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Ann Thorac Surg 2001;71:1100-1104
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Segmentectomy for roentgenographically occult bronchogenic squamous cell carcinoma

^a Lung Cancer Surgical Study Group (LCSSG), Japan
^b Japanese Clinical Oncology Group (JCOG), Japan

Accepted for publication November 28, 2000.

Address reprint requests to Dr Sagawa, Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, 4-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
e-mail: sagawam{at}idac.tohoku.ac.jp

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Roentgenographically occult bronchogenic squamous cell carcinomas (ROSCCs) are early squamous cell lung cancers of central type. Some of them cannot be treated with intrabronchial therapy. Although surgical treatment was performed for such tumors, it was unknown whether lobectomy was indispensable or not.

Methods. The clinicopathologic information of the 58 patients who underwent segmentectomy for ROSCCs were collected from 16 hospitals and reviewed retrospectively, compared with 98 patients who underwent lobectomy for ROSCCs.

Results. Five-year survival rate of the 58 patients based on lung cancer deaths was 96.8%, and 82.6% including all causes of death. The duration of chest tube drainage in the segmentectomy group was slightly longer than in the lobectomy group. Operative mortality and the frequency of postoperative complications were not statistically different in both groups. Postoperative/preoperative vital capacity and forced expiratory volume in 1 second were higher in the segmentectomy group.

Conclusions. These results suggest that segmentectomy may be an alternative for surgical therapy of carefully selected ROSCCs. More prospective studies are required to fully demonstrate clinical benefit.

	Introduction

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Most of the roentgenographically occult squamous cell carcinomas (ROSCCs) are early bronchogenic squamous cell carcinomas of central type, and are detected by sputum cytology in mass screening for lung cancer [1–3]. Some of them are treated with photodynamic therapy [4, 5] or intrabronchial radiation [6]. However, intrabronchial therapeutic modality cannot be selected when the invasion of the tumor is too deep [7]. Photodynamic therapy cannot cure carcinoma with extrabronchial invasion. Because such tumors sometimes have lymphatic involvement [8], the alternative should be standard operation, namely, lobectomy with systematic nodal dissection. On the other hand, when the location of the tumor is not appropriate for the intrabronchial therapeutic modality, that is, the distal end of the tumor is located beyond bronchoscopic visibility [9], that kind of ROSCC is also treated with standard operation. However, most of these ROSCCs are very small cancers and rarely involve lymph nodes [1–3]. Is the whole lobe resection indispensable for such ROSCCs?

A result of a randomized trial revealed that limited resection (segmentectomy or wedge resection) for peripheral T1N0M0 lung cancer should not be recommended [10]. However, no consensus has been established about the validity of limited resection for early lung cancer of central type. ROSCCs are very different from peripheral small cancers that sometimes involve small vessels or lymphatic systems. Actually, 5-year survival of clinical T1N0M0 peripheral cancers and that of ROSCCs are quite different (61% versus 93.5%) [3, 11]. Possibly ROSCCs are another candidates for limited resection.

Because the patients having ROSCCs frequently have synchronous or metachronous multiple lung cancers [12] and some of them have poor lung function, preserving lung function is very important. However, there have been no reports in the English literature concerning the patients who actually underwent limited resection for ROSCCs, due to limited number of patients [13], and the significance of this operative procedure has not been evaluated so far.

To elucidate the clinical significance of segmentectomy for ROSCCs, we collected the patients from the major cancer centers and universities in Japan. In this study, the clinicopathologic characteristics, postoperative course, and prognosis of the patients were analyzed retrospectively.

	Material and methods

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To collect patients, we sent the questionnaire concerning the survey to all the members of Lung Cancer Surgical Study Group in Japan Clinical Oncology Group [14] and 33 major hospitals responded the proposal. Of them, 16 hospitals had 1 or more patients who underwent segmentectomy for ROSCCs from 1980 through 1995 (see Acknowledgment). ROSCCs were defined as squamous cell carcinomas with no mass lesion on their chest roentgenogram. Cancers with atelectasis or pneumonia due to the tumor were excluded. Cancers with mass lesion on their chest computed tomographic scan were also excluded.

In the period, a total of 428 segmentectomies for primary lung cancer were performed in the 16 hospitals. Of 428 patients, 58 (13.6%) underwent segmentectomy for ROSCCs. Detailed clinicopathologic findings, surgical procedures, postoperative course, and prognosis of the 58 patients were investigated from their medical records. The characteristics of the patients are shown on Table 1. All of the patients were men, and most of them had no previous therapy. Because both of preoperative and postoperative lung functions were recorded in 38 patients, the change in lung function was analyzed in these patients.

The information from medical records of 98 patients who underwent one lobectomy with systematic nodal dissection for ROSCCs during the same period were also collected from hospitals in our group. All of them were men and mean age was 65.7 years, which was not statistically different with patients in segmentectomy group. Although the procedure (lobectomy or segmentectomy) was sometimes decided by surgeon’s preference, ROSCCs in the lobectomy group were generally located more proximal and often invaded deeper than those in the segmentectomy group. Therefore, the comparison of survival between these two groups was problematic, because survival must be influenced not only by surgical procedure, but also the difference of the tumors themselves. However, the change in lung function or the postoperative complication rate can be compared.

Preoperative and postoperative lung functions were recorded in 86 of the 98 patients who received one lobectomy, and the data from the 86 patients were analyzed to compare the change in lung function. In general, chest tube drainage was performed for 2 days (48 hours) in both groups, unless air leakage was prolonged. Postoperative complication, which required some therapy for 3 days or more, was counted in this study. Prolonged sputum retention that required tracheotomy or bronchial toilet for 3 days or more was also included, whereas retention of sputum for 1 to 2 days or transient arrhythmia were not counted.

The change in lung function and the duration of chest tube drainage were compared by Student’s t test. Postoperative complication was compared between the two groups with the ² test. Postoperative mortality was also compared with Fisher’s exact probability. A probability of less than 0.05 was regarded as statistically significant.

	Results

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The summary of the surgical therapy is shown on Table 2. One segmentectomy was performed in 26 of 58 patients. Seventeen of the 26 patients underwent S⁶ (the superior segment of the lower lobe) segmentectomy. Sleeve segmentectomy was performed in 31% of all segmentectomies. Intraoperative frozen section of bronchial stump and lymph nodes were examined pathologically in 45 (77.6%) and 19 (32.8%) of 58 patients, respectively.

As of March 1999, 13 patients died. Only 1 patient died of lung cancer within 5 years after the segmentectomy (59 months). Another 2 patients died of lung cancer 62 and 73 months after the segmentectomy. However, 2 of these 3 patients had synchronous secondary lung cancers, for which right upper sleeve lobectomy and left lower lobectomy had been performed before the segmentectomy, and the remaining patient had metachronous secondary lung cancer 16 months after the segmentectomy. Therefore, concerning these 3 patients, it was unknown whether the first carcinomas were the cause of death. One patient who underwent left upper divisionectomy died 10 days after the operation due to pneumonia and acute renal failure (operative death within 30 days, 1.7%). Postsurgical empyema was observed in 2 patients, and these 2 patients died 3 and 10 months after the first operation. Six patients died of other diseases 12, 17, 26, 39, 54, and 61 months after the operation (cancer of the small intestine, cardiac failure, multiple sclerosis, respiratory failure, emphysema, cardiac disease). The remaining 1 patient died of unknown cause 115 months after the operation. Five-year survival rate of the 58 patients based on lung cancer deaths was 96.8%, and 91.9% even including therapy-related deaths (renal failure and empyema). Five-year survival rate based on all causes of death was 82.6% (Fig 1).

View larger version (14K): [in this window] [in a new window]   Fig 1. Survival curves of the patients who underwent segmentectomy for roentgenographically occult bronchogenic squamous cell carcinoma. Cumulative 5-year survival rate based on all causes of death was 82.6%, and that based on lung cancer-related causes was 91.9%.

The duration of the chest tube drainage was compared (Table 3). The average duration in segmentectomy group was 3.8 days, whereas that in the lobectomy group was 2.9 days, which was statistically different. The postoperative complication treated for 3 days or more was also compared between the segmentectomy group and the lobectomy group (Table 3). In the segmentectomy group, 11 of 58 (19.0%) had postoperative complications, whereas 14 of 98 (14.3%) in the lobectomy group, which was not statistically different. The complications in the segmentectomy group were retention of sputum for 3 days or more in 3 patients, pneumonia in 3 patients, bronchial stenosis, intrabronchial hemorrhage, early bronchopleural fistula, late bronchopleural fistula (6 months after the operation), and gastric ulcer in 1 patient each.

	Comment

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In the patients with ROSCCs, synchronous or metachronous secondary lung cancer was frequently observed [1, 2, 12]. Actually, at least 7 of our 58 patients had synchronous and another 5 patients had metachronous secondary lung cancers. A lesser resection is preferable in such carcinoma, because preserving lung function is essential for the therapy against secondary lung cancer. Although segmentectomy is slightly more complicated than lobectomy, there is no large difficulty to perform segmentectomy and lymph node dissection.

Possible less curability is the most important concern when segmentectomy is considered for the surgical treatment of ROSCCs. Actually some recurrences were observed or suspected in our series. Although it is uncertain whether the recurrence was avoidable with standard operative procedure, we should make every effort to avoid incomplete resection of whole tumor. There are several issues to be discussed for such purpose.

First, intraoperative pathologic examination of the bronchial stump was performed in 77.6% of the patients in our series. Because ROSCCs sometimes extend beyond any abnormal bronchoscopic findings [13, 15], frozen section of the bronchial stump should be examined.

Second, nodal involvement was observed in 3 patients after pathologic evaluation in our series. Intraoperative pathologic examination of lymph nodes was not performed in all of the 3 patients. Segmentectomy should not be recommended for lung cancer with nodal involvement, because nodal involvement means spreading of cancer cells to the lymphatic system. Saito and colleagues [3] reported that 6.4% of ROSCCs had lymph node metastases, and most of the involved nodes were limited within hilar region, as it was observed in our series. Izbicki and associates [16] reported that the accuracy of intraoperative inspection of lymph nodes by the surgeon was not satisfactory. Therefore, intraoperative pathologic examination of intrapulmonary and hilar nodes should be proposed, and the standard operation (lobectomy with systematic nodal dissection) is recommended when any node is involved.

Third, as described, it is important to exclude the tumors with lymphatic invasion from the candidates for limited resection. Computed tomography is indispensable to eliminate tumors that form masses but are not detectable on routine chest roentgenograms. However, there have been no appropriate predictable methods for lymphatic involvement, especially in ROSCCs. Nagamoto and colleagues [8] reported that ROSCCs with extrabronchial invasion tend to have lymphatic involvement. Therefore, the tumor that was considered preoperatively to have extrabronchial invasion should be excluded. Careful preoperative bronchoscopic and cytologic evaluation enables to exclude some tumors with extrabronchial invasion [15, 17]. High-resolution computed tomography or transbronchial ultrasonography may detect thickening of the bronchial wall or extrabronchial invasion [18]. We insist again that the resection would be incomplete if preoperative evaluation is not performed carefully.

Overall 5-year survival rate of the 58 patients based on lung cancer deaths was 96.8%, 91.9% including therapy-related deaths, 82.6% including all causes of death. Even compared with the results of standard operation for ROSCCs (5-year survival rate based on lung cancer deaths: 93.5%; including all causes of death: 80.4%) [3], the prognosis of our patients was excellent. Follow-up chest roentgenogram and sputum cytology were essential to detect the recurrence or secondary lung cancer.

In this study, postoperative course and lung function were compared between the segmentectomy group and the lobectomy group. Although ROSCCs in the lobectomy group were generally located more proximal than those in the segmentectomy group, the procedure was sometimes decided by surgeon’s preference. There might be some methodologic problems in comparing these two groups, because some of clinical characteristics were different. Actually preoperative lung function of the two groups was statistically different. Some confounding factors might affect the results.

Preoperative vital capacity and forced expiratory volume in 1 second in the segmentectomy group were significantly smaller than those in the lobectomy group, probably because some patients underwent segmentectomy instead of lobectomy due to poor lung function. However, postoperative vital capacity in both groups were almost the same and postoperative forced expiratory volume in 1 second had no statistical difference. Reduction rate of both vital capacity and forced expiratory volume in 1 second by the operation was lower in the segmentectomy group than in the lobectomy group. Lung function was preserved by segmentectomy.

The duration of chest tube drainage was slightly longer in the segmentectomy group than in the lobectomy group (3.8 versus 2.9 days), which should be noted when segmentectomy is considered. Maximum effort to eliminate air leakage should be done intraoperatively, and the effort would also make postsurgical empyema decrease. On the other hand, the frequency of postoperative complication in both groups had no statistical difference, although the patients in the segmentectomy group had worse lung function than those in the lobectomy group. Operative mortality within 30 days was also similar in both groups. With careful intra- and postoperative management, segmentectomy for ROSCCs could be performed as safely as lobectomy.

We report here the analysis of the patients who underwent segmentectomy for ROSCCs. Although duration of chest tube drainage was slightly longer, operative mortality and postoperative complications were not statistically different between the segmentectomy group and the lobectomy group. Prognosis of the segmentectomy group was excellent, and the reduction of the lung function by the operation was smaller in the segmentectomy group. With careful preoperative selection of patients and intraoperative pathologic examination, segmentectomy might be an alternative for the surgical therapy for ROSCCs. Because the present study is retrospective with several possible biases, more prospective studies are required to fully demonstrate the clinical benefit of this operative procedure.

	Acknowledgments

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The study was carried out as a work (8S-1) in the Lung Cancer Surgical Study Group (Chairperson: Harubumi Kato) of the Japanese Clinical Oncology Group (Chairperson: Masanori Shimoyama). The patients in this study were collected from Tohoku University (Head: Shigefumi Fujimura), Niigata Cancer Center Hospital (Teruaki Koike), Kanazawa University School of Medicine (Yoh Watanabe), Cancer Institute Hospital (Ken Nakagawa), National Cancer Center Hospital East (Kanji Nagai), Tochigi Cancer Center (Kohei Yokoi), National Kinki Chuo Hospital (Keiji Iuchi), Sendai Kosei Hospital (Masashi Handa), Kin-Ikyo Chuo Hospital (Yoshio Hosokawa), Nakadohri General Hospital (Mitsuo Kawamura), Tsuboi Hospital (Hiroshi Iwanami), Ibaraki Prefectural Central Hospital and Cancer Center (Ryuta Amemiya), Keio University (Koichi Kobayashi), Osaka City General Hospital (Hirohito Tada), Osaka Prefectural Habikino Hospital (Tsutomu Yasumitsu), and National Shikoku Cancer Center (Hideyuki Saeki).

	References

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