Segmentectomy Supported for Select NSCLC Patients

SAN FRANCISCO – Thoracic surgeons should not shy away from segmentectomy in select patients with NSCLC, an expert advises, because the technique confers specific advantages.

In addition, it is as feasible as lobectomy. "If you can do a lobectomy, you can do a segmentectomy. There is no doubt about it," Dr. Matthew J. Schuchert said at the annual meeting of the American Association for Thoracic Surgery.

He shared patient selection criteria and technique tips based on experience with the more than 800 segmentectomies performed at the University of Pittsburgh Medical Center/UPMC Cancer Institute, where he is a general and thoracic surgeon.

Anatomic segmentectomy accomplishes the fundamental surgical tenets achieved by lobectomy, including R0 resection, adequate margins, and an opportunity for systematic nodal staging in early lung cancer, Dr. Schuchert said.

Lung preservation is another potential benefit of segmentectomy and the procedure is particularly useful for tumors with low malignancy potential where you may not have to take out an entire lobe to gain oncologic control, he said.

Equivalent survival to lobectomy has been demonstrated for stage 1A disease, especially for lesions smaller than 2 cm. In addition, "there may be decreased morbidity and mortality risk, especially among the elderly, a population we are going to be seeing more and more of."

Patient selection is paramount. In addition to the elderly, segmentectomy is particularly suitable for patients with marginal pulmonary function; those with "ground glass opacity" that may have low nodal positivity rates; and those who had prior lobectomy seeking parenchymal preservation.

"If you are contemplating the use of segmentectomy, it all really comes down to evaluation of the case," he said. Preoperative imaging ideally reveals a small tumor (less than 2 cm) in the outer one third of the lung. In addition, tumors should be confined to a discrete segmental boundary. "That’s critical. That’s the ticket for success," he said.

Surgeons can use the same anatomic approach they employ for lobectomy, only direct it at one segment. It is important to know segmental vascular and segmental bronchial anatomy, Dr. Schuchert noted.

"All of the same anatomic concerns, exposure concerns, and dissection concerns and techniques really apply." Segmentectomy can be performed through video-assisted thoracic surgery (VATS) or an open approach; the majority of cases at the University of Pittsburgh are VATS.

"We typically position the camera at about the seventh interspace in the mid-axillary line. Along the same interspace, a little more posteriorly, we will utilize a 10-mm incision for retraction and stapling. The access incision is pretty much the same as it is for a VATS lobectomy, usually somewhere along the line of the inframammary crease, and we place it right over the anterior hilum." This incision is usually around the level of the minor fissure on the right and slightly above the major fissure on the left, he added. Next, a 5-mm incision is made for retraction; it can also be particularly useful during node dissection, Dr. Schuchert said.

Preservation of the remaining lung is always a goal. "If you devitalize the remaining lung or impinge upon the bronchial supply, that patient is going to be doomed to have some perioperative issues." Remember that segmentectomy is a functional operation as well, he pointed out. "We are not just taking things out; what we leave behind still has to work."

Dissection assisted by an energy device is a more recent development in their hands. "We have now utilized energy in well over 100 patients undergoing both segmentectomy and lobectomy," he said.

Another essential goal of segmentectomy is to achieve a margin-to-tumor ratio greater than the size of the tumor itself, he said. As an example, he cited the case of a 71-year-old man with a history of diverticulitis with a pulmonary nodule picked up on an abdominal CT scan. The nodule was 1.7 cm, well confined in the outer third of the lung, and well centered within the basilar segment. Fine-needle aspiration of the nodule revealed adenocarcinoma. "He was considered to be an excellent candidate for segmentectomy. In this case, the margin was about 5 cm for a 1.7-cm tumor."

He and his colleagues published additional details of the segmentectomies they performed between 2002 and 2010 at UPMC in a retrospective study (Ann. Thorac. Surg. 2012:93:1780-7).

He said that he had no disclosures.

SAN FRANCISCO – Thoracic surgeons should not shy away from segmentectomy in select patients with NSCLC, an expert advises, because the technique confers specific advantages.

In addition, it is as feasible as lobectomy. "If you can do a lobectomy, you can do a segmentectomy. There is no doubt about it," Dr. Matthew J. Schuchert said at the annual meeting of the American Association for Thoracic Surgery.

He shared patient selection criteria and technique tips based on experience with the more than 800 segmentectomies performed at the University of Pittsburgh Medical Center/UPMC Cancer Institute, where he is a general and thoracic surgeon.

Anatomic segmentectomy accomplishes the fundamental surgical tenets achieved by lobectomy, including R0 resection, adequate margins, and an opportunity for systematic nodal staging in early lung cancer, Dr. Schuchert said.

Lung preservation is another potential benefit of segmentectomy and the procedure is particularly useful for tumors with low malignancy potential where you may not have to take out an entire lobe to gain oncologic control, he said.

Equivalent survival to lobectomy has been demonstrated for stage 1A disease, especially for lesions smaller than 2 cm. In addition, "there may be decreased morbidity and mortality risk, especially among the elderly, a population we are going to be seeing more and more of."

Patient selection is paramount. In addition to the elderly, segmentectomy is particularly suitable for patients with marginal pulmonary function; those with "ground glass opacity" that may have low nodal positivity rates; and those who had prior lobectomy seeking parenchymal preservation.

"If you are contemplating the use of segmentectomy, it all really comes down to evaluation of the case," he said. Preoperative imaging ideally reveals a small tumor (less than 2 cm) in the outer one third of the lung. In addition, tumors should be confined to a discrete segmental boundary. "That’s critical. That’s the ticket for success," he said.

Surgeons can use the same anatomic approach they employ for lobectomy, only direct it at one segment. It is important to know segmental vascular and segmental bronchial anatomy, Dr. Schuchert noted.

"All of the same anatomic concerns, exposure concerns, and dissection concerns and techniques really apply." Segmentectomy can be performed through video-assisted thoracic surgery (VATS) or an open approach; the majority of cases at the University of Pittsburgh are VATS.

"We typically position the camera at about the seventh interspace in the mid-axillary line. Along the same interspace, a little more posteriorly, we will utilize a 10-mm incision for retraction and stapling. The access incision is pretty much the same as it is for a VATS lobectomy, usually somewhere along the line of the inframammary crease, and we place it right over the anterior hilum." This incision is usually around the level of the minor fissure on the right and slightly above the major fissure on the left, he added. Next, a 5-mm incision is made for retraction; it can also be particularly useful during node dissection, Dr. Schuchert said.

Preservation of the remaining lung is always a goal. "If you devitalize the remaining lung or impinge upon the bronchial supply, that patient is going to be doomed to have some perioperative issues." Remember that segmentectomy is a functional operation as well, he pointed out. "We are not just taking things out; what we leave behind still has to work."

Dissection assisted by an energy device is a more recent development in their hands. "We have now utilized energy in well over 100 patients undergoing both segmentectomy and lobectomy," he said.

Another essential goal of segmentectomy is to achieve a margin-to-tumor ratio greater than the size of the tumor itself, he said. As an example, he cited the case of a 71-year-old man with a history of diverticulitis with a pulmonary nodule picked up on an abdominal CT scan. The nodule was 1.7 cm, well confined in the outer third of the lung, and well centered within the basilar segment. Fine-needle aspiration of the nodule revealed adenocarcinoma. "He was considered to be an excellent candidate for segmentectomy. In this case, the margin was about 5 cm for a 1.7-cm tumor."

He and his colleagues published additional details of the segmentectomies they performed between 2002 and 2010 at UPMC in a retrospective study (Ann. Thorac. Surg. 2012:93:1780-7).

He said that he had no disclosures.

SAN FRANCISCO – Thoracic surgeons should not shy away from segmentectomy in select patients with NSCLC, an expert advises, because the technique confers specific advantages.

In addition, it is as feasible as lobectomy. "If you can do a lobectomy, you can do a segmentectomy. There is no doubt about it," Dr. Matthew J. Schuchert said at the annual meeting of the American Association for Thoracic Surgery.

He shared patient selection criteria and technique tips based on experience with the more than 800 segmentectomies performed at the University of Pittsburgh Medical Center/UPMC Cancer Institute, where he is a general and thoracic surgeon.

Anatomic segmentectomy accomplishes the fundamental surgical tenets achieved by lobectomy, including R0 resection, adequate margins, and an opportunity for systematic nodal staging in early lung cancer, Dr. Schuchert said.

Lung preservation is another potential benefit of segmentectomy and the procedure is particularly useful for tumors with low malignancy potential where you may not have to take out an entire lobe to gain oncologic control, he said.

Equivalent survival to lobectomy has been demonstrated for stage 1A disease, especially for lesions smaller than 2 cm. In addition, "there may be decreased morbidity and mortality risk, especially among the elderly, a population we are going to be seeing more and more of."

Patient selection is paramount. In addition to the elderly, segmentectomy is particularly suitable for patients with marginal pulmonary function; those with "ground glass opacity" that may have low nodal positivity rates; and those who had prior lobectomy seeking parenchymal preservation.

"If you are contemplating the use of segmentectomy, it all really comes down to evaluation of the case," he said. Preoperative imaging ideally reveals a small tumor (less than 2 cm) in the outer one third of the lung. In addition, tumors should be confined to a discrete segmental boundary. "That’s critical. That’s the ticket for success," he said.

Surgeons can use the same anatomic approach they employ for lobectomy, only direct it at one segment. It is important to know segmental vascular and segmental bronchial anatomy, Dr. Schuchert noted.

"All of the same anatomic concerns, exposure concerns, and dissection concerns and techniques really apply." Segmentectomy can be performed through video-assisted thoracic surgery (VATS) or an open approach; the majority of cases at the University of Pittsburgh are VATS.

"We typically position the camera at about the seventh interspace in the mid-axillary line. Along the same interspace, a little more posteriorly, we will utilize a 10-mm incision for retraction and stapling. The access incision is pretty much the same as it is for a VATS lobectomy, usually somewhere along the line of the inframammary crease, and we place it right over the anterior hilum." This incision is usually around the level of the minor fissure on the right and slightly above the major fissure on the left, he added. Next, a 5-mm incision is made for retraction; it can also be particularly useful during node dissection, Dr. Schuchert said.

Preservation of the remaining lung is always a goal. "If you devitalize the remaining lung or impinge upon the bronchial supply, that patient is going to be doomed to have some perioperative issues." Remember that segmentectomy is a functional operation as well, he pointed out. "We are not just taking things out; what we leave behind still has to work."

Dissection assisted by an energy device is a more recent development in their hands. "We have now utilized energy in well over 100 patients undergoing both segmentectomy and lobectomy," he said.

Another essential goal of segmentectomy is to achieve a margin-to-tumor ratio greater than the size of the tumor itself, he said. As an example, he cited the case of a 71-year-old man with a history of diverticulitis with a pulmonary nodule picked up on an abdominal CT scan. The nodule was 1.7 cm, well confined in the outer third of the lung, and well centered within the basilar segment. Fine-needle aspiration of the nodule revealed adenocarcinoma. "He was considered to be an excellent candidate for segmentectomy. In this case, the margin was about 5 cm for a 1.7-cm tumor."

He and his colleagues published additional details of the segmentectomies they performed between 2002 and 2010 at UPMC in a retrospective study (Ann. Thorac. Surg. 2012:93:1780-7).

He said that he had no disclosures.