Accomplishes fundamental surgical tenets of R0 resection with systematic nodal staging for NSCLC Equivalent survival for Stage 1A disease
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1 Segmentectomy Made Simple Matthew J. Schuchert and Rodney J. Landreneau Department of Cardiothoracic Surgery University of Pittsburgh Medical Center
2 Financial Disclosures none
3 Why Consider Anatomic Segmentectomy? Accomplishes fundamental surgical tenets of R0 resection with systematic nodal staging for NSCLC Equivalent survival for Stage 1A disease Decreased morbidity and mortality risk - esp. in the elderly Lung Preservation - esp. in marginal patients, prior surgery, tumors of low malignant potential
4 Surgical Approach Anatomic Segmentectomy and Lobectomy - Tenets Same fundamental principles as lobectomy VATS vs. Open Individual bronchial and vascular isolation and division Extended segmentectomy with stapled parenchymal margin R0 Resection Adequate surgical margins Lymph node sampling (N1/N2)
5 VATS Segmentectomy VATS APPROACH
6 Patient Selection Favorable Criteria for Anatomic Segmentectomy Small Tumors: < 2 cm in diameter Confined to a discrete segmental boundary Peripheral location (outer 1/3) Pathologic Margin (Margin/Tumor ratio>1) Elderly (Age >80) Marginal pulmonary function (FEV1/DLCO < 60%) Ground glass opacities Adenocarcinoma in situ Prior lung resection Solitary Pulmonary Nodule Metastases
7 Segments Resected Operation n 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 Total 785
8 Incisional Access Camera: 7th Interspace, Mid-Axillary Line Retraction/Stapler: 7th Interspace, Posterior Axillary Line Access Incision: Inframammary Crease, Anterior Axillary Line Stab Incision Axillary hair line
9 General Principles Hilar approach avoid dissecting in fissure when possible Vein - Artery - Bronchus Exceptions: Superior and Posterior Segments Individual bronchial and vascular isolation and division; develop and complete fissures with stapled approach Stapled extended segmentectomy Preserve integrity of remaining lung Be mindful of aberrant anatomy
10 Segmental Pearls Right Upper Lobe Right Upper Lobe Vein anteroapical and interlobar branches Vein - Artery - Bronchus Smaller vascular branches can be divided with energy or clipped Posterior artery may arise as a proximal trunk from the main PA, as a side-branch of the anteroapical trunk or as a recurrent branch arising from the superior segment artery
11 Segmental Pearls Left Upper Lobe Left Upper Lobe Vein Upper Division and Lingular branches Vein - Artery - Bronchus Variable arterial anatomy multiple posterior branches Lingular artery may arise as a proximal trunk from the main PA, as a side-branch of the first apicoposterior trunk or as a recurrent branch arising from the basilar segment artery
12 Segmental Pearls Right Middle Lobe Right Middle Lobe Vein typically arises from upper lobe vein Vein - Bronchus - Artery Frequently incomplete fissure The middle lobe artery may arise as a common trunk or frequently as paired segmental branches
13 Segmental Pearls Lower Lobes Anatomic relationships most constant Lower Lobe Vein small superior trunk runs posterior to bronchus Vein - Artery - Bronchus Arterial variations include accessory branches from the RML or lingular arteries to the anterior basilar segment, accessory branches to superior segment from the basilar artery and recurring branches to the lingula and RUL posterior segment
14 Pure Energy Ease of use Open and VATS Low profile jaws facilitate instrument positioning Excellent hemostasis during the course of resection Can assist in development of the fissures Minimal thermal spread (2-3 mm) Reduced operative costs
15 Energy - Upper Division Pulmonary Vein
16 Energy - Upper Division Pulmonary Artery
17 Anatomic Segmentectomy 71 M Long-time smoker CT: 1.7 cm Lung Nodule No enlarged lymph nodes FNA: Adenocarcinoma
18 Basilar Segmentectomy Basilar Vein Superior Segmental Vein Superior Segmental Vein Divided Basilar Vein
19 Basilar Segmentectomy Basilar Artery
20 Basilar Segmentectomy Basilar Bronchus
21 Basilar Segmentectomy
22 Basilar Segmentectomy
23 T1a NSCLC ( 2 cm) Segmentectomy (n=227) Lobectomy (n=336) P Value 44 (19.4%) 11 (4.8%) 33 (14.5%) 49 (14.6%) 12 (3.6%) 37 (11.0%) Recurrence Locoregional Distant ACS 2011 P=0.18 Lobectomy Segmentectomy Time (Months) Freedom from Death (%) Freedom from Recurrence (%) Propensity-Matching (n=162) P=0.16 Lobectomy Segmentectomy Time (Months)
24 Sublobar Resection Why Consider Anatomic Segmentectomy? Decreased mortality risk in the elderly Lung Preservation - esp. in marginal patients Solitary Pulmonary Nodule - Diagnostic and Therapeutic Metastasectomy; GGOs Accomplishes fundamental surgical tenets of R0 resection with systematic nodal staging for NSCLC Taking more tissue does not enhance survival esp. small tumors Taking less tissue (e.g. SRS, RFA) does not accomplish R0 resection or systematic nodal staging
25 Conclusions Anatomic Segmentectomy can be performed safely in the setting of the indeterminate pulmonary nodule or clinical stage I NSCLC. Anatomic segmentectomy is associated with equivalent recurrence-free survival rates compared with lobectomy for clinical stage IA disease. Same anatomic dissection techniques as lobectomy Careful attention to adequacy of margin and preservation of residual bronchovascular unit In the era of image-guided ablation modalities, segmental resection for Stage I tumors affords complete resection with adequate margins, regional nodal staging and provides tissue for pharmacogenomic assessment.
26 Thank You
27
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