Anatomic Segmentectomy for the Solitary Pulmonary Nodule and Early-Stage Lung Cancer

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1 GENERAL THORACIC ORIGINAL ARTICLES: GENERAL THORACIC GENERAL THORACIC SURGERY: The Annals of Thoracic Surgery CME Program is located online at To take the CME activity related to this article, you must have either an STS member or an individual non-member subscription to the journal. Anatomic Segmentectomy for the Solitary Pulmonary Nodule and Early-Stage Lung Cancer Matthew J. Schuchert, MD, Ghulam Abbas, MD, Omar Awais, MD, Arjun Pennathur, MD, Katie S. Nason, MD, MPH, David O. Wilson, MD, Jill M. Siegfried, PhD, James D. Luketich, MD, and Rodney J. Landreneau, MD Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, and Division of Pulmonary Medicine, University of Pittsburgh Medical Center; Department of Pharmacology and Chemical Biology, University of Pittsburgh, Pittsburgh, Pennsylvania Background. Anatomic segmentectomy is a versatile sublobar resection approach that can be both diagnostic and therapeutic in the setting of the indeterminate pulmonary nodule (IPN), metastasectomy, as well as small, peripheral cancers. We analyzed the clinical indications and perioperative outcomes after anatomic segmentectomy and explored its utility in the diagnosis and treatment of IPNs and small stage IA lung cancers. Methods. This study is a retrospective review of 785 consecutive patients undergoing anatomic segmentectomy from 2002 to Primary outcome variables include perioperative course, morbidity, mortality, recurrence patterns, and survival. Results. Surgical indications included IPN (62.4%), known lung cancer (27.6%), suspected metastasis (4.1%), bullous disease (3.7%), or other (2.2%). Video-assisted thoracic surgery was employed in 468 (59.6%) and open thoracotomy in 317 (40.4%) patients. Median length of stay was 6 days. Overall complication rate was 34.9%. Thirty-day mortality was 1.1%. Among 490 patients with an IPN, 381 (77.7%) were found to have lung cancer, 41 (8.4%) metastatic cancer, and 68 (13.9%) benign disease. Among patients with pathologic stage IA lung cancer, there was no difference in recurrence rates (14.5% vs 13.9%) or 5-year freedom from recurrence estimates (78% in each group, p 0.738) when comparing segmentectomy and lobectomy. Conclusions. Anatomic segmentectomy provides acceptable morbidity and mortality when approaching the IPN. Cancer is identified in 86% of lesions. Complete surgical resection can be achieved with generous parenchymal margins and thorough nodal staging for small, peripheral stage IA non-small cell lung cancer. The use of anatomic segmentectomy should be considered in this era of competing image-guided diagnostic and therapeutic approaches to peripheral lung pathology. (Ann Thorac Surg 2012;93:1780 7) 2012 by The Society of Thoracic Surgeons There is renewed interest in the selective use of sublobar resection techniques (anatomic segmentectomy, extended wedge resection) in the management of small stage IA, peripheral non-small cell lung cancers (NSCLC) [1]. In particular, anatomic segmental resection techniques have been shown to achieve comparable rates of recurrence and survival for stage IA NSCLC in several recent large, nonrandomized studies from Japan, the United States, and Europe [2 4]. This subject is currently the focus of an on-going multicenter, prospective, randomized trial comparing sublobar resection versus lobectomy for non-small cell lung cancer 2 cm or less in Accepted for publication Nov 30, Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31 Feb 2, Address correspondence to Dr Schuchert, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Shadyside Medical Building, Ste 715, 5200 Centre Ave, Pittsburgh, PA 15232; schuchertmj@upmc.edu. size (Cancer and Leukemia Group B [CALGB ]) [5]. In addition to achieving a complete (R0) anatomic resection with adequate surgical margins and systematic nodal staging, anatomic segmentectomy may be associated with reduced morbidity and mortality profiles compared with lobectomy (especially in elderly patients over the age of 75) [6], can preserve pulmonary parenchyma and lung function [3, 7], and may be the only feasible surgical option in patients with severe pulmonary impairment that could otherwise not tolerate lobectomy [8]. With the recent publication of the preliminary findings of the National Lung Screening Trial, demonstrating a 20% reduction in mortality with the use of computed tomographic (CT) screening in patients at high risk for lung cancer [9], thoracic surgeons will likely encounter a dramatic increase in the number of small, indeterminate pulmonary nodules in clinical practice [10, 11]. With smaller and smaller lesions, the yield of bronchoscopic or percutaneous biopsy techniques decreases substantially, and sur by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 Ann Thorac Surg SCHUCHERT ET AL 2012;93: SEGMENTECTOMY FOR SOLITARY LUNG NODULES Abbreviation and Acronyms CT computed tomography Dlco lung diffusion capacity for carbon monoxide FEV 1 forced expiratory volume in one second NSCLC non-small cell lung cancer PET positron emission tomography PFTs pulmonary function tests VATS video-assisted thoracic surgery gical resection might be required for both diagnosis and definitive management [12]. If these lesions are deeply seated within the pulmonary parenchyma, localization or palpation at the time of surgery may also prove difficult, especially in the case of infiltrative lesions or ground-glass opacities. Anatomic segmentectomy represents an attractive option in these cases, permitting complete resection of the targeted segment. In addition to rendering a formal tissue diagnosis, this approach preserves parenchyma in the case of benign lesions, yet accomplishes a complete, anatomic R0 resection with systematic nodal staging in the setting of malignancy [13]. In the current study, we present our clinical experience with anatomic segmentectomy in 785 patients. Primary outcome variables include perioperative outcomes (operative time, estimated blood loss, length of stay), morbidity, and mortality. We also explore outcomes after resection of solitary pulmonary nodules, and evaluate the recurrence patterns and survival of patients with clinical stage IA NSCLC. Patients and Methods Patients Approval for this study was provided by the Institutional Review Board of the University of Pittsburgh, and individual patient consent was waived. We performed a review of 785 consecutive patients undergoing formal anatomic segmentectomy at the University of Pittsburgh from 2002 to The decision to perform segmentectomy was based on tumor size and location (ideally peripheral lesions 2cmin size), the patient s underlying cardiopulmonary status and other relevant comorbidities, as well as the desire to achieve parenchymal preservation in the case of indeterminate pulmonary nodules, lesions of low metastatic potential (carcinoid tumors, bronchoalveolar carcinoma, or carcinoma in situ), prior pulmonary resection, and benign processes (bronchiectasis, chronic fungal infections). Patients were identified from the Lung Cancer Database at the University of Pittsburgh. Patient demographics are detailed in Table 1. Operative Technique Anatomic segmentectomy is accomplished by the removal of 1 or more pulmonary parenchymal segments with its corresponding bronchovascular and lymphatic supply [14]. In contradistinction to wedge resection (which does not involve Table 1. Patient Characteristics Characteristic Segmentectomy (n 785) Age Mean Range Gender 365 M, 420 F Comorbidities (%) Hypertension 45.9 Hyperlipidemia 24.0 Coronary artery disease 20.9 Diabetes mellitus 17.0 Peripheral vascular disease 8.5 Prior cancer history 22.9 Gastroesophageal reflux 17.3 PFTs (preop) FEV 1 (%) 1.86 (73.0%) Dlco (%) 14.8 (65.6%) 1781 Dlco lung diffusion capacity for carbon monoxide; FEV 1 forced expiratory volume in one second; PFTs pulmonary function tests. anatomic hilar dissection), anatomic segmentectomy is accomplished by individual isolation and division of the targeted segmental bronchial and vascular structures and complete excision of the segmental pedicle by either an open (n 317, 40.4%) or video-assisted thoracic surgery (VATS; n 468, 59.6%) approach [1, 15]. The distribution of segments performed is provided in Table 2. We prefer the stapled, extended approach to segmentectomy which serves to incorporate the corresponding intersegmental veins (rather than a selective dissection and identification of the intersegmental veins) to minimize the risk of bleeding and prolonged postoperative air leaks [16]. We routinely perform systematic nodal sampling of N1 and N2 lymph nodes intraoperatively to evaluate for the possibility of occult nodal metastases. Particular attention is paid to achieving an adequate surgical margin during the parenchymal division and at frozen section. Based upon prior studies, we try to achieve a surgical margin at least as long as the diameter of the primary tumor [4, 17]. Follow-Up Perioperative data were actively collected from the hospital chart and anesthesia and operating room records, as well as the electronic medical record and office charts for each patient. Complications were documented for each patient within the Lung Cancer Database based upon standard definitions established for the Society of Thoracic Surgeons General Thoracic Database [18]. All patients were followed postoperatively at 2 weeks and at 4 to 6 month intervals for the first 2 years, then yearly thereafter with CT scans. Locoregional recurrence was defined as evidence of tumor within the same lobe, the hilum, or the mediastinal lymph nodes. Distant recurrences were defined as evidence of tumor in another lobe, the pleural space, or elsewhere outside the hemithorax. Perioperative mortality was defined as any pa- GENERAL THORACIC

3 GENERAL THORACIC 1782 SCHUCHERT ET AL Ann Thorac Surg SEGMENTECTOMY FOR SOLITARY LUNG NODULES 2012;93: Table 2. Distribution of Segmental Resections Operation No. Right upper lobe Apical 83 Anterior 43 Posterior 79 Apicoposterior 18 Right middle lobe Medial 10 Lateral 17 Right lower lobe Superior 78 Basilar 76 Left upper lobe Upper division 183 Lingula 69 Left lower lobe Superior 62 Basilar 67 tient who died within the first 30 days after surgery. Ninety-day mortality data were also calculated. Mean follow-up was 31.8 months for the entire cohort. Statistical Analysis The Student t test was used to compare the distributions of continuous data, and the Fisher exact test was used to compare the frequencies of categoric measures between groups. Time to recurrence was defined as the time from surgery to the first diagnosis of local, regional, or distant disease recurrence, or until last-follow-up. Time to recurrence was estimated with the Kaplan-Meier method. Significance was assessed with the log-rank test. Results Patient Characteristics Patient demographics are summarized in Table 1. The mean patient age was 67.0 years (range, 18 to 91 years). The patient cohort had, on average, a moderate degree of pulmonary impairment with a mean forced expiratory volume in one second of 1.86 (73.0% predicted) and a lung diffusion capacity for carbon monoxide of 14.8 (65.6% predicted). Indications for surgery included solitary pulmonary nodule or mass (n 490; 62.4%), biopsyproven non-small cell lung cancer (n 217; 27.6), suspected metastasis (n 32; 4.1%), bullous disease (n 29; 3.7%), lung abscess or infiltrate (n 14; 1.8%), or other (n 3; 0.4%). Perioperative Outcomes The distribution of segmental resections performed is listed in Table 2. Median operative time was 134 minutes (range, 30 to 367 minutes). Median estimated blood loss was 100 ml (range, 25 to 750 ml). Median length of stay was 6 days (range, 2 to 52 days). Overall morbidity was 34.9%, with a major morbidity rate of 9.3%. Pulmonary complications were encountered in 17.3% of patients. The most common significant pulmonary complications were respiratory failure (5.5%), pneumonia (4.5%), and persistent air leak greater than 5 days (3.8%). The most common minor complication was atrial fibrillation or supraventricular tachycardia (6.5%). Table 3 compares perioperative outcomes with previously published, randomized data on segmentectomy. There were 30 conversions (6.4%) from VATS to open in this study. The most common reasons for conversion were inadequate exposure, hilar fibrosis, and bleeding. Four patients (0.5%) were converted from a planned segmentectomy to lobectomy due to inadequate margins, N1 lymph node involvement, or difficulty with parenchymal division. One patient (0.1%) was converted from a segment to an extended wedge. Solitary Pulmonary Lesions Anatomic segmentectomy was performed for both diagnosis and management of 490 patients (62.4%) with solitary pulmonary nodules or mass lesions. In these patients, final pathology revealed non-small cell lung cancer in 359 patients (73.3%), metastasis from a prior cancer in 8.4%, granulomatous disease (6.1%), pneumonia or scar (4.2%), carcinoid tumor (2.9%), bronchoalveolar carcinoma (1.6%), hamartoma (1.2%) and other in Table 3. Perioperative Outcomes After Segmentectomy Variable Current Series (n 785) LCSG (n 82 of 122) Z0030 (n 70) Okada et al (n 230 of 305) Operative time (minutes) 134 NR NR NR EBL (cc) 100 NR NR NR LOS (days) 6 NR NR NR Complications (%) Overall 34.9 NR Pulmonary 17.3 NR 16 NR Mortality (30-day %) (90-day %) 3.0 NR NR NR EBL estimated blood loss; LCSG Lung Cancer Study Group; LN lymph nodes; LOS length of stay; NR not reported; Z0030 American College of Surgeons Oncology Group Z0030 trial.

4 Ann Thorac Surg SCHUCHERT ET AL 2012;93: SEGMENTECTOMY FOR SOLITARY LUNG NODULES Fig 1. Freedom from recurrence after anatomic segmentectomy (blue) and lobectomy (green) after resection for solitary pulmonary lesions ultimately found to represent non-small cell lung cancer. 2.2%. Anatomic segmentectomy was thus performed for malignancy in 86.2% of cases. Among the 41 patients with documented metastatic disease to the lungs from prior cancer, only 2 patients (4.9%) developed locoregional recurrence after anatomic segmentectomy. In addition, among the 22 patients with neoplasms of low malignant potential (carcinoid tumors, bronchoalveolar carcinoma) there have been no documented recurrences. The pathologic stage breakdown among those patients with solitary pulmonary nodules found to represent non-small cell lung cancer was stage 1A (56.2%), 1B (24.4%), 2A (6.6%), 2B (1.6%), 3A (7.8%), 3B (1.9%), and 4 (1.5%). Among those patients with a solitary pulmonary nodule found to represent non-small cell lung cancer, no significant difference was noted in time to recurrence when compared with those treated by lobectomy for the same indication (p 0.672) (Fig 1). Stage IA Non-Small Cell Lung Cancer Among the 576 patients with documented primary non-small cell lung cancer, 325 (56.4%) had pathologically confirmed stage 1A disease. When comparing outcomes to 432 patients undergoing lobectomy for pathologic stage IA NSCLC during the same time period, we found that patients undergoing segmentectomy were older (68.3 vs 66.2 years, p 0.004). There were no significant differences in gender (p 1.00), histology (p 0.1), or surgical approach (p 0.06). The median number of lymph nodes sampled was 5 for segments and 6 for lobes, with a median of 3 lymph node stations sampled in each group. At a mean follow-up of 31.8 months, there were 47 recurrences in the segmentectomy group (14.5%); 17 locoregional, 30 distant. Mean time to recurrence was 20.3 months. Overall recurrence rates were similar between the segmentectomy and lobectomy groups (Table 4). There was no significant difference in either locoregional (5.2% vs 5.3%) or distant (9.2% vs 8.6%) recurrence rates between groups. The majority of recurrences in each group were due to distant disease. Correspondingly, there was no difference in actuarial estimates of time to recurrence when comparing anatomic segmentectomy with lobectomy (77% versus 79% respectively, p 0.67) (Table 4). Impact of Surgical Margin Among all patients with documented non-small cell lung cancer on final pathologic evaluation (stage 1A or stage IB), 60 recurrences have been documented with available margin data. Whereas 65% of these recurrences had a surgical margin less than or equal to 2 cm, 78.3% of these patients were found to have a surgical margin to tumor size ratio less than 1, suggesting that a ratio of margin to tumor size may be a better indicator of recurrence risk when performing sublobar resection [4, 17]. When analyzing all patients with clinical stage I NSCLC, a margin to tumor ratio of less than 1 was associated with a recurrence rate of 13%, compared with 9.8% in cases where the margin to tumor ratio was 1 or greater (p 0.03). Comment 1783 The solitary pulmonary nodule represents one of the most common clinical situations faced by pulmonologists and thoracic surgeons, and can present the treating physician with a significant clinical challenge. More than 150,000 patients with indeterminate pulmonary nodules are identified each year by radiographic evaluation [19]. GENERAL THORACIC Table 4. Recurrence and Survival Patterns; Stage IA Non-Small Cell Lung Cancer Variable Segmentectomy (n 325) Lobectomy (n 432) Significance (p Value) NED 84% 83% 0.77 Overall recurrence 47 (14.5%) 60 (13.9%) 0.83 Locoregional 17 (5.2%) 23 (5.3%) 1.00 Distant 30 (9.2%) 37 (8.6%) 0.80 Freedom from recurrence (5-year) 77% 79% 0.67 NED no evidence of disease.

5 GENERAL THORACIC 1784 SCHUCHERT ET AL Ann Thorac Surg SEGMENTECTOMY FOR SOLITARY LUNG NODULES 2012;93: Though the majority of these nodules will ultimately prove benign, their malignant potential mandates accurate and expeditious diagnosis and management [20]. The combination of CT and positron emission tomographic imaging can accurately predict the presence of malignancy in 47% to 82% of cases depending on tumor size [21]. However, a tissue diagnosis is required unless there is radiographic stability for more than 2 years [22] or obvious benign radiographic characteristics (eg, calcification) [23]. Percutaneous CT-guided biopsy techniques have a sensitivity for diagnosing malignant lesions of greater than 90%; however, specificity can be as low as 50% due to the difficulty in accurately confirming a benign lesion [24]. Their accuracy diminishes rapidly for lesions smaller than 1 cm in diameter. Wedge resection is frequently employed for diagnostic purposes in this setting, and is readily accomplished with a VATS approach [25]. However, VATS wedge resection may not be feasible for small, non-palpable lesions [26], and does not represent the ideal surgical approach for definitive management of non-small cell lung cancer, necessitating completion of a higher order anatomic lung resection (eg, segmentectomy or lobectomy) [8, 27]. The use of an anatomic sublobar resection technique (anatomic segmentectomy) can overcome each of these limitations by accomplishing a complete, anatomic resection of the targeted nodule, providing both definitive diagnosis and therapy. In the current study, anatomic segmentectomy was employed for the management of solitary pulmonary lesions in 490 (62.4%) of cases. It provided definitive management for malignancy in 86.2% of these cases. The morbidity and mortality profile compares favorably with contemporary series such as the American College of Surgeons Oncology Group ZOO30 trial that reported a 46% overall morbidity rate for anatomic segmentectomy with a 3.0% mortality [28] [Table 3]. Anatomic segmentectomy might be advantageous when compared with lobectomy under certain circumstances. It can be performed safely by a VATS approach [16], and is associated with reduced operative time and estimated blood loss and when compared with lobectomy [4]. The morbidity (34.9% vs 49.9%) and mortality (1.1% vs 1.6%) rates also compare favorably with the published results for lobectomy from a propensitymatched analysis utilizing the Society of Thoracic Surgeon s database [29]. These differences have been shown to be especially pronounced in the elderly [6]. Anatomic segmentectomy has also been demonstrated to preserve lung function when compared with lobectomy in the setting of early-stage non-small cell lung cancer [3, 7, 30]. Sublobar resection has historically been associated with an increased risk of locoregional recurrence compared with lobectomy [30]. Anatomic segmentectomy has been shown to have a decreased risk of local recurrence compared with a simple wedge resection, and may more closely approximate the results of lobectomy in terms of recurrence and survival. Okada and colleagues [31] published 5-year survival rates of 96.7% (tumors 2 cm) and 84.6% (tumors 2 to 3 cm), which were superior to those of wedge resections (85.7 and 39.4%, respectively). El-Sherif and colleagues [32] reported a significantly higher risk of locoregional recurrence with wedge resection (14 of 55, 25.5%) compared with anatomic segmentectomy (1 of 26, 3.8%). Importantly, anatomic segmentectomy was associated with equivalent recurrence rates for stage IA NSCLC when compared with lobectomy in the current series [Table 4]. This finding is in accordance with previously published retrospective series, especially for tumors 2 cm or less in size [33]. Anatomic segmentectomy may therefore represent the ideal technique to minimize recurrence in situations where a parenchymal-sparing approach may be beneficial. The chosen approach should ultimately be tailored to individual patient and tumor characteristics, as well as surgeon experience and judgment. In addition to the management of the solitary pulmonary nodule and early-stage lung cancer, anatomic segmentectomy is ideally suited for the management of suspected metastases, chronic infections (eg, fungal), and bronchiectasis, as well as lesions of low metastatic potential (carcinoid tumors, bronchoalveolar carcinoma). During cases of suspected metastases, it is frequently difficult to distinguish a metastatic lesion from a new lung primary at the time of frozen section. The use of segmentectomy affords a complete, yet parenchymal-preserving, anatomic resection that provides definitive management in either circumstance. A similar benefit is attained in the case of carcinoid tumors, where the ability to distinguish between typical and atypical carcinoid tumors at the time of frozen section can be notoriously difficult. Anatomic segmental resection again achieves adequate clearance in both instances, with a 0% recurrence rate to date in the current series. Small ( 1cm) ground-glass opacities detected on CT imaging are frequently associated with early cancers that are highly amenable to anatomic segmentectomy, and can be associated with a 5-year survival of greater than 90% [34]. In addition to a formal anatomic resection with systematic nodal staging, obtaining an adequate surgical margin is an important tenet of lung cancer surgery. We, and others, have previously demonstrated that obtaining a surgical margin to tumor size ratio of greater than 1 can be associated with a decreased recurrence risk [4, 17] after sublobar resection. For resected patients with clinical stage I NSCLC in the current study, we found a similar reduction in recurrence risk when a margin to tumor ratio greater than 1 was achieved (13.0% vs 9.8%, p 0.03). The distance from the tumor to the closest staple line should be assessed at the time of surgery. If the final surgical margin is deemed inadequate after segmentectomy, lobectomy should be performed. There are several limitations with the current analysis. The retrospective design introduces the possibility of bias in patient selection when comparing surgical approaches. Our approach has evolved from thoracotomy early in our experience to VATS in a significant majority of cases over the last 5 years. Prospective, randomized studies, such as the currently active CALGB study, will be necessary to validate the findings of this report. Taken together, these data suggest that anatomic segmentectomy is a versatile procedure that can be performed safely in the setting of the indeterminate pulmo-

6 Ann Thorac Surg SCHUCHERT ET AL 2012;93: SEGMENTECTOMY FOR SOLITARY LUNG NODULES nary nodule and early-stage NSCLC. It is associated with equivalent recurrence patterns in the setting of stage IA disease. A VATS approach is currently preferred in the significant majority of cases. The use of anatomic segmentectomy may be particularly useful in cases where a nonpalpable lesion is localized radiographically to a discrete bronchopulmonary segment. In the era of competing image-guided ablation modalities, anatomic segmentectomy for small tumors maintains the advantage of complete (R 0 ) resection with adequate margins and the opportunity for regional nodal staging, and provides tissue for pharmacogenomic assessment. The authors wish to acknowledge the important contribution of Peg Reamer and Judy Forster in clinical trial enrollment. We would also like to recognize Althea Schneider of the Thoracic Surgery Tumor Registry for her assistance in database management and analysis. 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7 GENERAL THORACIC 1786 SCHUCHERT ET AL Ann Thorac Surg SEGMENTECTOMY FOR SOLITARY LUNG NODULES 2012;93: DISCUSSION DR SCOTT J. SWANSON (Boston, MA): It s a technical operation in some manner. Did everybody in this series have an individual vein, artery, and bronchus divided? Number two, for the VATS cases, was there any rib spreading or rib resection as part of those operations? DR SCHUCHERT: Every case in this series, every single operative report, was analyzed. Only cases where there was individual bronchial and vascular isolation and division were denoted as segmentectomy. All other cases were denoted as wedge resection. Even in cases where it s not clear, perhaps because of the wording, those are excluded. approach where we don t have adequate visualization, but, generally speaking, a segmentectomy can be performed just as easily with VATS as open. DR SUHAS V. PRADHAN (Syracuse, NY): I saw that you had some ground-glass opacities. They are sometimes very difficult to detect even with an open chest in a small area. It looks like you were able to detect that in a collapsed lung at thoracoscopy. DR SCHUCHERT: Yes. DR SWANSON: For the VATS [video-assisted thoracic surgery] cases, was there any rib spreading or rib resection? DR SCHUCHERT: It is dependent, in part, on the surgeon. The general approach is to avoid rib spreading or rib resection. However, in a small percentage of cases, one or two of our surgeons have occasionally removed a small segment of rib to enhance exposure. If the rib spaces are narrow and impeding access to the chest, that can be done through an excision of a small piece of rib at the level of the utility incision. But I would say the general practice by far is to avoid rib spreading and rib resection. DR M. BLAIR MARSHALL (Washington, DC): What is your indication for segmentectomy for a benign lesion over just a wedge resection? DR SCHUCHERT: When the nodules are identifiable and removable with a wedge, I think the wedge is adequate for diagnosis. Occasionally small nodules are not palpable but you know where they are in the segmental territories, so the segmentectomy affords an advantage under those circumstances. DR TODD L. DEMMY (Buffalo, NY): For 30-day and 90-day mortalities, others have observed substantial step up in mortality between those two times. It looks like you have about half the cases being VATS and were concerned that open may increase the complication rates after patients were discharged. Have you seen any change or difference in the mortality rates in 30-day or 90-day mortality for VATS versus open? DR SCHUCHERT: Yes. There is definitely a higher morbidity profile in our open patients compared to VATS, and we have analyzed that previously, and that has been associated with a higher 90-day risk of such complications as readmission and mortality. I don t have that number specifically for this analysis. DR DEMMY: Then I guess, as a follow-up, if you had to open to do a segmentectomy versus staying VATS for a lobe, is that ever part of your decision process? DR SCHUCHERT: That s an excellent question. Our policy is to utilize a VATS approach when appropriate and when possible in any circumstance. The decision to choose segmentectomy versus lobectomy frequently centers on size and location of tumor, adequacy of margin, and less so on type of surgical access. Occasionally we run into technical difficulties with a VATS DR PRADHAN: Question two, I saw that you did a fair number of segmentectomies of the upper lobe, and that s technically pretty difficult to do. DR SCHUCHERT: Yes. The first statement on ground-glass opacities, that sort of centers around what I mentioned to Dr Marshall, that sometimes these lesions are very difficult to detect and may be difficult to find and successfully remove with a simple wedge. If you know what segment it s in, you can remove that segment and feel assured that you re going to get it with careful evaluation of your preoperative CT [computed tomographic] scan. With regard to the upper lobe, we do find the upper lobe, especially the right upper lobe segmentectomies, to be technically the most demanding because of the relationship of the upper lobe vein, underlying artery, and bronchus, and preserving the remaining lung that you leave behind, making sure not to devascularize it or affect the airway adversely. So it is technically more demanding but very feasible for small tumors. DR JOSEPH S. FRIEDBERG (Philadelphia, PA): Great talk. I have two questions. One, do you have an upper size limit where you ll go from a segmentectomy to a lobectomy? I know you said 2 cm generally. DR SCHUCHERT: Yes. DR FRIEDBERG: And the other thing is, when I do these, I have been sending the intersegmental nodes for frozen section to see if it s truly N0. Am I getting carried away? Is that unnecessary? DR SCHUCHERT: I think those are excellent points. Looking at our data, in analyzing our whole segmentectomy experience, all the way up to about 5 cm, our recurrence rates are actually very similar to lobectomy. Certainly for stage IIA tumors, the greater than 5 cm tumors, there is a dramatic fall-off. Segments are not possible because the tumors are so large and they carry a much higher recurrence risk. I think our best recurrence data is for tumors less than 3 cm. So I would say anything less than 3 cm, we find very close recurrence curves for clinical stage I lung cancer. In terms of the frozen section question, I think that s also important. Ideally you want to sample lymph nodes during the course of the case. If you encounter an N1 that s positive, that may be an indication to go to lobectomy to get a more complete, ideally R0 resection, and also systematic N2 nodal sampling or dissection.

8 Ann Thorac Surg SCHUCHERT ET AL 2012;93: SEGMENTECTOMY FOR SOLITARY LUNG NODULES DR SETH FORCE (Atlanta, GA): That was a great talk. Obviously the main reason to do segmentectomies is for parenchymal preservation. Do you have any data on preoperative and postoperative lung function in your lobectomy patients versus your segmentectomy patients and whether you re actually sparing as much function as you think? 1787 DR SCHUCHERT: That s an excellent question, I think a very important question. We are now compiling that data and we re actually actively prospectively collecting that data. I don t have those numbers to share with you. This has been studied by several other groups and there has been demonstration of some improvement in lung function in previously published papers with the segmental resection approach. GENERAL THORACIC