complete/incomplete); tumor size; N1 and N2 station metastasis; p factor, and blood vessel and lymphatic invasion. Multivariable analysis indicated only 2 independent prognostic factors--cN and p factor.

CONCLUSIONS

CTLC appears to belong to a subgroup other than peripheral tumors, requiring a more accurate diagnosis of cT factors, particularly in the proximal bronchus, because cT and cN factors are the only 2 used preoperatively.

Therapy for stage I and stage II non-small cell lung cancer

Despite complete resection of what seems to be all evident tumor, one third to three quarters of patients with stages I and II NSCLC ultimately succumb to this neoplasm. Patients who are cured of an original NSCLC or small cell cancer remain at risk for a new primary lung cancer. Although the importance of lifelong surveillance is clear, the extent and timing of optimal follow-up remain undefined. Although clinicians refer to the development after treatment of clinically discernible sites of tumor as "recurrence," it is probably more accurate to consider these foci as "persistence"--that is, the locoregional site was not sterilized by surgery, and the distant implants were present from the outset but undetected. Although data are sparse, induction and improved adjuvant therapy for early NSCLC may be helpful. Much further experience is needed. Further study and application of biologic indicators in addition to TNM staging likely will help identify patients at high risk for surgical failure who may benefit by combination treatment.

Surgery for non-small cell lung cancer--new trends

New trends in lung cancer surgery focus on new approaches to the management of the primary tumour, combined modality approaches to both local and distant control of the tumour, new approaches to ensure resectability by staging and techniques to expand the limits of operability. With new screening methods for NSCLC there is a trend toward sublobar, segmental resections of smaller tumours including an expanding use of video assisted thoracoscopy. Improvements in surgical and anaesthetic procedures have stimulated a renewed interest in the resection of locally advanced tumours. The understanding that local control alone may not give the best chance of long term survival has stimulated new trends in the use of neoadjuvant and adjuvant chemotherapy. There is a trend towards more detailed preoperative and intraoperative nodal staging in NSCLC, including video assisted techniques, and the identification of sentinel lymph node involvement to direct lymph node dissection. Increased understanding of the physiological benefits of surgery in emphysema have resulted in a re-evaluation of the selection of patients for lung cancer surgery. This together with a greater application of bronchoplastic and angioplastic techniques is leading to greater resection rates.