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REV INST NAL ENF RESP MEX VOLUMEN 20 - NÚMERO 1 CONFERENCIA MAGISTRAL ENERO-MARZO 2007 PÁGINAS: 21-32

Role of sublobar resection (segmentectomy and ) in the surgical management of non-small cell cancer

BRIAN PETTIFORD* RODNEY J. LANDRENEAU*

* Heart, Lung, and Esophageal Surgery Institute University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Trabajo recibido: 13-XII-2006; aceptado: 23-I-2007

INTRODUCTION berculosis. Both of these pulmonary disease pro- cesses are commonly anatomically localized to Most thoracic surgeons regard pulmonary resec- discrete bronchopulmonary segments and the tion less than lobectomy as inadequate for the common bilateral involvement encourages the use management of lung cancers anatomically con- of parenchymal sparing resection techniques. 21 fined to a single lobe of the lung. Accordingly, The first reported use of segmentectomy for sublobar resection is considered by many sur- the management of bronchiectasis is credited to geons as a "compromise operation" that should Churchill and Belsey in 19391. Kent and Blades’ be only employed for the management of small advocacy of individual ligation of bronchial and peripheral lung cancers present in patients with vascular hilar structures coupled with Overholt significant impairment in cardiopulmonary re- and Langer’s 1947 description of the technique serve, who cannot withstand the physiologic rig- for resection of each bronchopulmonary segment ors of lobectomy. in the treatment of bronchiectasis established the High resolution computed tomography (CT) has use of anatomic segmentectomy for discrete sub- resulted in the increasingly common finding of new lobar pathology2,3. sub-centimeter malignant lesions. Surveillance CT Interestingly, total was still chest scanning efforts have led many surgeons to regarded as the only appropriate surgical option reassess the need for total lobectomy in the man- for the treatment of primary during agement of smaller peripheral non-small cell lung this period4. The dreadfully high mortality associ- cancers. Anatomic segmentectomy or extended ated with pneumonectomy (40%) at that time non-anatomic wedge resection has been consid- led to the use of lobectomy as the preferred ap- ered as an adequate surgical cure of early-stage proach to resection of peripheral lung cancers5. lung cancer. We review the clinical information The use of anatomic segmentectomy for the available today in formulating an opinion regard- management of peripheral lung cancers was ex- ing the appropriate use of sublobar resection for plored by some thoracic surgeons6-10, however, the small peripherally located NSCLC. the relative complexity of the operative approach edigraphic.comcompared to lobectomy and the increased mor- HISTORICAL PERSPECTIVE bidity related to prolonged air leak and local re- currence deterred the enthusiasm of most sur- Pulmonary segmentectomy was originally utilized geons for this approach to lung cancer11. The use for the resection of focal bronchiectasis and tu- of segmentectomy, and sublobar resection in

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general, was relegated as a "compromise proce- of sublobar resection in the primary management dure" for the management of patients with sig- of non-small cell lung cancer. We must first clar- nificant impairment in cardiopulmonary reserve ify that we believe sublobar resection is inappro- having peripheral lung lesions confined within priate for the management of most clinical non- segmental anatomic boundaries10-15. small cell lung cancer beyond that of stage I An increasing body of evidence is emerging disease. For the most part, we favor the use of suggesting that sublobar resection with accurate segmentectomy without adjuvant local therapy nodal staging may be an adequate resection for for small stage IA disease without endobronchi- the small peripheral non-small cell lung cancer. al extension within anatomic segmental bound- Surgical marginal status following sublobar resec- aries that are less than 2 centimeters in diame- tion continues to be an important concern, and ter (Figure 1a-b). A surgical margin of at least 2 measures to enhance the marginal clearance con- centimeters should be readily achieved with le- tinue to be explored16-32. sions of this size. Larger lesions will necessarily be associated with anatomic margins of resection CONTROVERSIES REGARDING THE USE that are more likely to recur locally unless adju- OF SUBLOBAR RESECTION vant therapeutic measures to be discussed are considered (Figure 2a-b and Figure 3). The use of anatomic segmentectomy is general- ly accepted for the management of benign dis- Patient survival with sublobar resection ease processes and metastatic carcinoma to the lung confined to an anatomic segment. The use The argument of use of sublobar resection for of sublobar resection and segmentectomy in par- stage I non-small cell lung cancer attracted inter- ticular has been accepted as a reasonable ap- national attention with the initiation of the ran- 22 proach for resection of patients with significant domized trial of sublobar resection versus lobec- impairment in cardiopulmonary reserve. The pri- tomy for good risk patients with stage IA disease mary controversy over the years among thoracic conducted by the now defunct North American surgeons has been with the use of segmentec- "Lung Cancer Study Group" during the late 1980’s tomySUSTRAÍDODE-M.E.D.I.G.R.A.P.H.I.C as primary management of peripheral pri- and early 1990’s11. This study was inspired by the mary non-small cell lung cancer for patients who survival results seen among women undergoing are:ROP physiologically ODAROBALE fit toFDP undergo lobectomy. less than total mastectomy for small primary We will review representative pertinent clini- breast cancers and Erret’s 1986 reporting of calVC investigations ED AS, CIDEMIHPARG addressing the appropriateness equivalent survival results among stage I Non-

ARAP

ACIDÉMOIB ARUTARETIL :CIHPARGIDEM

edigraphic.com A B

Figure 1. Computed tomographic roentgenographic images of small peripheral T1 lesions ideal for sublo- bar resection.

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AB

Figure 2. Computed tomographic roentgenographic images of lesion for which adjuvant brachytherapy should be used if sublobar resection is being considered. (T2 lesion confined to anatomic boundaries of the pulmonary segment).

an aside observation, they also stated that they found no difference in the loss of pulmonary func- tionality between lobectomy and sublobar re- section patients when assessed one year follow- ing surgery. This important conclusion regarding postoperative functionality certainly caught the at- 23 tention of many thoracic surgeons already con- vinced that lobectomy was the superior operation for even small stage I non-small cell lung can- cers. Interestingly, this conclusion regarding post- operative physiologic equivalency between resec- tion approaches was made despite the fact that over one third of the patients in the study were not available for pulmonary function testing at the one year postoperative mark. Subsequent analy- ses of the late effects of relative pulmonary func- Figure 3. Lesion for which lobectomy is required tional preservation with segmentectomy compared due to central lobar location limiting marginal clear- to lobectomy have countered the conclusions of ance of the tumor. this study18,19. Furthermore, the survival and local recurrence differences were based on a one-tailed analysis designed to demonstrate a statistically sig- small cell lung cancer patients with impaired cardio- nificant difference at a higher p-value threshold. pulmonary reserve undergoing sublobar resection Lastly, one-third of the sublobar resection pa- compared to physiologically fit stage I patients tients underwent wedge resection, which is not undergoing lobectomy33,34. an anatomical resection and has well-document- The results of the Lung Cancer Study Group’s ed local recurrence rates. Regardless of these find- efforts were reported in 1995. Primary findingsedigraphic.com of ings, many thoracic surgeons continue to regard this study were that survival between sublobar lobectomy as the gold standard treatment for ear- resection and lobectomy were not significantly ly-stage non-small cell lung cancer. different but local recurrence was three times In Japan, large computed tomographic (CT) greater when sublobar resection was utilized. As radiologic screening programs in place for well

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over a decade have exposed an increased num- ered as primary therapy for tumors 20 mm or less ber of small, peripheral, early stage lung can- in size. cers.35 Programs utilizing "fast" CT scanners El-sherif et al, evaluated a 13-year experience screening high-risk populations (older patients in the management of resectable stage I non- with significant smoking history and impairment in small cell lung cancer at their institution25. The re- pulmonary function) are underway now in North currence patterns and survival of 784 patients (577 America and Europe36. Renewed interests in sub- lobectomies, 207 sublobar resections that were lobar resection and emerging enthusiasm with primarily wedges) who underwent resection of non-surgical percutaneous management of small stage I NSCLC were evaluated. No significant dif- peripheral lung cancers identified through these ferences were observed in disease-free survival efforts are now seen18-25,29-32,37-40. between sublobar resection and lobectomy for Interestingly, analyses that have compared patients with stage IA disease, however a slightly sublobar resection with lobectomy identify patient worse disease-free survival was seen for stage IB age and the size of the tumor resected as the patients undergoing sublobar resection compared primary determinants of survival. Mery et al, ex- to lobectomy (58% vs 50% 5 year disease-free amined the effect of age and type of surgery on survival). Sublobar resection was also associated survival in patients with early-stage non-small cell with a lower overall 5-year survival compared to lung cancer.20 Their analysis of the Surveillance, lobectomy (40% vs 54%). The authors suggested Epidemiology, and End Results Database catego- that this reduced overall survival following sublo- rized the survival following resection of stage I bar resection might have been related to the gen- non-small cell lung cancer in three age groups: erally poorer functional status and co-morbidities <65 years, 65-74 years, and >75 years. A sta- of the patients chosen for this resection rather than tistically greater number of elderly patients under- lobectomy at their institution. 24 went limited resections, which included wedge resection. Two years following surgery, better Local recurrence concerns following sublo- survival was shown in young patients undergoing bar resection lobectomy as opposed to sublobar resection. No suchSUSTRAÍDODE-M.E.D.I.G.R.A.P.H.I.C survival time difference was demonstrated Although disease free survival remains the most in the elderly population. Furthermore, the statis- critical parameter in the assessment of any treat- tically:ROP significantODAROBALE long-term FDP survival advantage fa- ment related modality for lung cancer, local re- voring lobectomy for younger patients was lost currence is following primary therapy is also an comparedVC ED AS, to CIDEMIHPARG sublobar resection among patients important concern. Local recurrence can result in greater than 70 years of age. significant morbidity such as invasion into the ARAPOkada et al, conducted a retrospective anal- chest wall or vital mediastinal structures, malig- ysis of 1,272 consecutive patients who under- nant pleural effusion, and problems related to air- wentACIDÉMOIB complete ARUTARETIL resection with :CIHPARGIDEM complete lymph way obstruction and hemoptysis. node staging of non-small cell lung cancer strat- It is generally established that the risk of local ifying individuals in 4 groups according to tumor recurrence is increased with the use of sublobar size: 10 mm or less, 11-20 mm, 21-30 mm and resection for the management of stage I non- >30 mm21. The cancer-specific 5-year survivals small cell lung cancer. Primary factors related to were 100%, 83.5%, 76.5%, and 57.9%, re- local recurrence are the surgical marginal distance spectively for the 4 groups. Furthermore, no dif- of resection and the related presence of micro- ference in cancer-specific survival was seen be- scopic extension of disease or "in transit" local tween patients undergoing lobectomy compared metastases. Recent investigations have noted that to segmentectomy for cancers smalleredigraphic.com than the molecular immunohistochemical assessment 30 mm in diameter. The authors identified tumor of the tissue margin may assist in predicting the size as an independent prognostic factor and sug- risk for local recurrence following sublobar resec- gested that segmentectomy with systematic nod- tion17. Such pathologic assessment of surgical al staging to avoid "stage shift" bias, be consid- margins may aid in decision-making regarding

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www.iner.gob.mx Role of sublobar resection in the surgical management of non-small cell lung cancer local adjuvant treatment measures or re-resection beam radiotherapy after thoracotomy26. d’Amato to obtain clearance of disease. The present rec- and colleagues initially reported the use of intra- ommendations for sublobar resection are to es- operative 125I brachytherapy as a local measure tablish a margin at least that of the diameter of following sublobar resection of peripheral stage the pulmonary lesion resected16. I lung cancers when pathologically clear surgi- Adjuvant radiotherapy has been considered as cal margins had been obtained27. These inves- a possible option used in conjunction with sub- tigators described the fabrication of a radiation lobar resection to possibly reduce local recur- implant based upon a polyglycolate hernia mesh rence. Miller and Hatcher reported a significant template in which polyglycolate suture having decrease in local recurrence in follow-up of a 125I pellets incorporated at one centimeter inter- small group of sublobar resection patients under- vals along the length of the suture are woven going postoperative focal external beam "postage into the mesh to create a treatment grid with stamp" radiation compared to an earlier group of pellets at 1 cm2 intervals (Figure 4a-b). This patients they managed with sublobar resection mesh template was then introduced into the alone12. Unfortunately, radiation treatment plan- chest and sutured onto the lung parenchymal ning problems created by the unpredictable three surface at the suture line of resection to provide dimensional course of staple lines, the risk of local at least two centimeters of lateral margin cov- radiation injury to the treated remaining lobar erage from the staple line. Usually 40 to 60 125I segments of the lung, and the transportation dif- pellets within 4 to 5 lines of suture material ficulties associated with a several week course of were used with each brachytherapy implant. radiation therapy following thoracic surgery led to The total delivered radiation dose to the local little enthusiasm with adjuvant external beam ra- tissues was calculated to be 10,000cGY at a 1 cm diation therapy. depth. In essence, this very high intensity local Others have utilized intraoperative brachy- therapy effectively extended the margin of re- 25 therapy as an adjunctive local control measure section by another centimeter. Santos et al, sub- following lung resection associated with close or sequently reported a longitudinal follow-up of positive margins of resection. This use of adju- the use of intraoperative 125I brachytherapy from the vant intraoperative brachytherapy was primarily same institution identifying that local recurrence used in the setting of locally advanced lung can- following sublobar resection appeared to be sig- cer where margins could not be reliably steril- nificantly reduced compared to historical control ized, and in an effort to provide immediate po- sublobar resection cases28. On this further anal- tential salvage therapy without the intrinsic ysis, no local important radiation fibrosis, implant delays associated with initiation of external migration, nor unexpected decline in postoper-

Figure 4. Fabrica- tion of brachythe- rapy implant: A) brachytherapy im- plant template B) edigraphic.com radiation oncolo- gist fabricating ra- dioactive iodine ABbrachytherapy im- plant.

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ative pulmonary function was noticed among complications occurred in patients undergoing an patients receiving intraoperative 125I brachytherapy. open procedure. Overall survival was 76.9% with Other retrospective reports of the use of intra- a local recurrence rate of 16%. Of note, 83% of operative 125I brachytherapy utilized with sublobar the recurrences were observed when the surgi- resection have been encouraging and have cal margin was less than 2 cm. A margin: tumor helped to further define the use of this adjuvant ratio <1 was associated with a higher recurrence therapy approach aimed at reducing local recur- rate. The authors concluded that segmentectomy rence. Fernando and associates reported a retro- is feasible by an open or VATS method with spective multi-center analysis of 291 patients, mobidity, mortality, recurrence and survival rates which compared outcomes after lobectomy similar to lobectomy. The latter is recommended, (n=167) with those following sublobar resec- however when margins >1.5 cm cannot be tion (n=124). Nearly one-half of the sublobar re- achieved. section group (n=60) received adjuvant 125I brachytherapy. The local recurrence rate in the Future investigative efforts regarding the sublobar resection group was decreased from utility of sublobar resection 17.2% to 3.3% with the use of adjuvant 125I brachytherapy29. Finally Birdas et al, retrospective- Much of the information provided here has been ly compared the outcomes of sublobar resection the product of retrospective reviews of collected with brachytherapy to lobectomy for patients with clinical experiences with sublobar resection. Ran- pathologic stage IB non-small cell lung cancer. A domized studies in progress or in conception will total of 167 stage IB patients (126 patients under- do much to define the role of sublobar resection going lobectomy, 41 patients undergoing sublobar and the use of adjuvant local control measures resection) were evaluated for local recurrence, following these resections. Presently, the Amer- 26 disease-free survival and overall survival. Local ican College of Surgeons Oncology Group recurrence seen in the sublobar resection with (ACOSOG) is conducting a randomized trial 125I brachytherapy group (4.8%) was similar to the (Z04042) of sublobar resection (by anatomic seg- lobectomy group (3.2%). There was no statisti- mentectomy or extended wedge resection) alone callySUSTRAÍDODE-M.E.D.I.G.R.A.P.H.I.C significant difference in disease-free survival to similar sublobar resection with intraoperative and overall survival between the two groups30. 125I brachytherapy for stage IA non-small cell lung These:ROP ODAROBALEinvestigators concluded FDP that sublobar re- cancers. Over 200 patients are to be accrued for section with intraoperative 125I brachytherapy pro- study. Cancer and Leukemia Group B (CALGB) is videdVC ED equivalent AS, CIDEMIHPARG local control, disease-free and in the final phase of preparation of a random- overall survival outcomes similar to lobectomy for ized investigation of surgical resection of small IBARAP non-small lung cancer patients. In accordance (less than 2 centimeter in diameter) Stage IA with other investigators’ concern for close surgical non-small cell lung cancers by either lobectomy marginsACIDÉMOIB leading ARUTARETIL to increased risk :CIHPARGIDEM for local recur- or sublobar resection by segmentectomy or rence16, they emphasized the potential utility of wedge resection. Over 800 patients will be en- intraoperative 125I brachytherapy in theoretically rolled in this later study. The results of these "extending" the margin of resection when larger studies should aid in establishing the role of sub- (T2) tumors are chosen for sublobar resection. lobar resection in the future management of We recently presented outcomes of a retro- stage I non-small cell lung cancer. spective analysis of 147 segmental resections performed over nearly a four-year period. All pa- PREOPERATIVE EVALUATION PRIOR TO tients had either Stage IA (n=86) or IB (n=61) SUBLOBAR RESECTION NSCLC with a mean age of 70 years. Twenty-edigraphic.com eight percent of the patients underwent VATS Patients being considered for non-anatomic ex- segmentectomy (n=41). Although complication tended wedge resection or anatomic segmentec- rates were similar between the open (n=106) tomy for the primary management of stage I and VATS groups, a higher number of major non-small cell lung cancers have usually been

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www.iner.gob.mx Role of sublobar resection in the surgical management of non-small cell lung cancer those with potentially important impairment in pacity assessment. Split-lung ventilation/perfusion cardiopulmonary reserve. As mentioned, this may nuclear scintigraphic assessment and maximum include borderline or marginal pulmonary func- oxygen consumption exercise testing may be se- tional physiology that prohibits formal lobectomy. lectively considered prior to surgery based upon Predicted postoperative pulmonary function based general functional concerns. Cardiac function- upon the volume of functional pulmonary paren- al assessment using standard or pharmacological chyma to be resected may dictate the resection stress testing and 2-D echocardiography with es- options for the patient with underlying pulmonary timates of pulmonary arterial pressures should be impairment. considered. Most patients will present to the thoracic sur- Once the patient has been deemed a can- geon with an abnormal chest CT scan. This CT didate for anesthesia and sublobar resection, scan should include imaging of the liver and ad- Radiation Oncology consultation is obtained if renal glands. Special attention should be focused adjuvant intraoperative 125I brachytherapy is be- on the and the size and segmental ing considered as part of the treatment plan. In location of the pulmonary parenchymal lesion in general, a tissue diagnosis of high PET avidity is question. is performed if indicat- required before radiation oncology evaluation. ed based on enlarged mediastinal lymph nodes (greater than 1 centimeter in diameter) or Fluo- OPERATIVE CONSIDERATIONS FOR ro-Deoxy-Glucose avidity on Positron Emission SUBLOBAR RESECTION Tomographic scanning. The thoracic surgeon must also carefully evalu- Anesthetic airway control and ate the anatomic characteristics of lesion being incision considered for sublobar resection, as manifested through preoperative CT scan imaging and pre- At the time of operation, laterality is marked. Af- 27 operative bronchoscopic evaluation. It is gener- ter intubation with a single-lumen endotracheal ally appreciated that lesions chosen for sublobar tube, a flexible is performed in the resection by extended wedge resection done ei- standard fashion to insure the absence of endo- ther by open thoracotomy or VATS approaches bronchial extension of the malignant process pre- should be located within the outer third of the cluding the use of sublobar resection. A double- lung parenchyma, measure less than 3 cm in di- lumen tube is then inserted and the patient ameter, and have no evidence of endobronchial positioned laterally. It is important that the tho- involvement. These concepts should be honored racic surgeon confirm proper positioning of the to prevent deep application of stapling devices endotracheal tube after initial placement and af- during the course of a non-anatomic wedge re- ter patient lateral positioning to insure the ade- section. This approach will minimize the possibil- quacy of selective contralateral lung ventilation ity of inadequate resection margins, staple line and ipsilateral pulmonary atelectasis for the pro- dehiscence and associated air leak/bleeding prob- cedure. These actions can reduce the occurrence lems related to the distortion of the remaining of time consuming intraoperative problems asso- lung parenchyma. ciated with inadequate selective airway control A complete physiologic evaluation of the with double lumen intubation. patient being chosen for sublobar resection is im- Whenever possible, we prefer the use of the portant. One must remember that the individ- VATS approach for the performance of sublobar ual usually chosen for sublobar resection, as defin- resection. When the appropriate lesion is selected itive management of a peripheral malignant lesion for this approach we find the VATS approach to is usually one whose cardiopulmonaryedigraphic.com func- be advantageous with regard to reduction in op- tionality is in question. Thorough pulmonary erative time, perioperative blood loss, hospital functional evaluation is indicated. This must in- stay and postoperative morbidity. This technique clude formal pulmonary , arterial blood is also equivalent in utility compared to open tho- gas analysis, and carbon monoxide diffusion ca- racotomy approaches41-45.

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Lesion identification and VATS sublobar resection approach

Some important strategies for lesion localization and intercostal access for VATS instrumentation should be discussed when diagnostic sublobar resection of suspicious indeterminant nodules (prior to anatomic resection) or sublobar resection as definitive management of peripheral non-small cell lung cancers is being considered. The intercostals access orientation of the tho- racoscope and instrumentation established should facilitate exploration of the entire cavity and iden- tification of "target" lung pathology as deter- mined through careful preoperative review of the chest radiograph and computed tomographic (CT) images. Generally, the initial intercostal access is achieved for the thoracoscope at the seventh in- tercostal space along the anterior superior iliac spine. Endosurgical instrumentation and the sta- pling device are introduced through a 1 cm in- tercostal access at the fifth or sixth interspace Figure 5. Port placement in the seventh intercostal along the posterior axillary line, and a 1 cm ver- space provides exposure of the confluence of the 28 tical incision in the third interspace along the mi- oblique and horizontal fissures. daxillary line. These intercostal access locations provide panoramic video imaging and permit tri- angulation of most lesions being considered for of the known small peripheral lung cancer cho- VATSSUSTRAÍDODE-M.E.D.I.G.R.A.P.H.I.C wedge resection (Figure 5). Furthermore, sen for primary VATS sublobar resection. Certain- the vertical mid-axillary incision can be extended ly all efforts should be centered in obtaining a if:ROP conversion ODAROBALE to thoracotomy FDP is indicated. The clear surgical margin of resection. This does re- position of the thoracoscope and endoscopic quire a conscientious effort on the part of the grasper/endostaplerVC ED AS, CIDEMIHPARG may be alternated as needed surgeon through each step of the endosurgical to facilitate exposure to important visual angles stapled extended wedge resection. Once the le- andARAP application of the surgical stapler to facilitate sion is identified, it is important to assess and es- wedge resection. timate the thickness of the parenchymal margin ACIDÉMOIBCareful examination ARUTARETIL of the surface :CIHPARGIDEM of the lung of resection. For small subpleural lesions, a sim- in the region of the suspected lesion identified by ple wedge resection can be accomplished with preoperative CT scanning of the chest will often adequate surgical margins. The visceral lung sur- reveal local visceral pleural scarring or retraction face is grasped with forceps and an initial firing in the case of malignancy. Once full atelectasis of the endostapler is applied beneath the elevat- of the lung in the region of the lesion is ob- ed, atelectatic lung tissue deep to the subpleural tained, localization can usually be achieved lesion. The staple line is inspected for parenchymal through effacement of the nodule against the closure and then the endostapler is introduced surrounding collapsed lung. Gentle palpation of the through an alternate intercostal access site to com- lung in the area in question with a spongeedigraphic.com forceps plete a standard "V" wedge resection with ade- or endoscopic grasper can also identify the lesion quate margins. After completion of the resection, the when videoscopic inspection is less rewarding. lung is inspected for adequate pneumostasis. Issues related to the resection of the indeter- For deeper lesions, the surgeon must deter- minant pulmonary nodule necessarily apply to that mine if the required depth and thickness of the

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www.iner.gob.mx Role of sublobar resection in the surgical management of non-small cell lung cancer resection will preclude a safe and effective is removed when drainage is minimal and the air wedge resection of the lesion. This can be as- leak has resolved. This is customarily accom- sessed by grasping the lung parenchymal surface plished on the 2nd or 3rd postoperative day. near the lung lesion and then applying an endo- scopic grasping forceps (Masher Forceps, Starr Mini-thoracotomy approach to sublobar Medical, NY) across the line of possible parenchy- resection mal resection. If the tissue can be "thinned" be- neath the lesion without compromising resection We do prefer to use a vertical axillary muscle spar- margins as determined by this tissue thickness ing mini-thoracotomy incision when the VATS approximating technique, the 45 mm or 60 mm approach is not chosen for most sublobar pulmo- length endostapler with thick tissue staplers (3.5 nary resections47. When performing upper lobe to 4.8 mm staple height) is used to transect the and middle lobe sublobar resections, the incision parenchymal tissue for the wedge resection. The is placed at the lower border of the axillary hair- relationship of the pulmonary lesion to the line of line in the mid-axillary plane and extended dis- resection is assessed again before each subse- tally for 8 cm. The pectoralis minor muscle is re- quent stapler application with the aid of the flected anteriorly. The muscle fibers of the serratus "Masher" forceps estimation of the lung paren- anterior muscle overlying the third rib are split. chymal thickness. The resection is continued with The lateral aspect of the third rib is resected sub- successive applications of the endostapler along periosteally and a 2 cm portion of the 4th rib is the waist of pulmonary parenchyma deemed ad- also resected to further enhance mini-thoracot- equate for a clear resection margin. omy exposure. Two pediatric rib spreaders are Several techniques have been described for inserted and positioned at right angles to each localization of pulmonary nodules that are not other for exposure. easily identified at the time of VATS sublobar re- For lower lobe sublobar mini-thoracotomy re- 29 section. Beyond the careful preoperative assess- sections, the skin incision is begun approximately ment of the CT images of the chest to determine 3 cm inferior to the axillary hairline along the pos- the segmental location of the lesion, preoperative terior axillary line, near the anterior border of the injection of methylene blue and or a needle lo- latissimus dorsi muscle and a similar 8 cm inci- calization techniques to identify the "soft" small, sional length utilized for thoracotomy. The latis- subpleural nodule have been described. Intraop- simus dorsi is reflected posteriorly and the serratus erative ultrasonography has also been utilized anterior is detached along a segment of its infe- with variable success46. rior muscular origin. The 4th rib is resected sub- At completion of the sublobar resection, the periosteally, and a 2 cm portion of the 5th rib is pulmonary specimen is removed from the chest removed. We have found that these vertical ap- in a specimen retrieval bag, commercially available proaches allow for adequate exposure through a through a number of endosurgical companies, to "mini-thoracotomy" incision with minimal chest avoid chest wall contamination by a potentially wall trauma48. The vertical incisional approach also malignant lesion within the specimen. Alterna- increases versatility in accessing a number of seg- tively, a sterile operating room latex glove can be ments of the lung, and it is relatively cosmetically introduced into the chest through an intercostal appealing compared to lateral thoracotomy. access site to be used as a retrieval bag. Follow- In a small number of patients who may have ing removal of the specimen, the lung is partial- had prior external beam irradiation or chemo- ly expanded, and the resection staple line mar- therapy and are diagnosed with a second pri- gin is reexamined for hemostasis and air-leak mary lung cancer, we prefer an anterior thora- control. A single is inserted throughedigraphic.comcotomy, particularly for sublobar resections in one of the lower intercostal access sites and po- the upper lobes. A transverse incision is made sitioned under thoracoscopic guidance toward a over the bed of the ipsilateral third rib, a seg- posterior apical position. The other intercostal ment of which is resected subperiosteally. We access sites are closed primarily. The chest tube have found that this method provides better

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access to the hilar structrures than does a more the VATS approach when this adjuvant measure lateral approach. is felt to an important compliment for local con- A final concern regarding the performance of trol of the lung cancer28. sublobar resection relates to the handling of pa- renchymal staple lines of resection when dividing CONCLUSION severely emphysematous or indurated pulmonary tissues. The most important consideration is care- Segmentectomy demands a thorough knowledge of ful handling of the pulmonary parenchymal tissue the three-dimensional bronchovascular anatomy and gentle manipulation of the open or endosta- of the lung. This anatomic detail makes segment- pling devices across the pulmonary parenchyma. ectomy significantly more challenging than lobec- Staple line bolstering material and or topical seal- tomy. Several principles must be applied when per- ants may be helpful in obtaining pneumostasis forming segmental lung resection: 1. the surgeon when the pulmonary parenchyma is emphysema- should avoid dissection in a poorly developed fis- tous or indurated49,50. sure, 2. use the transected as the base of the segmental resection during the division of the Intraoperative brachytherapy lung parenchymal in the intersegmental plane, 3. consider the use of endostapler division of the pul- To reduce the likelihood of local recurrence, we monary parenchyma in order to reduce the air leak commonly employ adjuvant 125I brachytherapy in complications related to "finger fracture" dissection patients we have performed anatomic segmentec- of the intersegmental plane, 4. consider the use of tomy or extended wedge resections as defini- adjuvant 125I brachytherapy as a means of reducing tive management of non-small cell lung cancer. local recurrence following sublobar resection. We conform to the technical details for creation of Increasing evidence supports the use of anatom- 30 the brachytherapy implant and insertion described ic segmentectomy in the treatment of primary lung by d’Amato et al, detailed earlier in this chapter28. cancer for appropriately selected patients. This re- An alternative approach described by Lee et al, in- section approach appears most appropriate in the volves direct suturing of the polyglycolic acid su- management of the small (less than 2 cm in diam- tureSUSTRAÍDODE-M.E.D.I.G.R.A.P.H.I.C with the incorporated 125I pellets within it’s eter) peripheral stage I non-small cell lung cancer length directly to the lung surface without the uti- in which a generous margin of resection can be lization:ROP ODAROBALE of the polyglycolic FDP acid hernia mesh tem- obtained. Accurate intraoperative nodal staging is plate50. The relative merits of these approaches important to estimate the relative utility of these willVC ED be AS, one CIDEMIHPARG of the points of analysis in the ACOSOG Z04032 study mentioned earlier. ARAP Thoracoscopic approach to formal segment- ectomyACIDÉMOIB ARUTARETIL :CIHPARGIDEM

The Video-Assisted Thoracoscopic Surgical (VATS) approach for segmental resections is similar to that for VATS lobectomy. Port placement is sim- ilar to that used during VATS wedge resection. In cases of formal anatomic segmentectomy or lobectomy, an additional 2.5 to 3 cm incision is made in the fourth or fifth interspace on the an- terior axillary line (Figure 6). The performanceedigraphic.com of VATS segmentectomy adds a new dimension to the hilar dissection that is not appreciated with Figure 6. Skin incisions for thoracoscopic segmen- VATS lobectomy. The application of a brachy- tectomy and lobectomy. Note the location of the therapy implant is also easily accomplished with larger "utility" incision.

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www.iner.gob.mx Role of sublobar resection in the surgical management of non-small cell lung cancer approaches compared to more aggressive resection Five-year survival and patterns of intrathoracic recur- and to determine the need for adjuvant systemic rence. J Thorac Cardiovasc Surg 1993;107:1087-1094. 11.Ginsberg RJ, Rubinstein LV. Randomized trial of therapy if metastatic lymphadenopathy is identified. lobectomy vs limited resection for T1 NO non-small Future investigations comparing the results of sub- cell lung cancer. Lung Cancer Study Group. Ann Tho- lobar resection compared to lobectomy will more racic Surg 1995;60:615-623. clearly define the role of segmentectomy among 12.Miller JI, Hatcher CR Jr. Limited resection of bronchogenic carcinoma in the patient with good risk patients with clinically stage I non-small marked impairment of pulmonary function. Ann cell lung cancer. At the present time, it appears that Thorac Surg 1987; 44:340-343. sublobar resection is an appropriate therapy for the 13.Landreneau RJ, Sugarbaker DJ, Mack MJ, et al. management of stage I non-small cell lung cancer Wedge resection versus lobectomy for stage I (T1 NO MO) non-small cell lung cancer. J Thorac Cardiovasc identified in the elderly patient, those individuals Surg 1997;113:691-698. with significant cardiopulmonary dysfunction, and 14.Shennib HA, Landreneau RJ, Mulder DS, Mack MJ. for the management of peripheral, low volume, Video-assisted thoracoscopic wedge resection of T1 metastatic disease to the lung. As the primary lung cancer in high-risk patients. Ann Surg 1993; 218:555-558. disadvantage of sublobar resection is that of lo- 15.Lewis RJ. The role of video-assisted thoracic surgery cal recurrence, intraoperative adjuvant 125I brachy- for carcinoma of the lung: wedge resection to lobec- therapy may be considered to minimize this local tomy by simultaneous individual stapling. Ann Thorac recurrence risk. Surg 1993;56:762-768. 16.Sawabata N, Ohta M, Matsumura A, et al; Thoracic Surgery Study Group of Osaka University. Optimal distance of malignant negative margin in excision of REFERENCES non-small cell lung cancer: a multicenter prospective study. Ann Thorac Surg 2004;77:415-420. 1. Churchill ED, Belsey R. Segmental pneumonectomy 17.Masasyesva BG, Tong BC, Brock MV, et al. Mole- in bronchiectasis: the lingula segment of the left up- cular margin analysis predicts local recurrence after sub- 31 per lobe. Ann Surg 1939;109:481-499. lobar resection of lung cancer. Int J Cancer 2005; 2. Kent EM, Blades B. The anatomic approach to pulmo- 113:1022-1025. nary resection. Ann Surg 1942;116:782-794. 18.Keenan RJ, Landreneau RJ, Maley RH Jr, et al. Seg- 3. Overholt RH, Langer L. A new technique for pul- mental resection spares pulmonary function in pa- monary segmental resection, its application in the tients with stage I lung cancer. Ann Thorac Surg treatment of bronchiectasis. Surg Gynecol Obstet 2004;78:228-233. 1947;84: 257. 19.Harada H, Okada M, Sakamoto T, Matsuoka H, 4. Oschner A, DeBakey M. Primary pulmonary malignan- Tsubota N. Functional advantage after radical segmen- cy. Treatment by total pneumonectomy. Analysis of tectomy versus lobectomy for lung cancer. Ann Thorac 79 collected cases and presentation of 7 personal ca- Surg 2005;80:2041-2045. ses. Surg Gynecol Obstet 1939;68:435-441. 20.Mery CM, Pappas AN, Bueno R, et al. Similar long- 5. Churchill ED, Sweet RH, Soutter L, Scannell JG. The term survival of elderly patients with non-small cell lung surgical management of carcinoma of the lung; a cancer treated with lobectomy or wedge resection study of cases treated at the Massachusetts General within the surveillance, epidemiology, and end results Hospital from 1930 to 1950. J Thorac Surg 1950; database. Chest 2005;128:237-245. 20:349-365. 21.Okada M, Nishio W, Sakamoto T, et al. Effect of tu- 6. Churchill ED, Sweet RH, Scannell JG, Wilkins EW Jr. mor size on prognosis in patients with non-small cell lung Further studies in the surgical management of carcino- cancer: the role of segmentectomy as a type of lesser ma of the lung; a further study of the cases treated resection. J Thorac Cardiovasc Surg 2005;129:87-93. at the Massachusetts General Hospital from 1950 to 22.Yoshikawa K, Tsubota N, Kodoma K, Ayabe H, Taki 1957. J Thorac Surg 1958;36:301-308. T, Mori T. Prospective study of extended segment- 7. Bonfils-Roberts EA, Clagett OT. Contemporary indi- ectomy for small lung tumors: the final report. Ann cation for pulmonary segmental resections. J Thoracic Thorac Surg 2002;73:1055-1058. Cardiovasc Surg 1972;63:433-438. 23.Koike T, Yamato Y, Yoshiya K, Shimoyama T, Su- 8. Jensik RJ, Faber LP, Milloy FJ, Monson DO. Segmental zuki R. Intentional limited pulmonary resection for resection for lung cancer. A fifteen-year experience. peripheral T1 NO MO small-sized lung cancer. J J Thorac Cardiovasc Surg 1973;66:563-572.edigraphic.comThorac Cardiovasc Surg 2003;125:924-928. 9. Read RC, Yoder G, Schaeffer RC. Survival after con- 24.Okada M, Yoshikawa K, Hatta T, Tsubota N. Is servative resection for T1 NO MO non-small cell lung segmentectomy with lymph node assessment an al- cancer. Ann Thorac Surg 1990; 49:391-398. ternative to lobectomy for non-small cell lung can- 10.Warren WH, Faber LP. Segmentectomy versus lobec- cer of 2 cm or smaller? Ann Thorac Surg 2001;71: tomy in patients with stage I pulmonary carcinoma. 956-960.

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www.iner.gob.mx Brian Pettiford, et al.

25.El-Sherif A, Gooding WE, Santos R, et al. Outcomes body radiotherapy in 4 fractions for primary lung can- of sublobar resection versus lobectomy for stage I cer using a stereotactic body frame. Int J Radiat On- non-small cell lung cancer: a 13-year analysis. Ann Tho- col Biol Phys 2005;63:1427-1431. rac Surg 2006;82:408-415. 41.Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Video- 26.Nori D, Li X, Pugkhem T. Intraoperative brachytherapy assisted thoracic surgery: basic technical concepts and using Gelfoam radioactive plaque implants for resected intercostal approach strategies. Ann Thorac Surg stage III non-small cell lung cancer with positive margin: 1992;54:800-807. a pilot study. J Surg Oncol 1995;60:257-261. 42.Landreneau RJ, Mack MJ, Keenan RJ, Hazelrigg SR, 27.d’Amato TA, Galloway M, Szydlowski G, Chen A, Dowling RD, Ferson PF. Strategic planning for video- Landreneau RJ. Intraoperative brachytherapy follow- assisted thoracic surgery. Ann Thorac Surg 1993; ing thoracoscopic wedge resection of stage I lung 56:615-619. cancer. Chest 1998;114:1112-1115. 43.Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Post- 28.Santos R, Colonias A, Parda D, et al. Comparison operative pain-related morbidity: video-assisted thoracic between sublobar resection and 125Iodine brachy- surgery versus thoracotomy. Ann Thorac Surg therapy after sublobar resection in high-risk patients 1993;56:1285-1289. with stage I non-small-cell lung cancer. Surgery 44.Landreneau RJ, Mack MJ, Hazelrigg SR, Naunheim 2003;134:691-697. KS, Keenan RJ, Ferson PF. Video-assisted thoracic 29.Fernando HC, Santos RS, Benfield JR, et al. Lobar surgery: a minimally invasive approach to thoracic and sublobar resection with and without brachyther- oncology. In: DeVita V, Hellman S, Rosenberg S, editors. apy for small stage IA non-small cell lung cancer. J Tho- Cancer: principles and practice of oncology - "Update rac Cardiovasc Surg 2005;129:261-267. series". Philadelphia: Lippincott Raven; 1994;8:1-14. 30.Birdas TJ, Koehler RP, Colonias A, et al. Sublobar 45.Mack MJ, Shennib H, Landreneau RJ, Hazelrigg SR. resection with brachytherapy versus lobectomy for Techniques for localization of pulmonary nodules for stage Ib non small cell lung cancer. Ann Thorac Surg thoracoscopic resection. J Thorac Cardiovasc Surg 2006;81:434-438. 1993;106:550-553. 31.Patel AN, Santos RS, De Hoyos A, Luketich JD, 46.Noirclerc M. Muscle-sparing thoracotomy. Ann Tho- Landreneau RJ. Clinical trials of peripheral stage I rac Surg 1989;47:330. (T1N0M0) non-small cell lung cancer. Semin Thorac 47.Szwerc MF, Landreneau RJ, Santos RS, Keenan RJ, 32 Cardiovasc Surg 2003;15:421-430. Murray GF. Minithoracotomy combined with me- 32. Jones DR, Stiles BM, Denlinger CE, Antippa P, chanically stapled bronchial and vascular ligation for Daniel TM. Pulmonary segmentectomy: results and anatomical lung resection. Ann Thorac Surg complications. Ann Thorac Surg 2003;76:343-348. 2004;77:1904-1909. 33.Fisher B, Anderson S, Bryant J, et al. Twenty-year 48.Miller JI Jr, Landreneau RJ, Wright CE, Santucci TS, follow-up of a randomized trial comparing total mas- Sammons BH. A comparative study of buttressed SUSTRAÍDODE-M.E.D.I.G.R.A.P.H.I.Ctectomy, lumpectomy, and lumpectomy plus irradiation versus nonbuttressed staple line in pulmonary resec- for the treatment of invasive breast cancer. N Engl J tions. Ann Thorac Surg 2001;71:319-322. Med 2002;347:1233-1241. 49.Gagarine A, Urschel JD, Miller JD, Bennett WF, 34.:ROPErrett ODAROBALE LE, Wilson J, Chiu FDP RC, Munro DD. Wedge re- Young JE. Effect of fibrin glue on air leak and length section as an alternative procedure for peripheral bron- of hospital stay after pulmonary lobectomy. J Cardio- VCchogenic ED AS, carcinomasCIDEMIHPARG in poor-risk patients. J Thorac vasc Surg (Torino) 2003;44:771-773. Cardiovasc Surg 1985;90:656-661. 50.Lee W, Daly BD, DiPetrillo TA, et al. Limited resection 35.Ikeda N, Hayashi A, Miura Y, et al. Present strate- for non-small cell lung cancer: observed local control ARAPgy of lung cancer screening and surgical management. with implantation of I-125 brachytherapy seeds. Ann Ann Thorac Cardiovasc Surg 2005;11:363-366. Thorac Surg 2003;75:237-242. 36.ACIDÉMOIBHenschke CI; ARUTARETIL I-ELCAP Investigators :CIHPARGIDEM. CT screening for lung cancer: update 2005. Surg Oncol Clin N Am 2005;14:761-776. 37.Uematsu M. Stereotactic radiation therapy for non small cell lung cancer. Nippon Geka Gakkai Zasshi Address correspondence to: 2002;103:256-257. Rodney Landreneau, M.D. 38.Fernando HC, de Hoyos A, Landreneau RJ, et al. Heart, Lung and Esophageal Surgery Radiofrequency ablation for the treatment of non- Institute small cell lung cancer in marginal surgical candidates. University of Pittsburgh Medical J Thorac Cardiovasc Surg 2005;129:639-644. Center 39.El-Sherif A, Luketich JD, Landreneau RJ, UPMC Shadyside Medical Center, Fernando HC. New therapeutic approachesedigraphic.com for Suite 715 early stage non-small cell lung cancer. Surg Oncol 5200 Centre Avenue 2005;14:27-32. Pittsburgh, Pennsylvania 15232 40.Nagata Y, Takayama K, Matsuo Y, et al. Clinical out- Phone: 412-623-2030 comes of a phase I/II study of 48 Gy of stereotactic e-mail: [email protected]

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