новая папка / Operative Standards for Cancer Surgery Volume I 1st Edition

9.Ceppa DP, Balderson S, D’Amico TA. Technique of thoracoscopic basilar segmentectomy. Semin Thorac Cardiovasc Surg 2011;23:64-66.

10.Schuchert MJ, Pettiford BL, Luketich JD, et al. Parenchymal-sparing resections: why, when, and how. Thorac Surg Clin 2008;18:93-105.

11.Lewis RJ. The role of video-assisted thoracic surgery for carcinoma of the lung: wedge resection to lobectomy by simultaneous individual stapling. Ann Thorac Surg 1993;56(3):762-768.

12.Roviaro GC, Rebuffat C, Varoli F, et al. Videoendoscopic thoracic surgery. Int Surg 1993;78:4-9.

13.Iwasaki A, Shirakusa T, Shiraishi T, et al. Results of video-assisted thoracic surgery for stage I/II non-small cell lung cancer. Eur J Cardiothorac Surg 2004;26:158-164.

14.Ohtsuka T, Nomori H, Horio H, et al. Is major pulmonary resection by video-assisted thoracic surgery an adequate procedure in clinical stage I lung cancer? Chest 2004;125:1742-1746.

15.Shiraishi T, Shirakusa T, Miyoshi T, et al. A completely thoracoscopic lobectomy/segmentectomy for primary lung cancer-technique, feasibility, and advantages. Thorac Cardiovasc Surg 2006;54:202-207.

16.Atkins BZ, Harpole DH Jr, Mangum JH, et al. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach. Annals Thorac Surg 2007;84:1107-1112; discussion 12-13.

17.Schuchert MJ, Pettiford BL, Pennathur A, et al. Anatomic segmentectomy for stage I non-smallcell lung cancer: comparison of video-assisted thoracic surgery versus open approach. J Thorac Cardiovasc Surg 2009;138:1318-1325.

18.Kilic A, Schuchert MJ, Pettiford BL, et al. Anatomic segmentectomy for stage I non-small cell lung cancer in the elderly. Ann Thorac Surg

2009;87:1662-1666; discussion 7-8.

19. Leshnower BG, Miller DL, Fernandez FG, et al. Video-assisted thoracoscopic surgery segmentectomy: a safe and effective procedure. Ann Thorac Surg 2010;89:1571-1576.

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20.Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56:1285-1289.

21.Alam N, Flores RM. Video-assisted thoracic surgery (VATS) lobectomy: the evidence base. JSLS 2007;11:368-374.

22.Demmy TL, Plante AJ, Nwogu CE, et al. Discharge independence with minimally invasive lobectomy. Am J Surg 2004;188:698-702.

23.Whitson BA, Andrade RS, Boettcher A, et al. Video-assisted thoracoscopic surgery is more favorable than thoracotomy for resection of clinical stage I non-small cell lung cancer. Ann Thorac Surg 2007;83:1965-1970.

24.Cattaneo SM, Park BJ, Wilton AS, et al. Use of video-assisted thoracic surgery for lobectomy in the elderly results in fewer complications. Ann Thorac Surg 2008;85:231-235; discussion 5-6.

25.Ceppa DP, Kosinski AS, Berry MF, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis. Ann Surg 2012;256:487-493.

26.Burt BM, Kosinski AS, Shrager JB, et al. VATS lobectomy is not associated with prohibitive morbidity or mortality in patients with predicted postoperative FEV1 (ppoFEV1) less than 40% of normal: a Society of Thoracic Surgeons Database analysis. J Thorac Cardiovasc Surg

2014;148(1):19-28.

27. Pardolesi A, Park B, Petrella F, et al. Robotic anatomic segmentectomy of the lung: technical aspects and initial results. Ann Thorac Surg

2012;94:929-934.

28.Miyasaka Y, Oh S, Takahashi N, et al. Postoperative complications and respiratory function following segmentectomy of the lung-comparison of the methods of making an inter-segmental plane. Int Cardiovasc Thorac Surg 2011;12:426-429.

29.Fernando H, Landreneau RJ, Mandrekar S, et al. Impact of brachytherapy on local recurrence after sublobar resection: results from ACOSOG Z4032 (Alliance), a phase III randomized trial for high-risk operable non-small cell lung cancer (NSCLC). JCO 2014;32(23):2456-2462.

30.Higashiyama M, Kodama K, Takami K, et al. Intraoperative lavage cytologic analysis of surgical margins in patients undergoing limited surgery for lung cancer. J Thorac Cardiovasc Surg 2003;125:101-107.

31.Sawabata N, Matsumura A, Ohota M, et al. Cytologically malignant margins of wedge resected stage I non-small cell lung cancer. Ann Thorac Surg

2002;74:1953-1957.

32. El-Sherif A, Fernando HC, Santos R, et al. Margin and local recurrence after sublobar resection of non-small cell lung cancer. Ann Surg Oncol

2007;14:2400-2405.

33. Sienel W, Stremmel C, Kirschbaum A, et al. Frequency of local recurrence following segmentectomy of stage IA non-small cell lung cancer is influenced by segment localisation and width of resection margins-implications for patient selection for segmentectomy. Eur J Cardiothorac Surg

2007;31:522-527; discussion 7-8.

34.Sawabata N, Maeda H, Matsumura A, et al; Thoracic Surgery Study Group of Osaka University. Clinical implications of the margin cytology findings and margin/tumor size ratio in patients who underwent pulmonary excision for peripheral non-small cell lung cancer. Surg Today 2012;42: 238-

35.Mohiuddin K, Haneuse S, Sofer T, et al. Relationship between margin distance and local recurrence among patients undergoing wedge resection for small (≤2 cm) non-small cell lung cancer. J Thorac Cardiovasc Surg 2014;147(4):1169-1175; discussion 1175-1177.

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Segmentectomy: Key Question

In patients with stage I non-small cell lung cancer, what factors determine if segmentectomy should be abandoned for lobectomy?

INTRODUCTION

As detailed in the preceding section, lobectomy remains the gold standard for anatomical lung resection. However, some authors have demonstrated equivalent results to lobectomy in specific subsets of patients with early-stage lung cancer. Anatomic segmentectomy may be especially helpful to the patient with limited pulmonary reserve.

METHODOLOGY

We searched PubMed for English language articles published from 2005 through 2011 that were related to various factors that may influence the decision to abandon segmentectomy in favor of lobectomy in patients undergoing surgical resection for stage I NSCLC. Search terms were “non-small cell lung carcinoma” and “segmentectomy” and “lymph node involvement” or “lymphovascular invasion” or “CEA” or “SUV” or “visceral pleural invasion.” In total, this search identified 583 potential abstracts. After excluding studies that contained insufficient patient numbers, included pathology other than NSCLC, focused on nonsurgical treatments for NSCLC, involved primarily advanced-stage NSCLC, or were descriptive technical papers, 70 abstracts were reviewed to identify articles addressing specific factors that may influence preoperative or intraoperative surgical decision making. After further excluding papers that involved additional intraoperative treatments (brachytherapy), we identified 26 publications (Table 10-2 and Fig. 10-2). These studies provided information about outcomes for anatomic segmentectomy for early-stage NSCLC; the prognostic significance of preoperative serum carcinoembryonic antigen (CEA) levels, SUVmax on positron emission tomography (PET)/computed tomography (CT), and visceral pleural invasion; and the significance of interlobar/hilar lymph node involvement on surgical resection outcomes of early-stage NSCLC.

FINDINGS

The decision to utilize anatomic segmentectomy rather than lobectomy for the definitive surgical management of stage IA NSCLC is affected by a number of preoperative diagnostic considerations and patient functional issues. Certainly, the patient’s clinical early disease must be as accurately defined as possible using preoperative imaging studies (i.e., CT and/or PET) and minimally invasive interventions (i.e., mediastinoscopy and/or endobronchial ultrasonography). In spite of these preoperative measures to accurately identify stage I disease prior to surgical exploration, clinical disease stage and

pathologic disease stage differ in 15% to 35% of patients.1,2,3

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TABLE 10-2 Studies Examining Factors that May Influence When to Abort Segmentectomy in Favor of Lobectomy for Stage IA Non-Small Cell Lung Cancer

prognosis

AJCC, American Joint Committee on Cancer; CEA, carcinoembryonic antigen; COPD, chronic obstructive pulmonary disease; CT, computed tomography; DLCO, diffusion capacity for carbon dioxide; FDG, fluorodeoxyglucose; FVC, forced vital capacity; ICU, intensive care unit; IPN, indeterminate pulmonary nodules; LN, lymph node; LOS, length of stay; MVV, maximum voluntary ventilation; NSCLC, non-small cell lung cancer; OR, operating room; PET, positron emission tomography; SCC, squamous cell carcinoma; SEER, Surveillance, Epidemiology, and End Results; SUV, standardized uptake value; TNM, tumor, node, metastasis; VATS, video-assisted thoracoscopic surgery.

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Cardiothorac Surg 2013;43(1):e7-e12.

3.Al-Sarraf N, Aziz R, Gately K, et al. Pattern and predictors of occult mediastinal lymph node involvement in non-small cell lung cancer patients with negative mediastinal uptake on positron emission tomography. Eur J Cardiothorac Surg 2008;33:104-109.

4.Schuchert MJ, Pettiford BL, Keeley S, et al. Anatomic segmentectomy in the treatment of nonsmall cell lung cancer. Ann Thorac Surg 2007;84:926-

5.Okada M, Nishio W, Sakamoto T, et al. Effect of tumor size on prognosis in patients with nonsmall cell lung cancer: the role of segmentectomy as a type of lesser resection. J Thorac Cardiovasc Surg 2005;129:87-93.

6.Tsutani Y, Miyata Y, Nakayama H, et al. Oncologic outcomes of segmentectomy compared with lobectomy for clinical stage IA lung adenocarcinoma: propensity sore-matched analysis in a multicenter study. J Thorac Cardiovasc Surg 2013;146(2):358-364.

7.Landreneau RJ, Normolle DP, Christie NA, et al. Recurrence and survival outcomes following anatomic segmentectomy vs. lobectomy for clinical stage I non-small cell cancer: a propensitymatched analysis. J Clin Oncol 2014;32(23):2449-2455.

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8.Al-Sarraf N, Gately K, Lucey J, et al. Clinical implications and prognostic significance of standardized uptake values of primary non-small cell lung cancer on positron emission tomography: analysis of 176 cases. Eur J Cardiothorac Surg 2008;34:892-897.

9.Inoue M, Minami M, Shiono H, et al. Clinicopathologic study of resected, peripheral, small sized, non-small cell lung cancer tumors of 2 cm or less in diameter: pleural invasion and increased preoperative carcinoembryonic antigen levels as predictors of nodal involvement. J Thorac Cardiovasc Surg

2006;131:988-993.

10.Stiles BM, Nasar A, Mirza F, et al. Ratio of positron emission tomography uptake to tumor size in surgically resected non-small cell lung cancer. Ann Thorac Surg 2013;95(2):397-403.

11.Li M, Wu N, Zheng R, et al. Primary tumor PET/CT [18F]FDG uptake is an independent predictive factor for regional lymph node metastasis in patients with non-small cell lung cancer. Cancer Imag 2013;12:566-572.

12.Bille A, Okiror L, Skanjeti A, et al. The prognostic significance of maximum standardized uptake value of primary tumor in surgically treated non- small-cell lung cancer patients: analysis of 413 cases. Clin Lung Cancer 2013;14(2):149-156.

13.Chen Y, Huang T, Tsai W, et al. Risk factors of postoperative recurrences in patients with clinical stage I NSCLC. World J Surg Oncol 2014;12:10.

14.Kozu Y, Maniwa T, Takahashi S, et al. Prognostic significance of postoperative serum carcinoembryonic antigen levels in patients with completely resected pathological-stage I non-small cell lung cancer. J Cardiothorac Surg 2013;8(1):106.

15.Kozu Y, Maniwa T, Takahashi S, et al. Risk factors for both recurrence and survival in patients with pathological stage I non-small-cell lung cancer.

Eur J Cardiothoracic Surg 2013;44(1): e53-e58.

16.Li L, Ren S, Zhang Y, et al. Risk factors for predicting the occult nodal metastasis in T1-2N0M0 NSCLC patients staged by PET/CT: potential value in the clinic. Lung Cancer 2013;81(2): 213-217.

17.Keenan RJ, Landreneau RJ, Maley RH Jr, et al. Segmental resection spares lung function in patients with stage I lung cancer. Ann Thorac Surg

2004;78:228-233.

18. Kilic A, Schuchert MJ, Pettiford BL, et al. Anatomic segmentectomy for stage I non-small cell lung cancer in the elderly. Ann Thorac Surg

2009;87:1662-1666.

19.Nomori H, Mori T, Ikeda K, et al. Segmentectomy for selected cT1N0M0 non-small cell lung cancer: a prospective study at a single institute. J Thorac Cardiovasc Surg 2012;144:87-93.

20.Smith CB, Kale M, Mhango G, et al. Comparative outcomes of elderly stage I lung cancer patients treated with segmentectomy via video-assisted thoracoscopic surgery versus open resection. J Thorac Oncol 2014;9:383-389.

21.Sawabata N. Locoregional recurrence after pulmonary sublobar resection of non-small cell lung cancer: can it be reduced by considering cancer cells at the surgical margin. Gen Thorac Cardiovasc Surg 2013;61:9-16.

22.Schuchert MJ, Awais O, Abbas G, et al. Influence of age and IB status after resection of nodenegative non-small cell lung cancer. Ann Thorac Surg

2012;93:929-935.

23.Schuchert MJ, Schumacher L, Kilic A, et al. Impact of angiolymphatic invasion and pleural invasion on surgical outcomes for stage I non-small cell lung cancer. Ann Thorac Surg 2011;91: 105901065.

24.Okada M, Koike T, Higashiyama M, et al. Radical sublobar resection for small-sized non-small cell lung cancer: a multi-institutional study. J Thorac Cardiovasc Surg 2006;132:769-775.

25.Tsutani Y, Miyata Y, Nakayama H, et al. Prediction of pathologic node-negative clinical stage IA lung adenocarcinoma for optimal candidates undergoing sublobar resection. J Thorac Cardiovasc Surg 2012;144:1365-1371.

26.Rena O, Boldorini R, Papalia E, et al. Metastasis to subsegmental and segmental lymph nodes in patients resected for non-small cell lung cancer: prognostic impact. Ann Thorac Surg 2014;97(3):987-992.

Intraoperative Technical Suggestions

Anatomic lobectomy is based on the individual dissection, ligation, and division of the lobar pulmonary arteries and venous branches to the lobe. The order in which these structures are divided often depends on the lobe being resected and/or the surgeon’s preferred technique.

The branch points of the pulmonary artery offer an opportunity to meticulously dissect intraand interlobar N1 nodal stations. Although published guidelines recommend that level 10 nodes be dissected, we believe that it is

good practice to identify and separately dissect other N1 stations to more accurately stage the disease.1,3 One recent study indicated that the presence of extralobar N1 disease (stations 10 and 11) predicts worse prognosis

than does the presence of intralobar N1 disease (stations 12 to 14).4 Dissecting the hilar lymph nodes (levels 10, 11, and 12), which exposes the hilar structures prior to their division, is extremely helpful during lobectomy. Following vascular division, the lobar bronchus or bronchi should be discreetly dissected, divided, and closed grossly free of tumor.

2. PATIENT SELECTION FOR BILOBECTOMY OR OTHER ADVANCED LUNG RESECTION

Recommendation: The parenchymal margin and bronchial margin should be evaluated to determine whether a bilobectomy or other advanced lung resection is required.

Rationale

The major and minor fissures of the lungs are often incomplete. In patients with incomplete lung fissures who are undergoing surgery for lung cancer, the lobes must be separated, and this is usually accomplished using a stapler-based technique. Interlobar venous anatomy may be used to distinguish the borders of the lobes. The location of

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a tumor relative to an incomplete fissure should be assessed to determine whether bilobectomy or other advanced lung resection is warranted. Bilobectomy may be considered for tumors that cross a fissure.

Although segmentectomy may be used for small tumors, >1 cm from the parenchymal margin, lobectomy should be performed for tumors ≤1 cm from the margin due to increased rates of locoregional failure.

The location of the tumor relative to the bronchial margin may also dictate the need for bilobectomy or advanced sleeve procedures. The findings of a preoperative bronchoscopic evaluation, especially for patients with more central tumors, or intraoperative frozen section analysis may indicate the need for a more advanced resection. Unless the tumor is small (i.e., T1 disease) or truly peripheral (Fig. 11-2A-D), intraoperative frozen section analysis should be used to assess the bronchial margin to determine whether a microscopically negative margin (R0 resection) has been

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obtained. If frozen section analysis reveals the bronchial margin to be positive for malignancy, the surgeon should either resect additional bronchial tissue or perform a sleeve lobectomy to achieve a microscopically negative bronchial margin.