Minimal Resection for Bronchogenic Carcinoma* An Update Maj . Mark M. Crabbe, MC, USAF;t Geoffrey A. Patrissi, M.A.;* and
Larry J Fontenelle, M.D.§
Minimal resection with curative intent was performed for 24 patients with stage I bronchogenic carcinoma at our institutions over a 12-year period. This was usually done for patients who could not tolerate more extensive resections. The 6ve-year actuarial survival rate was 65 percent. The rate of local recurrences was 13 percent (3/24), and the rate of distant recurrences was 17 percent (4124), with a
median follow-up of 38 months. Survival and recurrence rates are similar for patients undergoing minimal resection and those being reported for patients undergoing more extensive resections for stage I bronchogenic carcinoma. In selected patients, minimal resection should be considered as an acceptable alternative treatment for patients with stage I bronchogenic carcinoma. (Che•t 1991; 99:1421-24)
T obectomy and pneumonectomy are considered the
one-year follow-up in all patients. Survival was calculated from the date of surgery to the time of death or to the end of the study period. A five-year actuarial survival was determined. Local recurrence was defined as disease recurring in the same operated hemithorax. Distal recurrence was defined as disease recurring anywhere else. Preoperative evaluation included history and physical examination, chest x-ray film, laboratory analysis, pulmonary function tests, bronchoscopy, and tomograms or a computerized axial tomographic scan of the chest. Surgical techniques included the use of a doublelumen endotrachael tube, arterial catheters, epidural catheters, and stapling devices for the wedge resections. Pulmonary artery catheters were employed as indicated. All patients undergoing minimal resection for known bronchogenic carcinoma had a grossly complete resection of the tumor and lymph node sampling. No adjuvant therapy was offered to these patients with stage I disease.
..I...J standard surgical treatments for stage I broncho-
genic carcinoma; however, many patients with potentially resectable bronchogenic carcinoma are not candidates for these procedures because of limited pulmonary reserve. Minimal resection, (ie, wedge resection or segmentectomy) has been performed in these patients with favorable results being reported by many authors. 1- 12 We reported our initial experience with 15 patients who underwent minimal resection with curative intent for stage I bronchogenic carcinoma. 1 We have subsequently expanded our series to a total of 24 patients. In this report the reasons for minimal resection are discussed. Survival and recurrence rates are determined, and these are compared to those being reported by other authors for minimal resection, as well as for more extensive resections, for stage I bronchogenic carcinoma. MATERIALS AND METHODS
The tumor registry records were reviewed for all patients diagnosed with bronchogenic carcinoma at the Biloxi VA Medical Center, USAF Medical Center Keesler, and USAF Medical Center Wright-Patterson over a 12-year period. Those patients undergoing minimal resection for stage I (T1NO; T2NO) disease were identified, and the inpatient as well as the outpatient records were reviewed. Minimal resection was defined as wedge resection or segmentectomy. No patients were lost to follow-up, and there was at least a *From USAF Medical Center Wright-Patterson, Wright-Patterson AFB, Ohio; USAF Medical Center Keesler, Keesler AFB, Miss; and Biloxi VA Medical Center, Biloxi, Miss. All opinions are those of the authors and not necessarily those of the United States Air Force or VA Medical Center. tDepartment of Surgery, USAF Medical Center Wright-Patterson. tBiostatistician, USAF Medical Center Keesler. §Chief, Surgical Service, Biloxi VA Medical Center. Manuscript received September 17; revision accepted November 6. Reprint requests: Dr. Crabbe, Department of Surgery/SCHSG, USAF Medical Center; Wright-lbtterson AFB, Ohio 45433-5300
RESULTS
There was a total of 2,390 patients diagnosed with bronchogenic carcinoma at the Biloxi VA Medical Center (n = 662), USAF Medical Center Keesler (n = 1,331), and USAF Medical Center Wright-Patterson (n=397) from Jan 1, 1977 to Oct 31, 1988. Of these, 477 patients underwent potentially curative resections for bronchogenic carcinoma. One hundred twenty-four patients underwent pneumonectomy, 329 patients underwent lobectomy, 23 patients underwent wedge resection, and one patient underwent segmentectomy. All patients undergoing minimal resection had stage I disease (see Table I). The most common reason for minimal resection was impaired pulmonary function (n = 12). In general, this was defined as a predicted FEV 1 after resection of less than 800 ml if a lobectomy was performed. Four patients underwent wedge resection because of a history of having a previous pulmonary resection. Four patients had a benign lesion diagnosed by frozen section at the time of surgery and were subsequently CHEST I 99 I 6 I JUNE, 1991
1421
Table 1- Patients Undergoing Minimal Resection for Stage I Bronchogenic Carcinoma Case, Sex , Age (yr) 1, M, 49 2, M,69 3, M, 59 4, M,54 5, F, 58 6, M,62 7, F, 72 8, M, 63 9, M, 57 10, M, 61 ll,M , 64 12, M,74 13, F, 72 14, M, 75 15, M, 67 16, M, 63 17, M, 82 18, M, 59 19, M, 56 20, M, 68 21, M, 64 22, F.60 23, M, 62 24 , F.63
Date Surgery oon8 04180 03181 06181 ll/81 02183
06184 07/84 08/84 08/84 12/84 01186 07186 02187 10/87 ll/87 02188 06188 07/88 07/88
08188 10/88 10/88 10/88
Cell Typet
Resection*
Reasont
Stage
W-LLL W-LLL W-RLL S-LLL W-RUL W-LUL W-LLL W-LUL W-RLL W-LUL&LLL W-RLL W-LUL W-RUL W-RLL W-LUL W-LLL W-RUL W-RUL W-RUL W-RLL W-RLL W-LUL W-RUL W-LUL
Previous RUL Previous R UL IPS Misdiagnosis IPS IPS Misdiagnosis IPS IPS Synchronous IPS Previous R UL Misdiagnosis IPS IPS IPS PMS IPS PMS IPS Previous LUL Misdiagnosis IPS PMS
I(T1NO) I(T1NO) I(T1NO) I(T1NO) I(T1NO) I(T1NO) I(TINO) I(TINO) I(TINO) I(T2NO) I(TINO) I(TINO) I(TINO) I(TINO) I(T2NO) I(T2NO) I(TINO) I(T1NO) I(T1NO) I(T2NO) I(T1NO) I(T2NO) I(TINO) I(T1NO)
WDSCC AC UDLCC BAC PDAC WDSCC BAC PDSCC PDAC WDSCC WDAC WDSCC WDAC WDAC UDSCC PDSCC BAC UDLCC WDAC BAC BAC BAC WDAC MDSCC
Survival§
Statusll
D-78 mo D-25mo A-101 mo D-80 mo D-9I mo A-78 mo
DR-50 mo LR-I7 mo NED DR-76mo NED NED NED NED NED NED DR-IOmo NED NED LR-I3 mo NED DR-14 mo NED LR-9mo NED NED NED NED NED NED
A~2mo
A-41 mo D-59mo A-52 mo D-IOmo A-44 mo A-36mo D-13 mo A-23mo D-17 mo A-17 mo D-09mo A-14 mo A-14 mo A-14 mo A-12 mo A-12 mo A-12 mo
*\V, Wedge; S, segmentectomy; LLL, left lower lobe; RLL, right lower lobe; RUL, right upper lobe; and LUL, left upper lobe. tiPS , Impaired pulmonary status; and PMS, poor medical status. tWD, Well differentiated; SCC , small-cell carcinoma; AC, adenocarcinoma; UD, undifferentiated; LCC, large-cell carcinoma; BAC, bronchoalveolar carcinoma; and PD, poorly differentiated. §D . Dead; and A, alive . II DR, Distant recurrence; LR, local recurrence; and NED, no evidence of disease.
found to have a malignant lesion on permanent section. three patients underwent wedge resection because of overall poor medical status, ie, a history of congestive heart failure or recent myocardial infarction. One patient had a wedge resection because of a synchronous lesion found at the time of resection. The perioperative mortality was zero for patients undergoing minimal resection for stage I bronchogenic carcinoma. The five-year actuarial survival for these patients was 65 percent (see Fig 1). There was a local recurrence rate of 13 (3/24) and a distant recurrence rate of 17 percent (4/24), with a median follow-up time of 38 months. DISCUSSION
Pneumonectomy was initially believed to be the standard surgical therapy for bronchogenic carcinoma in the 1930s and 1940s; 13 however, patients who could not tolerate a pneumonectomy underwent a lesser procedure, ie , lobectomy. Those patients who underwent lobectomy were subsequently found to have survival and recurrence rates comparable to those being reported for pneumonectomy. 14 Lobectomy has become a standard surgical treatment for bronchogenic carcinoma. 1422
A similar trend has been noted with respect to minimal resection for bronchogenic carcinoma. Again, there is a group of patients with resectable carcinoma who cannot tolerate a lobectomy. Through retrospective series, patients with stage I bronchogenic carcinoma who underwent minimal resection and more extensive resections (ie, lobectomy or pneumonecC)
z
1.0
> 0 .9 > a: :::;)
Ul
z
0
i= a: 0 Q. 0
a:
D.
w
> i= < ....1
:::;)
:::0
:::;)
(.)
0 .8 0 .7
0 .6 0 .5 0.4 0 .3 0 .2 0.1 0 .0 0 10
20
30
40
50
60
70
80
MONTHS fiGURE 1. Actuarial survival curve for wedge resection for stage I bronchogenic carcinoma.
Minimal Resection for Bronchogenic Carcinoma (Crabbe, Patrissi, Fontenel/e)
Table 2-Survivalfor Stage I (NO) Bronchogenic Carcinoma
Treatment and Authors
Years
Minimal resection 1957-78 Jensik et al' 1972-78 Williams et al" 1965-82 Errett et al" 1977-88 Crabbe et al Lobectomy/pneumonectomy 1972-78 Williams et al" 1974-84 Little et al" 1965-82 Errett et al"
No. of Patients
Five-Year Survival (Actuarial), percent
24
53 64 69* 65
461 91 97§
69 70 75*
168* 22 lOOt
*Includes ll patients with N l status. tlncludes 28 patients with N l status. *Six-year actuarial survival . §Includes 21 patients with N l status.
tomy) were found to have comparable survival and recurrence rates. 1-1 2 In our series, there was a five-year actuarial survival of 65 percent for patients undergoing minimal resection for bronchogenic carcinoma. Other authors have found similar actuarial survival rates after minimal resection for stage I bronchogenic carcinoma (see Table 27 •11 · 12). Survival rates (five-year actuarial) reported for patients undergoing lobectomy or pneumonectomy for stage I bronchogenic carcinoma range from 69 percent to 75 percent (see Table 2 11 •12 •15). Recurrence rates are likewise similar between patients who underwent minimal resection and those being reported for patients who underwent more extensive resections for stage I bronchogenic carcinoma. In our series the local recurrence rate was 13 percent and the distant recurrence rate was 17 percent. These rates are similar to those reported by Jensik et aF for patients undergoing minimal resection (mostly segmentectomy) for stage I bronchogenic carcinoma (see Table 3). Recurrence rates reported by multiple authors for patients undergoing lobectomy or pneumonectomy for stage I bronchogenic carcinoma range from zero to 24 percent for local recurrence and from 3 to 29 percent for distant recurrence (see Table 3 1s. 20). In our series the three patients who subsequently developed a local recurrence had either an adenocarcinoma (two patients) or large-cell carcinoma. No patients with a squamous cell carcinoma developed a local recurrence. As we reported in our previous series, 1 those patients who underwent minimal resection for bronchogenic carcinoma had less operating time required to complete the resection when compared to patients who underwent more extensive resections for stage I bronchogenic carcinoma. Likewise, the length of post-
operative stay was less for patients undergoing minimal resection when compared to patients undergoing lobectomy or pneumonectomy. Our perioperative mortality was zero for patients undergoing minimal resection for stage I bronchogenic carcinoma. In general, these were high-risk patients because of their limited pulmonary reserve. The Lung Cancer Study Group reported a perioperative mortality of 6.2 percent for patients undergoing pneumonectomy, 2.9 percent for patients undergoing lobectomy, and 1.4 percent for patients undergoing minimal resection for stage I bronchogenic carcinoma. 21 In our series, there were four patients who were believed to have a benign lesion diagnosed by frozen section at the time of thoracotomy. All had a wedge resection only, and when the final pathologic examination revealed a malignancy, no further resection was done. Three of these four patients had a bronchoalveolar carcinoma on permanent section, and the fourth patient had a well-differentiated adenocarcinoma. In these patients, there was no lymph node sampling; however, because there was no gross adenopathy at the time of surgery, these patients were staged as having stage I disease. One patient developed a distant recurrence at 76 months and subsequently died at 80 months. The other three patients are free of disease at 62 months, 36 months, and 12 months. The Lung Cancer Study Group has recently closed a randomized prospective study (no. 821) comparing minimal resection to more extensive resection for bronchogenic carcinoma. This study is in the followup phase now, and in the future, there should be an answer concerning the extent of resection for bronTable 3-Recurrencefor Stage 1 (NO) Bronchogenic Carcinoma Recurrences, Percent Treatment and Authors Minimal resection Jensik et al' Crabbe et al Lobectomy/ pneumonectomy Immerman et al•• Martini et al" Pairolero et al" Little et al" Feld et al'• Iascone et al"'
Years
No. of Median Cases Follow-Up, mo L>eal Distant
1957-78 1977-88
168*
? 38
lO
24
12
17 17
1967-75
77
?
12
27
1973-77
llO
21
0
18
1972-78 328
84
6
29
1974-78 91 1977-80 358 ?-1986 34
78 40t 62t
4 lO
12 24 3
24
*Includes ll patients with N l status. tMean. CHEST I 99 I 6 I JUNE. 1991
1423
chogenic carcinoma. Oftentimes, in order to get a complete resection of a stage I bronchogenic carcinoma, a pneumonectomy or lobectomy has to be performed; however, for a small peripheral lesion a complete wedge resection can be easily accomplished. The data from our series suggest that in select patients, minimal resection is an acceptable alternative treatment for stage I bronchogenic carcinoma. REFERENCES
2
3
4 5
6 7 8
9
10
Crabbe MM. Patrissi GA. Fontenelle LJ. Minimal resection for bronchogenic carcinoma: should this be standard therapy? Chest 1989; 95:968 Steele JD, Kleitsh WP, Dunn JE Jr, Buell P. Survival in males \\~th bronchogenic carcinoma resected as asymptomatic solitary pulmonary nodules. Ann Thorac Surg 1966; 2:368-76 Bonfils-Roberts EA. Clagett OT. Contemporary indications for pulmonary segmental resections. J Thorac Cardiovasc Surg 1972; 63:433-38 LeRoux BT. Management of bronchial carcinoma by segmental resection. Thorax 1972; 27:70-4 Jensik RJ, Faber LP, Milloy FJ, Monson DO. Segmental resection for lung cancer: a fifteen-year experience. J Thorac Cardiovasc Surg 1973; 66:563-72 Shields 1W, Higgins GA. Minimal pulmonary resection in treatment of carcinoma of the lung. Arch Surg 1974; 108:420-22 Jensik RJ, Faber LP, Kittle CF. Segmental resection for bronchogenic carcinoma. Ann Thorac Surg 1979; 28:475-83 Hoffman TH, Ransdell HT. Comparison oflobectomy and wedge resection for carcinoma of the lung. J Thorac Cardiovasc Surg 1980; 79:211-17 Stevenson DR, Stair JM, Reed RC. Fifteen years surgical experience ~th carcinoma of the lung. Am J Surg 1983; 146:70811 Miller JI , Hatcher CR Jr. Limited resection of bronchogenic carcinoma in the patient ~th marked impairment of pulmonary
1424
function. Ann Thorac Surg 1987; 44:340-43 11 Williams DE, Pairolero PC, Davis CS, Bernatz PE, Payne WS, Taylor WF, et al. Survival of patients surgically treated for stage I lung cancer. J Thorac Cardiovasc Surg 1981; 82:70-6 12 Errett LE, Wilson J, Chiu R C-J, Munro DD. Wedge resection as an alternative procedure for peripheral bronchogenic carcinoma in poor risk patients. J Thorac Cardiovasc Surg 1985; 90:656 13 Ochsner A, DeBakey M. Surgical considerations of primary carcinoma of the lung: review of the literature and report of 19 cases. Surgery 1940; 8:992-1023 14 Churchill ED, Sweet RH, Scannell JG, Wilkins EW Further studies in the surgical management of carcinoma of the lung. J Thorac Surg 1958; 36:301-08 15 Little AG, DeMeesterTR, Ferguson MK, Skinner DB, Hoffman PC, Skosey C , et al. Modified stage I (T1NOMO, T2NOMO), nonsmall cell lung cancer: treatment results, recurrence patterns, and adjuvant immunotherapy. Surgery 1986; 100:621-28 16 Immerman SC, Vanecko RM, Fry WA, Head LR, Shields TW Site of recurrence in patients ~i:h stage I and II carcinoma of the lung resected for cure. Ann Thorac Surg 1981; 32:23-7 17 Martini N, Beattie EJ. Results of surgical treatment in stage I lung cancer. J Thorac Cardiovasc Surg 1977; 74:499-505 18 Pairolero PC, Williams DE, Bergstrahl EJ, Piehler JM, Bernatz PE, Payne WS. Postsurgical stage I bronchogenic carcinoma: morbid implications of recurrent disease. Ann Thorac Surg 1984; 38:331-38 19 Feld R, Rubinstein LV, Weisenberger TH , the Lung Cancer Study Group. Sites of recurrence in resected stage I non-smallcell lung cancer: a guide for future studies. J Clin Oncol 1984; 2:1352-58 20 Iascone C, Demeester TR, Albertucci M, Little AG, Golomb HM. Local Recurrence of resectable non oat cell carcinoma of the lung: a warning against conservative treatment for NO and N1 disease. Cancer 1986; 57:471 21 Ginsberg RJ, Hill LD, Eagan RT, Thomas P, Mountain CF, Deslauriers J, et al. Modern thirty-day operative mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 1983; 86:654-58
Minimal Resection for Bronchogenic Carcinoma (Crabbe, Patrissi, Fontenelle)
Larry J Fontenelle, M.D.§
Minimal resection with curative intent was performed for 24 patients with stage I bronchogenic carcinoma at our institutions over a 12-year period. This was usually done for patients who could not tolerate more extensive resections. The 6ve-year actuarial survival rate was 65 percent. The rate of local recurrences was 13 percent (3/24), and the rate of distant recurrences was 17 percent (4124), with a
median follow-up of 38 months. Survival and recurrence rates are similar for patients undergoing minimal resection and those being reported for patients undergoing more extensive resections for stage I bronchogenic carcinoma. In selected patients, minimal resection should be considered as an acceptable alternative treatment for patients with stage I bronchogenic carcinoma. (Che•t 1991; 99:1421-24)
T obectomy and pneumonectomy are considered the
one-year follow-up in all patients. Survival was calculated from the date of surgery to the time of death or to the end of the study period. A five-year actuarial survival was determined. Local recurrence was defined as disease recurring in the same operated hemithorax. Distal recurrence was defined as disease recurring anywhere else. Preoperative evaluation included history and physical examination, chest x-ray film, laboratory analysis, pulmonary function tests, bronchoscopy, and tomograms or a computerized axial tomographic scan of the chest. Surgical techniques included the use of a doublelumen endotrachael tube, arterial catheters, epidural catheters, and stapling devices for the wedge resections. Pulmonary artery catheters were employed as indicated. All patients undergoing minimal resection for known bronchogenic carcinoma had a grossly complete resection of the tumor and lymph node sampling. No adjuvant therapy was offered to these patients with stage I disease.
..I...J standard surgical treatments for stage I broncho-
genic carcinoma; however, many patients with potentially resectable bronchogenic carcinoma are not candidates for these procedures because of limited pulmonary reserve. Minimal resection, (ie, wedge resection or segmentectomy) has been performed in these patients with favorable results being reported by many authors. 1- 12 We reported our initial experience with 15 patients who underwent minimal resection with curative intent for stage I bronchogenic carcinoma. 1 We have subsequently expanded our series to a total of 24 patients. In this report the reasons for minimal resection are discussed. Survival and recurrence rates are determined, and these are compared to those being reported by other authors for minimal resection, as well as for more extensive resections, for stage I bronchogenic carcinoma. MATERIALS AND METHODS
The tumor registry records were reviewed for all patients diagnosed with bronchogenic carcinoma at the Biloxi VA Medical Center, USAF Medical Center Keesler, and USAF Medical Center Wright-Patterson over a 12-year period. Those patients undergoing minimal resection for stage I (T1NO; T2NO) disease were identified, and the inpatient as well as the outpatient records were reviewed. Minimal resection was defined as wedge resection or segmentectomy. No patients were lost to follow-up, and there was at least a *From USAF Medical Center Wright-Patterson, Wright-Patterson AFB, Ohio; USAF Medical Center Keesler, Keesler AFB, Miss; and Biloxi VA Medical Center, Biloxi, Miss. All opinions are those of the authors and not necessarily those of the United States Air Force or VA Medical Center. tDepartment of Surgery, USAF Medical Center Wright-Patterson. tBiostatistician, USAF Medical Center Keesler. §Chief, Surgical Service, Biloxi VA Medical Center. Manuscript received September 17; revision accepted November 6. Reprint requests: Dr. Crabbe, Department of Surgery/SCHSG, USAF Medical Center; Wright-lbtterson AFB, Ohio 45433-5300
RESULTS
There was a total of 2,390 patients diagnosed with bronchogenic carcinoma at the Biloxi VA Medical Center (n = 662), USAF Medical Center Keesler (n = 1,331), and USAF Medical Center Wright-Patterson (n=397) from Jan 1, 1977 to Oct 31, 1988. Of these, 477 patients underwent potentially curative resections for bronchogenic carcinoma. One hundred twenty-four patients underwent pneumonectomy, 329 patients underwent lobectomy, 23 patients underwent wedge resection, and one patient underwent segmentectomy. All patients undergoing minimal resection had stage I disease (see Table I). The most common reason for minimal resection was impaired pulmonary function (n = 12). In general, this was defined as a predicted FEV 1 after resection of less than 800 ml if a lobectomy was performed. Four patients underwent wedge resection because of a history of having a previous pulmonary resection. Four patients had a benign lesion diagnosed by frozen section at the time of surgery and were subsequently CHEST I 99 I 6 I JUNE, 1991
1421
Table 1- Patients Undergoing Minimal Resection for Stage I Bronchogenic Carcinoma Case, Sex , Age (yr) 1, M, 49 2, M,69 3, M, 59 4, M,54 5, F, 58 6, M,62 7, F, 72 8, M, 63 9, M, 57 10, M, 61 ll,M , 64 12, M,74 13, F, 72 14, M, 75 15, M, 67 16, M, 63 17, M, 82 18, M, 59 19, M, 56 20, M, 68 21, M, 64 22, F.60 23, M, 62 24 , F.63
Date Surgery oon8 04180 03181 06181 ll/81 02183
06184 07/84 08/84 08/84 12/84 01186 07186 02187 10/87 ll/87 02188 06188 07/88 07/88
08188 10/88 10/88 10/88
Cell Typet
Resection*
Reasont
Stage
W-LLL W-LLL W-RLL S-LLL W-RUL W-LUL W-LLL W-LUL W-RLL W-LUL&LLL W-RLL W-LUL W-RUL W-RLL W-LUL W-LLL W-RUL W-RUL W-RUL W-RLL W-RLL W-LUL W-RUL W-LUL
Previous RUL Previous R UL IPS Misdiagnosis IPS IPS Misdiagnosis IPS IPS Synchronous IPS Previous R UL Misdiagnosis IPS IPS IPS PMS IPS PMS IPS Previous LUL Misdiagnosis IPS PMS
I(T1NO) I(T1NO) I(T1NO) I(T1NO) I(T1NO) I(T1NO) I(TINO) I(TINO) I(TINO) I(T2NO) I(TINO) I(TINO) I(TINO) I(TINO) I(T2NO) I(T2NO) I(TINO) I(T1NO) I(T1NO) I(T2NO) I(T1NO) I(T2NO) I(TINO) I(T1NO)
WDSCC AC UDLCC BAC PDAC WDSCC BAC PDSCC PDAC WDSCC WDAC WDSCC WDAC WDAC UDSCC PDSCC BAC UDLCC WDAC BAC BAC BAC WDAC MDSCC
Survival§
Statusll
D-78 mo D-25mo A-101 mo D-80 mo D-9I mo A-78 mo
DR-50 mo LR-I7 mo NED DR-76mo NED NED NED NED NED NED DR-IOmo NED NED LR-I3 mo NED DR-14 mo NED LR-9mo NED NED NED NED NED NED
A~2mo
A-41 mo D-59mo A-52 mo D-IOmo A-44 mo A-36mo D-13 mo A-23mo D-17 mo A-17 mo D-09mo A-14 mo A-14 mo A-14 mo A-12 mo A-12 mo A-12 mo
*\V, Wedge; S, segmentectomy; LLL, left lower lobe; RLL, right lower lobe; RUL, right upper lobe; and LUL, left upper lobe. tiPS , Impaired pulmonary status; and PMS, poor medical status. tWD, Well differentiated; SCC , small-cell carcinoma; AC, adenocarcinoma; UD, undifferentiated; LCC, large-cell carcinoma; BAC, bronchoalveolar carcinoma; and PD, poorly differentiated. §D . Dead; and A, alive . II DR, Distant recurrence; LR, local recurrence; and NED, no evidence of disease.
found to have a malignant lesion on permanent section. three patients underwent wedge resection because of overall poor medical status, ie, a history of congestive heart failure or recent myocardial infarction. One patient had a wedge resection because of a synchronous lesion found at the time of resection. The perioperative mortality was zero for patients undergoing minimal resection for stage I bronchogenic carcinoma. The five-year actuarial survival for these patients was 65 percent (see Fig 1). There was a local recurrence rate of 13 (3/24) and a distant recurrence rate of 17 percent (4/24), with a median follow-up time of 38 months. DISCUSSION
Pneumonectomy was initially believed to be the standard surgical therapy for bronchogenic carcinoma in the 1930s and 1940s; 13 however, patients who could not tolerate a pneumonectomy underwent a lesser procedure, ie , lobectomy. Those patients who underwent lobectomy were subsequently found to have survival and recurrence rates comparable to those being reported for pneumonectomy. 14 Lobectomy has become a standard surgical treatment for bronchogenic carcinoma. 1422
A similar trend has been noted with respect to minimal resection for bronchogenic carcinoma. Again, there is a group of patients with resectable carcinoma who cannot tolerate a lobectomy. Through retrospective series, patients with stage I bronchogenic carcinoma who underwent minimal resection and more extensive resections (ie, lobectomy or pneumonecC)
z
1.0
> 0 .9 > a: :::;)
Ul
z
0
i= a: 0 Q. 0
a:
D.
w
> i= < ....1
:::;)
:::0
:::;)
(.)
0 .8 0 .7
0 .6 0 .5 0.4 0 .3 0 .2 0.1 0 .0 0 10
20
30
40
50
60
70
80
MONTHS fiGURE 1. Actuarial survival curve for wedge resection for stage I bronchogenic carcinoma.
Minimal Resection for Bronchogenic Carcinoma (Crabbe, Patrissi, Fontenel/e)
Table 2-Survivalfor Stage I (NO) Bronchogenic Carcinoma
Treatment and Authors
Years
Minimal resection 1957-78 Jensik et al' 1972-78 Williams et al" 1965-82 Errett et al" 1977-88 Crabbe et al Lobectomy/pneumonectomy 1972-78 Williams et al" 1974-84 Little et al" 1965-82 Errett et al"
No. of Patients
Five-Year Survival (Actuarial), percent
24
53 64 69* 65
461 91 97§
69 70 75*
168* 22 lOOt
*Includes ll patients with N l status. tlncludes 28 patients with N l status. *Six-year actuarial survival . §Includes 21 patients with N l status.
tomy) were found to have comparable survival and recurrence rates. 1-1 2 In our series, there was a five-year actuarial survival of 65 percent for patients undergoing minimal resection for bronchogenic carcinoma. Other authors have found similar actuarial survival rates after minimal resection for stage I bronchogenic carcinoma (see Table 27 •11 · 12). Survival rates (five-year actuarial) reported for patients undergoing lobectomy or pneumonectomy for stage I bronchogenic carcinoma range from 69 percent to 75 percent (see Table 2 11 •12 •15). Recurrence rates are likewise similar between patients who underwent minimal resection and those being reported for patients who underwent more extensive resections for stage I bronchogenic carcinoma. In our series the local recurrence rate was 13 percent and the distant recurrence rate was 17 percent. These rates are similar to those reported by Jensik et aF for patients undergoing minimal resection (mostly segmentectomy) for stage I bronchogenic carcinoma (see Table 3). Recurrence rates reported by multiple authors for patients undergoing lobectomy or pneumonectomy for stage I bronchogenic carcinoma range from zero to 24 percent for local recurrence and from 3 to 29 percent for distant recurrence (see Table 3 1s. 20). In our series the three patients who subsequently developed a local recurrence had either an adenocarcinoma (two patients) or large-cell carcinoma. No patients with a squamous cell carcinoma developed a local recurrence. As we reported in our previous series, 1 those patients who underwent minimal resection for bronchogenic carcinoma had less operating time required to complete the resection when compared to patients who underwent more extensive resections for stage I bronchogenic carcinoma. Likewise, the length of post-
operative stay was less for patients undergoing minimal resection when compared to patients undergoing lobectomy or pneumonectomy. Our perioperative mortality was zero for patients undergoing minimal resection for stage I bronchogenic carcinoma. In general, these were high-risk patients because of their limited pulmonary reserve. The Lung Cancer Study Group reported a perioperative mortality of 6.2 percent for patients undergoing pneumonectomy, 2.9 percent for patients undergoing lobectomy, and 1.4 percent for patients undergoing minimal resection for stage I bronchogenic carcinoma. 21 In our series, there were four patients who were believed to have a benign lesion diagnosed by frozen section at the time of thoracotomy. All had a wedge resection only, and when the final pathologic examination revealed a malignancy, no further resection was done. Three of these four patients had a bronchoalveolar carcinoma on permanent section, and the fourth patient had a well-differentiated adenocarcinoma. In these patients, there was no lymph node sampling; however, because there was no gross adenopathy at the time of surgery, these patients were staged as having stage I disease. One patient developed a distant recurrence at 76 months and subsequently died at 80 months. The other three patients are free of disease at 62 months, 36 months, and 12 months. The Lung Cancer Study Group has recently closed a randomized prospective study (no. 821) comparing minimal resection to more extensive resection for bronchogenic carcinoma. This study is in the followup phase now, and in the future, there should be an answer concerning the extent of resection for bronTable 3-Recurrencefor Stage 1 (NO) Bronchogenic Carcinoma Recurrences, Percent Treatment and Authors Minimal resection Jensik et al' Crabbe et al Lobectomy/ pneumonectomy Immerman et al•• Martini et al" Pairolero et al" Little et al" Feld et al'• Iascone et al"'
Years
No. of Median Cases Follow-Up, mo L>eal Distant
1957-78 1977-88
168*
? 38
lO
24
12
17 17
1967-75
77
?
12
27
1973-77
llO
21
0
18
1972-78 328
84
6
29
1974-78 91 1977-80 358 ?-1986 34
78 40t 62t
4 lO
12 24 3
24
*Includes ll patients with N l status. tMean. CHEST I 99 I 6 I JUNE. 1991
1423
chogenic carcinoma. Oftentimes, in order to get a complete resection of a stage I bronchogenic carcinoma, a pneumonectomy or lobectomy has to be performed; however, for a small peripheral lesion a complete wedge resection can be easily accomplished. The data from our series suggest that in select patients, minimal resection is an acceptable alternative treatment for stage I bronchogenic carcinoma. REFERENCES
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Minimal Resection for Bronchogenic Carcinoma (Crabbe, Patrissi, Fontenelle)
