Randomized
trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung
Cancer Study Group
Ginsberg RJ, Rubinstein LV Ann Thorac Surg; 60(3):615-22
It has been reported that limited resection (segment or wedge) is equivalent to lobectomy
in the management of early stage (T1-2 N0) non-small cell lung cancer. METHODS. A
prospective, multiinstitutional randomized trial was instituted comparing limited
resection with lobectomy for patients with peripheral T1 N0 non-small cell lung cancer
documented at operation. Analysis included locoregional and distant recurrence rates,
5-year survival rates, perioperative morbidity and mortality, and late pulmonary function
assessment. RESULTS. There were 276 patients randomized, with 247 patients eligible for
analysis. There were no significant differences for all stratification variables, selected
prognostic factors, perioperative morbidity, mortality, or late pulmonary function. In
patients undergoing limited resection, there was an observed 75%
increase in recurrence rates attributable to an observed tripling of the local recurrence
rate an observed 30% increase in overall death rate and an observed 50% increase in
death with cancer rate compared to patients undergoing lobectomy. CONCLUSIONS.
Compared with lobectomy, limited pulmonary resection does not confer improved
perioperative morbidity, mortality, or late postoperative pulmonary function. Because of
the higher death rate and locoregional recurrence rate associated with limited resection, lobectomy
still must be considered the surgical procedure of choice for patients with peripheral
T1 N0 non-small cell lung cancer.Incidence of local recurrence and second primary tumors in resected stage
I lung cancer.
J Thorac Cardiovasc Surg; 109(1):120-9 1995 Martini N, Bains MS, Burt ME,
Zakowski MF, McCormack P, Rusch VW, Ginsberg RJ
From 1973 to 1985, 598 patients underwent resection for stage I non-small-cell lung
cancer. There were 291 T1 lesions and 307 T2 lesions. The male/female ratio was 1.9:1. The
histologic type was squamous carcinoma in 233 and nonsquamous carcinoma in 365. Lobectomy
was performed in 511 patients (85%), pneumonectomy in 25 (4%), and wedge resection or
segmentectomy in 62 (11%). A mediastinal lymph node dissection was carried out in 560
patients (94%) and no lymph node dissection in 38 (6%). Fourteen postoperative deaths
occurred (2.3%). Ninety-nine percent of the patients were observed for a minimum of 5
years or until death with an overall median follow-up of 91 months. The overall 5- and
10-year survivals (Kaplan-Meier) were 75% and 67%, respectively. Survival in patients with
T1 N0 tumors was 82% at 5 years and 74% at 10 years compared with 68% at 5 years and 60%
at 10 years for patients with T2 tumors (p < 0.0004). The overall incidence of
recurrence was 27% (local or regional 7%, systemic 20%) and was not influenced by
histologic type. Second primary cancers developed in 206 patients (34%). Of these, 70
(34%) were second primary lung cancers. Despite complete resection,
31 of 62 patients (50%) who had wedge resection or segmentectomy had recurrence. Five- and
10-year survivals after wedge resection or segmentectomy were 59% and 35%, respectively,
significantly less than survivals of those undergoing lobectomy (5 years, 77%; 10 years,
70%). The 5- and 10-year survivals in the 38 patients who had no lymph node dissection
were reduced to 59% and 32%, respectively. Apart from the favorable prognosis
observed in this group of patients, three facts emerge as significant: (1) Systematic
lymph node dissection is necessary to ensure that the disease is accurately staged; (2)
lesser resections (wedge/segment) result in high recurrence rates and reduced survival
regardless of histologic type; and (3) second primary lung cancers are prevalent in
long-term survivors.
Video-assisted thoracoscopic
wedge resection of T1 lung cancer in high-risk patients.
Ann Surg; 218(4):555-8; 1993 Shennib HA, Landreneau R, Mulder DS,
Mack M
OBJECTIVE: This study assessed the reliability and safety of VATR for treatment of
peripheral T1 lung cancer in high-risk patients. SUMMARY BACKGROUND DATA: Surgical
resection is the best therapy for stage I lung cancer. Patients with poor cardiopulmonary
status or those who are elderly (> 75 years of age) are considered to be at high risk
from thoracotomy and are frequently referred for radiation therapy or expectant palliative
management. Data from previous studies suggest that survival with wedge resection is
similar to that with lobectomy. The authors propose VATR, which is minimally invasive, as
a therapeutic option in patients considered to be at high risk for resection by
thoracotomy. METHODS: Between November 1990 and November 1992, more than 400 thoracoscopic
lung resections were performed. Thirty patients with poor pulmonary function (forced
expiratory volume FEV1] < 1 L or < 35% predicted; arterial oxygen tension [PaO2]
< 60 mmHg on room air; diffusion capacity [DCO] < 40%) underwent 31 VATRs (1 patient
had a staged procedure for bilateral synchronous lung cancers). All patients had T1
peripheral lesions with no bronchoscopically visible lesions. Computed tomography of the
chest revealed no evidence of mediastinal disease in all patients. RESULTS: Patients had a
mean FEV1 value of 0.9 L (38% predicted) and a mean age of 71 years. Tumors were located
in left upper lobe (LUL) in 13 patients, in right lower lobe (RLL) in 7 patients, in right
upper lobe (RUL) in 6 patients, in left lower lobe (LLL) in 4 patients, and in right
middle lobe (RML) in 1 patient. Computed tomography-guided wire localization, methylene
blue surface injection, and intraoperative ultrasonography were used to assist in defining
difficult lesions. All lesions were successfully resected without converting to
thoracotomy. One patient died on the 34th postoperative day of myocardial infarction
(operative mortality rate of 3%). Five patients had prolonged air leaks (< 5 days),
with a median chest tube time of 3 days. Two patients experienced pneumonia. CONCLUSION:
The authors concluded that VATR is a safe and reliable procedure for
treatment of peripheral T1 lung cancer in high-risk patients. Long-term follow-up will be
required to determine the efficacy of this procedure regarding survival and locoregional
recurrence.
Segmentectomy versus lobectomy in
patients with stage I pulmonary carcinoma. Five-year survival and patterns of
intrathoracic recurrence.
J Thorac Cardiovasc Surg; 107(4):1087-93;
1994 Warren WH, Faber LP
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 years. 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 than 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 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. |
