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The role of limited resection in the treatment of early stage lung cancer
Monday, June 27, 1994
Surgery I - Boundaries The Role of Limited Resection in the Treatment of Early Stage Lung Cancer Robert J. Ginsberg, M.D. Memorial Sloan-Kettering Cancer Center, New York, New York For over 50 years, pulmonary resection has been the accepted treatment for early stage lung cancer. initially, pneumonectomy was the treatment of choice, no matter the stage or location of the disease. Wiih the advent of techniques of hiiar dissection, lobectomy became a feasible alternative and, for the past 30 years, this procedure has been accepted as the minimal resection of choice in lung cancer when the site and stage of disease allows a complete resection by this lesser operation. Lobectomy continues to be the procedure of choice for early stage lung cancer limited to a lobe, even if a lesser resection could encompass all disease.(l) However, in the past two decades, limited resections have been utilized for selected indications, and with the enthusiasm now generated for video thoracoscopic procedures, has been promulgated for early stage lung cancer. lNDlCAflONS Lesser pulmonary resections (segmental resection, wedge resection, precision cautety dissection) were initially utilized as compromise operations in those patients with lung cancer suffering from poor pulmonary reserve who could withstand a thoracotomy but were felt not to be able to tolerate a lobectomy. Both segmental and wedge resections have been used for this “compromise” operation. Despite being a compromise procedure, and despite some locally advanced tumors being treated in this fashion, retrospective reports suggested a reasonable five-year survival when a lesser resection is utilized as a compromise procedure. in many cases, incomplete resections were necessarily performed, and the local recurrence rate of lesser resections in this group of patients was significant. Most authors including those from our institution, felt that lesser resection, because of the high local recurrence rate, should not be advised in patients could tolerate a lobectomy. (2,3,4,5,6,7,6). More recently, patients presenting with bilateral synchronous or metachronous primary tumors have been managed, on a selective basis, with standard pulmonary resections if required, but lesser resections whenever possible to preserve as much pulmonary function tissue as possible. The use of lesser resections for this indication does not appear to have compromised the ability to cure. A third indication for lesser pulmonary resections has been in those instances of very peripheral T3 tumors (e.g. superior suicus tumor) where the majority of the malignancy invdves the chest wall and pleural space rather than pulmonary tissue. Many authors have accepted the use of wedge resection with en-bloc chest wail resection in these instances. In this very selected group of T3NO patients, a limited resection does not appear to have compromised curability or increased the risk of local recurrence, although a recent analysis of superior suicus tumors in our institution suggests a distant disadvantage to this approach.(g) in 1973, Jensik reported the first experience with intentional segmental resection as the treatment of choice in early stage lung cancer. Since that first report, many other centers have adopted this approach, initially in a tentative fashion but more recently as the procedure of choice. In the past few years, many of the centers advocating this approach have pubiished their updated results. In the larger series, the survival rate appears comparable to that expected from standard iobectomy in the treatment of stage I carcinama. (10,ll) There has been a persisting fear that local recurrence could prove to be a major problem. Until more recently, none of the historical series have demonstrated this to be the case. However, there is general agreement that patients suitable for this type of resection should have Tl NOtumors, peripherally located and preferably not transgressing a segmental plane. The postoperative mortality and morbidity from this lesser resection has been acceptable and is comparable to that seen with iobectomy for stage I lung cancer. With the advent of prospective clinical trials, many surgeons felt that a prospective randomized trial comparing lobectomy to lesser resections should be carried out prior to advising this type of lesser resection in early stage disease. In 1962, the North American Lung Cancer Study Group initiated such a prospective trial of limited resection (segmentectomy or wedge resection) for those patients defined as having small peripheral tumors and staged at operation to have peripheral TlNO lung cancer. Rigid criteria for acceptance into this protocol included: a peripheral tumor, without nodal involvement and not visible at bronchoscopy, and measuring 3 cm or less on plain chest radiographs. In ail cases, patients were able to tolerate a iobectomy. Foilowing intraoperative frozen section staging for T and N status, patients were randomized to undergo standard lobectomy or lesser pulmonary resection. The results of this trial have been reported in abstract form. The triil has been closed for four years. Lung Cancer Study Group, awaiting a minimum of three-year follow-up on all patients, has recently presented the final results. (12,13,14) Over 400 patients were considered eligible for this limited resection trial, but only 50% were found at surgery to qualify for either a large wedge or segmental resection. The reasons for patients requiring iobectomy as the treatment of choice included: location of the tumor (50%),
35
36
frozen section identification of Nl or N2 disease (25%) a T2 or greater tumor (13%) and other miscellaneous reasons (12%). A further 9% of patients required completion lobectomy because of inadequate margins after the initial limited resection. This study has reported the postoperative morbidity and mortality data of each type of resection. There appears to be no significant difference in either morbidity or mortality (1.2%) for either procedure. At a minimum three year foilow-up, there was a significant increase in local recurrence rate and drecreased survival following limited resection. A recent retrospective analysis from the Rush-Presbyterian Group confirms this result.(l5) For the present, therefore, lobectomy does remain the minimal resection of choice in dealing with even early stage lung cancer. This has significant impact when one considers the rising tide of enthusiasm for minimal access surgery wlth video thoracoscopy. References 1.
Ginsberg RJ, et al. Surgery for Non-Small Cell Lung Cancer. in Thoracic Oncology. Ruckdeschel and Roth (eds) WB Saunders Publisher, 1988. pp 177-199.
2.
Bennett WF, et al: Segmental resection for bronchogenic carcinoma: A surgical alternative for the compromised patient. Ann Thorac Surg 1979:27:170-l 72.
3.
Errett LE, et al. Wedge resection as an alternative procedure for peripheral bronchogenic carcinoma in poor-risk patients. J Thorac Cardiovasc Surg 1985:90:656-661.
4.
Hoffmann TH, et al. Comparison of a lobectomy and wedge resection for carcinoma of the lung. J Thorac Cardiovasc Surg 1980:79:21l-21 7.
5.
Miller JI, et al. Limited resection of bronchogenic carcinoma in the patient with marked impairment of pulmonary function. Ann Thorac Surg 1987:44:340-343.
6.
Jensik RJ, et al. Survival following resection for a second primary bronchogenlc carcinoma. J Cardiovasc Surg 1981:82:658+X8.
7.
Kutschera W: Segment resection for lung cancer. Thorac Cardiovasc Surg 1984:32:102104.
8.
McCormack PM, et al. Primary Lung Carcinoma: Results with Conservative Resection in Treatment. NY State J Med 1980;80:612-616.
9.
Stair JM, et al. Segmental pulmonary resection for cancer. Am J Surg 1985654659.
10.
Jensik RJ: The Extent of Resection for Localized Lung Cancer: Segmental Resection. in Kiile CF (ed): 1986, Current Controversies in Thoracic Surgery. 175-182.
11.
Kulka F, et al. The segmental and apical resection of primary lung cancer. Proc IV World Conf on Lung Cancer, 1985. p 81.
12.
Ginsberg RJ for the Lung Cancer Study Group: tumors. Lung Cancer 1988:4:A80.
13.
Ginsberg RJ, et al. A Randomized comparative Trial of Lobectomy vs Limited Resection for Patients with TI NO Non-small cell lung cancer. “Lung Cancer” vol. 7 (1991)Supplement, pp83, A304
14.
Ginsberg RJ, et al. LCSG 821-The Comparison of limited resection to lobectomy for TIN0 nonsmall cell lung cancer. (Presented at the Lung Cancer Study Group:Final Analysis meeting. Tampa, Florida March 9-13, 1994
15.
Warren WH, et al. Segmentectomy vs lobectomy in patients with stage I pulmonary carcinoma: Five year survival and patterns of intrathoracic recurrence. (Presented at the AATS 73rd Annual Meeting, Chicago, Illinois. April 25-28, 1993.
Limited resection for peripheral TIN0
Surgery I - Boundaries The Role of Limited Resection in the Treatment of Early Stage Lung Cancer Robert J. Ginsberg, M.D. Memorial Sloan-Kettering Cancer Center, New York, New York For over 50 years, pulmonary resection has been the accepted treatment for early stage lung cancer. initially, pneumonectomy was the treatment of choice, no matter the stage or location of the disease. Wiih the advent of techniques of hiiar dissection, lobectomy became a feasible alternative and, for the past 30 years, this procedure has been accepted as the minimal resection of choice in lung cancer when the site and stage of disease allows a complete resection by this lesser operation. Lobectomy continues to be the procedure of choice for early stage lung cancer limited to a lobe, even if a lesser resection could encompass all disease.(l) However, in the past two decades, limited resections have been utilized for selected indications, and with the enthusiasm now generated for video thoracoscopic procedures, has been promulgated for early stage lung cancer. lNDlCAflONS Lesser pulmonary resections (segmental resection, wedge resection, precision cautety dissection) were initially utilized as compromise operations in those patients with lung cancer suffering from poor pulmonary reserve who could withstand a thoracotomy but were felt not to be able to tolerate a lobectomy. Both segmental and wedge resections have been used for this “compromise” operation. Despite being a compromise procedure, and despite some locally advanced tumors being treated in this fashion, retrospective reports suggested a reasonable five-year survival when a lesser resection is utilized as a compromise procedure. in many cases, incomplete resections were necessarily performed, and the local recurrence rate of lesser resections in this group of patients was significant. Most authors including those from our institution, felt that lesser resection, because of the high local recurrence rate, should not be advised in patients could tolerate a lobectomy. (2,3,4,5,6,7,6). More recently, patients presenting with bilateral synchronous or metachronous primary tumors have been managed, on a selective basis, with standard pulmonary resections if required, but lesser resections whenever possible to preserve as much pulmonary function tissue as possible. The use of lesser resections for this indication does not appear to have compromised the ability to cure. A third indication for lesser pulmonary resections has been in those instances of very peripheral T3 tumors (e.g. superior suicus tumor) where the majority of the malignancy invdves the chest wall and pleural space rather than pulmonary tissue. Many authors have accepted the use of wedge resection with en-bloc chest wail resection in these instances. In this very selected group of T3NO patients, a limited resection does not appear to have compromised curability or increased the risk of local recurrence, although a recent analysis of superior suicus tumors in our institution suggests a distant disadvantage to this approach.(g) in 1973, Jensik reported the first experience with intentional segmental resection as the treatment of choice in early stage lung cancer. Since that first report, many other centers have adopted this approach, initially in a tentative fashion but more recently as the procedure of choice. In the past few years, many of the centers advocating this approach have pubiished their updated results. In the larger series, the survival rate appears comparable to that expected from standard iobectomy in the treatment of stage I carcinama. (10,ll) There has been a persisting fear that local recurrence could prove to be a major problem. Until more recently, none of the historical series have demonstrated this to be the case. However, there is general agreement that patients suitable for this type of resection should have Tl NOtumors, peripherally located and preferably not transgressing a segmental plane. The postoperative mortality and morbidity from this lesser resection has been acceptable and is comparable to that seen with iobectomy for stage I lung cancer. With the advent of prospective clinical trials, many surgeons felt that a prospective randomized trial comparing lobectomy to lesser resections should be carried out prior to advising this type of lesser resection in early stage disease. In 1962, the North American Lung Cancer Study Group initiated such a prospective trial of limited resection (segmentectomy or wedge resection) for those patients defined as having small peripheral tumors and staged at operation to have peripheral TlNO lung cancer. Rigid criteria for acceptance into this protocol included: a peripheral tumor, without nodal involvement and not visible at bronchoscopy, and measuring 3 cm or less on plain chest radiographs. In ail cases, patients were able to tolerate a iobectomy. Foilowing intraoperative frozen section staging for T and N status, patients were randomized to undergo standard lobectomy or lesser pulmonary resection. The results of this trial have been reported in abstract form. The triil has been closed for four years. Lung Cancer Study Group, awaiting a minimum of three-year follow-up on all patients, has recently presented the final results. (12,13,14) Over 400 patients were considered eligible for this limited resection trial, but only 50% were found at surgery to qualify for either a large wedge or segmental resection. The reasons for patients requiring iobectomy as the treatment of choice included: location of the tumor (50%),
35
36
frozen section identification of Nl or N2 disease (25%) a T2 or greater tumor (13%) and other miscellaneous reasons (12%). A further 9% of patients required completion lobectomy because of inadequate margins after the initial limited resection. This study has reported the postoperative morbidity and mortality data of each type of resection. There appears to be no significant difference in either morbidity or mortality (1.2%) for either procedure. At a minimum three year foilow-up, there was a significant increase in local recurrence rate and drecreased survival following limited resection. A recent retrospective analysis from the Rush-Presbyterian Group confirms this result.(l5) For the present, therefore, lobectomy does remain the minimal resection of choice in dealing with even early stage lung cancer. This has significant impact when one considers the rising tide of enthusiasm for minimal access surgery wlth video thoracoscopy. References 1.
Ginsberg RJ, et al. Surgery for Non-Small Cell Lung Cancer. in Thoracic Oncology. Ruckdeschel and Roth (eds) WB Saunders Publisher, 1988. pp 177-199.
2.
Bennett WF, et al: Segmental resection for bronchogenic carcinoma: A surgical alternative for the compromised patient. Ann Thorac Surg 1979:27:170-l 72.
3.
Errett LE, et al. Wedge resection as an alternative procedure for peripheral bronchogenic carcinoma in poor-risk patients. J Thorac Cardiovasc Surg 1985:90:656-661.
4.
Hoffmann TH, et al. Comparison of a lobectomy and wedge resection for carcinoma of the lung. J Thorac Cardiovasc Surg 1980:79:21l-21 7.
5.
Miller JI, et al. Limited resection of bronchogenic carcinoma in the patient with marked impairment of pulmonary function. Ann Thorac Surg 1987:44:340-343.
6.
Jensik RJ, et al. Survival following resection for a second primary bronchogenlc carcinoma. J Cardiovasc Surg 1981:82:658+X8.
7.
Kutschera W: Segment resection for lung cancer. Thorac Cardiovasc Surg 1984:32:102104.
8.
McCormack PM, et al. Primary Lung Carcinoma: Results with Conservative Resection in Treatment. NY State J Med 1980;80:612-616.
9.
Stair JM, et al. Segmental pulmonary resection for cancer. Am J Surg 1985654659.
10.
Jensik RJ: The Extent of Resection for Localized Lung Cancer: Segmental Resection. in Kiile CF (ed): 1986, Current Controversies in Thoracic Surgery. 175-182.
11.
Kulka F, et al. The segmental and apical resection of primary lung cancer. Proc IV World Conf on Lung Cancer, 1985. p 81.
12.
Ginsberg RJ for the Lung Cancer Study Group: tumors. Lung Cancer 1988:4:A80.
13.
Ginsberg RJ, et al. A Randomized comparative Trial of Lobectomy vs Limited Resection for Patients with TI NO Non-small cell lung cancer. “Lung Cancer” vol. 7 (1991)Supplement, pp83, A304
14.
Ginsberg RJ, et al. LCSG 821-The Comparison of limited resection to lobectomy for TIN0 nonsmall cell lung cancer. (Presented at the Lung Cancer Study Group:Final Analysis meeting. Tampa, Florida March 9-13, 1994
15.
Warren WH, et al. Segmentectomy vs lobectomy in patients with stage I pulmonary carcinoma: Five year survival and patterns of intrathoracic recurrence. (Presented at the AATS 73rd Annual Meeting, Chicago, Illinois. April 25-28, 1993.
Limited resection for peripheral TIN0