Comparison Of Surgical Procedures For Early Stage Non-small Cell Lung Cancer

PartⅠ: Pulmonary function changes after video-assisted thoracoscopic lobectomy versus segmentectomy for early stage lung cancersObjective: To compare pulmonary function changes after video-assisted thoracoscopic lobectomy and segmentectomy.Methods: Pulmonary function changes after video-assisted thoracoscopic lobectomy and segmentectomy were evaluated in this prospective observational study.Between 2012 and 2017,427 patients with stage IA non-small cell lung cancer who underwent video-assisted thoracoscopic lobectomies or video-assisted thoracoscopic segmentectomies were included in Shanghai Chest Hospital.Information was collected such as age,gender,height and weight,preoperative comorbidities,history of pulmonary surgery,history of smoking,the location of tumor.Spirometry tests,including forced vital capacity(FVC),forced expiratory volume in 1 second(FEV1)and diffusing capacity of the lungs for carbon monoxide(DLCO),were performed preoperatively and 6 months postoperatively.Changes after different resection extents were then compared.Results: Between 2012 and 2017,237 video-assisted thoracoscopic lobectomies and 190 video-assisted thoracoscopic segmentectomies were included in Shanghai Chest Hospital.There were 56 left upper division segmentectomies.Other than that,most patients in the segmentectomy group received single segmentectomy.No differences existed in demographic characteristics and preoperative pulmonary function between the segmentectomy group and the lobectomy group.FVC,FEV1,and DLCO loss after lobectomy were significantly greater than after segmentectomy in general(all the three indexes: P<0.01).However,average pulmonary function loss for each subsegment resected was significantly greater after segmentectomy than that after lobectomy(all the three indexes: P<0.01).When the number of subsegments resected was no greater than half of the corresponding lobe,the loss of FVC,FEV1 and DLCO after segmentectomy were significantly less than after lobectomy(all the three indexes: P<0.01,similar results can be detected before the propensity score matching or after the propensity score matching.Otherwise,there were no significant differences in spirometry changes between segmentectomy and lobectomy when the number of subsegments resected was greater than half of the corresponding lobe(FVC: P=0.055;FEV1: P=0.985;DLCO: P=0.733).Conclusions: Overall,video-assisted thoracoscopic segmentectomy may help to preserve more pulmonary function than video-assisted thoracoscopic lobectomy.However,average pulmonary function loss is greater after segmentectomy than after lobectomy when calculated by each subsegment resected.Therefore,the number of subsegments resected need to be considered when deciding the extent of resection for patients with early stage NSCLC.When the number of subsegments resected is more than half of the total number of subsegments in the corresponding lobe,such as basal segmentectomy or left upper division segmentectomy,segmentectomy has no functionpreserving advantage over lobectomy.PartⅡ: Comparison of postoperative complication after video-assisted thoracoscopic lobectomy versus segmentectomy for early stage lung cancersObjective: To compare the incidence of postoperative complications after video-assisted thoracoscopic lobectomy and segmentectomy.Methods: Between 2012 and 2017,469 patients with stage IA non-small cell lung cancer who underwent video-assisted thoracoscopic lobectomies or video-assisted thoracoscopic segmentectomies were included in Shanghai Chest Hospital.Information was collected such as age,gender,height and weight,preoperative comorbidities,history of lung surgery,history of smoking,and postoperative complications recorded.The incidences of postoperative complications were compared after lobectomy and segmentectomy and correlative factors were detected.Multivariate Logistics regression analysis was used to analyze the incidence of postoperative complications.Results: Of the 469 patients with stage IA non-small cell lung cancer enrolled,261 patients underwent video-assisted thoracoscopic lobectomy and 208 patients underwent video-assisted thoracoscopic segmentectomy.The postoperative technical complications included 22 cases of diaphragmatic paralysis,12 cases of air leakage,1 case of incisional hernia,1 case of subcutaneous emphysema,4 cases of recurrent laryngeal nerve injury,and 1 case of postoperative re-intubation.Meanwhile,the postoperative functional complications were mainly atrial fibrillation.In terms of overall technical complications,multivariate logistic regression analysis showed that the incidences of postoperative technical complications were related with surgical procedures performed(lobectomy or segmentectomy)(OR=0.447;95% CI: 0.218-0.917;P=0.028).The analysis of two major types of technical complications showed that the incidence of diaphragmatic paralysis was significantly higher after lobectomy than that after segmentectomy(OR=0.353;95% CI: 0.128-0.975;P=0.045);meanwhile,as to air leakage,male(OR=0.208;95% CI: 0.055-0.783;P=0.020)and increasing age(OR=1.084;95% CI: 1.004-1.170;P=0.039)was independent risk factors;and the surgical procedures performed was not0 significantly related to the incidence of postoperative air leakage(P=0.243).In terms of functional complications,univariate analysis showed that the incidence of postoperative atrial fibrillation may be connected with increasing age(P = 0.042),the extent of lymph node resection(P = 0.011),and surgical procedures performed(P = 0.007),but multivariate analysis indicated none of the above three factors was the independent risk factors of the incidence of postoperative functional complications.Conclusions: The incidence of diaphragmatic paralysis after video-assisted thoracoscopic lobectomy is higher than video-assisted thoracoscopic segmentectomy;except for diaphragmatic paralysis,there are no significant differences between videoassisted thoracoscopic lobectomy and segmentectomy no matter in the incidences of postoperative technical and functional complications.PartⅢ: Oncological prognosis after video-assisted thoracoscopic lobectomy versus segmentectomy for early stage lung cancersObjective: To compare the oncological prognosis after video-assisted thoracoscopic lobectomy and segmentectomy.Methods: Between 2012 and 2017,327 patients with T1 b N0M0 non-small cell lung cancer who underwent video-assisted thoracoscopic lobectomies or segmentectomies were included in Shanghai Chest Hospital according to the eighth edition TNM staging.Information was collected such as age,gender,preoperative comorbidities,history of pulmonary surgery,history of smoking,serum tumor marker and follow-up information.The survival and recurrence after video-assisted thoracoscopic lobectomies or segmentectomies were compared.Results: 327 patients with T1 b N0M0 non-small cell lung cancer were enrolled according to the eighth edition TNM staging,including 150 lobectomies and 173 segmentectomies.Of the 327 patients,321 patients were still alive,6 patients were dead;316 patients had no evidences of recurrence and metastasis,and postoperative recurrence and metastasis happened in 11 patients.80 patients diagnosed with microinvasive adenocarcinoma pathologically survived and had no evidences of postoperative recurrence and metastasis.Univariate analysis showed that the overall survival of non-small cell lung cancer was related with the density of lesion on CT(P=0.004)and surgical procedures(P=0.079).Recurrence-free survival was related with the density of lesion on CT(P=0.017)and tumor markers elevated(P = 0.086). Multivariate Cox analysis showed that the independent risk factors for survival were the density of lesion on CT(HR=0.099,95% CI: 0.018-0.547,P=0.008),and the surgical procedures did not affect postoperative survival significantly(P =0.073);The independent risk factor affecting recurrence-free survival was the density of lesion on CT(HR=0.262,95% CI: 0.080-0.860,P=0.027).The surgical procedures still did not affect the postoperative recurrence significantly(P =0.145).For subsolid nodules,there were no significant differences between segmental resection and lobectomy in overall survival(P=0.169)and recurrence-free survival(P=0.336);similarly,there were no significant differences between segmental resection and lobectomy for solid nodules in overall survival(P = 0.111)and recurrence-free survival(P = 0.238).Conclusion: For microinvasive adenocarcinoma diagnosed pathologically within 2 cm,lobectomy and segmentectomy can achieve similar oncological prognosis.For invasive adenocarcinoma within 2 cm,the density of lesion on preoperative CT was the independent risk factor for overall survival and recurrence-free survival,while there was no significant difference between lobectomy and segmentectomy in overall survival and recurrence-free survival.For solid nodules diagnosed with invasive adenocarcinomas pathologically within 2 cm,there was no significant difference between lobectomy and segmentectomy in overall survival and recurrence-free survival.