VATS Lobektomie

Surgical outcomes

At the end of 2019, the VIOLET investigators reported that patients woho underwent VATS lobectomy experienced significantly fewer in-hopsital complications compared with those who underwent open lobectomy (32.8% vs. 44.3%; p=0.008), as well as a shorter length of stay (4 vs. 5 days; p =0.008)

Oncological issues

Technical Aspects

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Umgang R1 Resektion

difficult-dicesion #erweiterte-resektion

Frau Uhl, VATS Lobektomie OL links. R1-Resektion an Bronchus-Absetzungsrand. keine Manschettenresektion, weil „Qualität“ des Hauptbronchus für Manschettenresektion nicht geeignet sei (Witte). Gute Ausrede. Pat auch sehr adipös. Risikopatientin

Functional preservation

VATS Segmentektomie

wichtige Topics über Segmentektomie

• oncological issues (lymph node dissection)
• preservation of pulmonar function
• morbidity.
• technical aspects

Oncological issues

3 completed studies on Segmentectomy vs lobectomy

SevLobT1a study (stamatis dgt)

Meeting-2022-Vortrag-Stamatis-SevLobT1a-DGT

• prospective randomized phase III
• DACH deutsch-sprachige Länder: 11 zentren
• n= 107: 53 segmentecotmy, 54 lobectomy
• 2012 bis 2021
• primary outcome: QoL, OS, 2. outcome: morbidity, DFS
• vergleichsweise wenig VATS!: 23% bei Segmentektomie, 43% bei Lobektomie (fast 80% VATS bei CAGLB study)
• 5y OS: NS, DFS: segmentectomy better, local recurrence: NS recommendation
• LAD in all levels: segmental, interlobar, hilar and mediastinal
• Switch from segmentectomy to lobectomy in case of N1 or N2 (_PS: wirklich nötig?!)
• R0 and margin > 2cm; if < 2 cm partial or complet resection of proximate segments
• for NLPA: lobectomy may better than segmentectomy

CALGB 140503 trial USA

• n > 690, cT1a/ stage IA (<= 2 cm)
• sublobar (58,8% wedge) vs lobectomy
• OS und DFS: NS,
• segmentectomy: higher local recurrence, but lower? distal relapse (15,2% vs 16,8%)!? sehr hohe Fernmetastasenrate!
• vergleichsweise schlechte studienqualität, hohe komplikationsrate (morbidity 51%, 54% for segmentectomy and lobectomy), kein Bericht über R0-resektion status.
• omission of oncological principles in sublobar resection SLR?

Altorki N, Wang X, Kozono D, Watt C, Landrenau R, Wigle D, Port J, Jones DR, Conti M, Ashrafi AS, Liberman M, Yasufuku K, Yang S, Mitchell JD, Pass H, Keenan R, Bauer T, Miller D, Kohman LJ, Stinchcombe TE, Vokes E. Lobar or Sublobar Resection for Peripheral Stage IA Non-Small-Cell Lung Cancer. N Engl J Med. 2023 Feb 9;388(6):489-498. doi: 10.1056/NEJMoa2212083. PMID: 36780674; PMCID: PMC10036605.

Datei 202310141812

in Sublobar group: 59% wedge resection!

Abstract
Background: The increased detection of small-sized peripheral non-small-cell lung cancer (NSCLC) has renewed interest in sublobar resection in lieu of lobectomy.

Methods: We conducted a multicenter, noninferiority, phase 3 trial in which patients with NSCLC clinically staged as T1aN0 (tumor size, ≤2 cm) were randomly assigned to undergo sublobar resection or lobar resection after intraoperative confirmation of node-negative disease. The primary end point was disease-free survival, defined as the time between randomization and disease recurrence or death from any cause. Secondary end points were overall survival, locoregional and systemic recurrence, and pulmonary functions.

Results: From June 2007 through March 2017, a total of 697 patients were assigned to undergo sublobar resection (340 patients) or lobar resection (357 patients). After a median follow-up of 7 years, sublobar resection was noninferior to lobar resection for disease-free survival (hazard ratio for disease recurrence or death, 1.01; 90% confidence interval [CI], 0.83 to 1.24). In addition, overall survival after sublobar resection was similar to that after lobar resection (hazard ratio for death, 0.95; 95% CI, 0.72 to 1.26). The 5-year disease-free survival was 63.6% (95% CI, 57.9 to 68.8) after sublobar resection and 64.1% (95% CI, 58.5 to 69.0) after lobar resection. The 5-year overall survival was 80.3% (95% CI, 75.5 to 84.3) after sublobar resection and 78.9% (95% CI, 74.1 to 82.9) after lobar resection. No substantial difference was seen between the two groups in the incidence of locoregional or distant recurrence. At 6 months postoperatively, a between-group difference of 2 percentage points was measured in the median percentage of predicted forced expiratory volume in 1 second, favoring the sublobar-resection group.

Conclusions: In patients with peripheral NSCLC with a tumor size of 2 cm or less and pathologically confirmed node-negative disease in the hilar and mediastinal lymph nodes, sublobar resection was not inferior to lobectomy with respect to disease-free survival. Overall survival was similar with the two procedures. (Funded by the National Cancer Institute and others; CALGB 140503 ClinicalTrials.gov number, NCT00499330.).

JCOG0802 Trail

Lancet 2022;399:1607-17

• more than 1000 pts
• segmentectomy (vs. lobectomy): OS: segmentectomy better, DFS: segmentectomy better, local recurrence rate: segmentectomy worse :-(, equivalent postoperative morbidity

Lymphadenektomie / Lymph node dissection

(inter)segmental lymph node
[[02_Lunge_VATS_Segmentectomy/Webinar-ESTS-Segmentectomy-Gossot2022/Note-ESTS-Webinar-Segmentektomie-Gossot#Issue of LN dissection]]

Specialty of location / site

• S6 Segmentectomy has poor oncological results: margin?

[[02_Lunge_VATS_Segmentectomy/Webinar-ESTS-Segmentectomy-Gossot2022/Note-ESTS-Webinar-Segmentektomie-Gossot#Differences according to segments]]

[[Technical Aspects]]

Functional preservation

Changes in Pulmonary Function in lobectomy vs. Segmentectomy vs WedgeResection

Poonyagariyagorn (2008). „Lung Cancer Preoperative Pulmonary Evaluation of the Lung Resection Candidate.“

There is not much literature about the differences in loss of pulmonary function when a lobectomy is performed compared with when a lesser resection is performed.

One study reported the 12-month postoperative FEV1 to be 93.3% of the preoperative value in patients with normal lung function who underwent segmentectomy.19 This was compared with a value of 87.3% of the preoperative value in those who had a lobectomy.
Another report comparing changes in pulmonary function after lobectomy and segmentectomy for stage I lung cancer found the FVC, FEV1, maximum voluntary ventilation (MVV), and DLCO all decreased after lobectomy.113 Only the DLCO was decreased in those who had a segmentectomy. A final report reviewed 40 patients who had undergone thoracotomy—13 had a wedge resection, 14 a lobectomy, and 13 a thoracotomy alone due to finding an inoperable tumor.114 There was no decline in measures of pulmonary function or exercise capacity in the wedge resection group. Similar declines were seen in the lobectomy and thoracotomy alone
groups (perhaps a result of progression of the tumor or the effect of radiation therapy in the thoracotomy alone group).(Poonyagariyagorn 2008)