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Ann Thorac Surg 2002;73:1058-1059
© 2002 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 109, Houston, TX 77030-4095, USA email: putnam@mdanderson.org
Resection for local control in patients with clinical T1 non-small cell lung cancer (NSCLC) provides both a survival advantage and the potential to diagnose regional nodal metastases. Based upon a prospective randomized study, lobectomy is considered the standard operation for T1N0 non-small cell lung cancer [1].
In this article, the authors examine the role of wide segmental resection in a consecutive series of patients with peripheral (T1, 
2 cm) NSCLC with five-year or longer follow-up on all patients. Five-year survival was excellent (91.8%) and decrease in FEV1 was minimal (13.4 ± 10.4 %). Limited resection did not appear to worsen survival, local control, or functional results compared to known results of lobectomy. When performed in this manner, extended segmentectomy with segmental, hilar, and mediastinal lymph node dissection may have results equivalent to lobectomy.
Can optimal local control be obtained with an extended segmentectomy? Even in this highly selected T1 population, 18 patients (18 of 73 patients, 25%) were excluded based on intraoperative findings of local invasion or positive lymph nodes on frozen section. Surgeons who apply this technique may struggle with a tumor larger than 2 cm or one that straddles two segments or two lobes.
The technique of segmental and hilar lymph node dissection may be tedious and demands a close interaction between the surgeon and the pathologist. Nodal metastases do not necessarily follow a linear progression from primary tumor to the segmental nodes, hilar nodes, and then to the mediastinum. "Skip" metastasis may occur. Hilar and mediastinal lymph node dissection are required in this procedure to adequately stage these patients and to optimize intraoperative and postoperative treatment decisions. The surgeon must have sufficient patience to await the results of the intraoperative lymph node histology and then to proceed with lobectomy if necessary.
In a physiologically fit individual, lobectomy remains the standard resection for clinical stage I NSCLC. Although extended segmentectomy appears to be an appropriate alternative to lobectomy as defined within this report, further evidence to support equivalency or improvement over lobectomy is necessary. Application of this technique in the absence of a randomized trial may be appropriate in selected patients with limited pulmonary function, or with multiple synchronous primary lung cancers. A prospective randomized trial to further investigate the role of this technique in lieu of lobectomy for NSCLC is needed.
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