Open Segmentectomy for Early Stage Lung Cancer

1. Open Segmentectomy for Early Stage Lung Cancer Douglas E. Wood Professor and Chief Division of Cardiothoracic Surgery Vice-Chair, Department of Surgery Endowed Chair in Lung Cancer Research University of Washington

2. Segmentectomy Why? When? How? What?

3. Segmentectomy Why and when? LDCT screening nodules If the patient cannot tolerate lobectomy (but can tolerate an operation) Resection still preferred over SBRT If it is oncologically equivalent (or nearly so) Metastases Adenocarcinoma in situ (bronchoalveolar carcinoma) ? Peripheral <2cm node negative NSCLC

5. Segmentectomy Evidence, guidelines, and practice direct lobectomy as standard resection LCSG 821 ↓ local recurrence p=0.02 ↑ survival p=0.09

7. 3. In patients with stage I and II NSCLC who are medically fit for conventional surgical resection, lobectomy or greater resection are recommended rather than sublobar resections (wedge or segmentectomy). Grade of recommendation, 1A 4. In patients with stage I NSCLC who may tolerate operative intervention but not a lobar or greater lung resection because of comorbid disease or decreased pulmonary function, sublobar resection is recommended over nonsurgical interventions. Grade of recommendation, 1B

9. 3. In patients with stage I and II NSCLC who are medically fit for conventional surgical resection, lobectomy or greater resection are recommended rather than sublobar resections (wedge or segmentectomy). Grade of recommendation, 1A 4. In patients with stage I NSCLC who may tolerate operative intervention but not a lobar or greater lung resection because of comorbid disease or decreased pulmonary function, sublobar resection is recommended over nonsurgical interventions. Grade of recommendation, 1B

10. Segmentectomy Segment versus wedge Size and location Margins Lymph nodes Eligible segments Right apical, anterior, posterior, superior, medial basilar, basilar Left apicoposterior, anterior, lingular, superior, anteromedial basilar, basilar

11. Segmentectomy Individual division of segmental vessels and bronchus Stapling of parenchyma and fissures Nodal staging

13. Disease-Free Survival Overall Survival

19. J ThoracCardiovascSurg 2012; 143:390-7.

22. Cancer Specific Survival

23. Cancer Specific Survival (<2.1 cm tumors)

24. Segmentectomy In general, lobectomy preferred High-risk patients Poor pulmonary reserve Multiple primaries Possibly select “favorable” tumors Peripheral Node negative < 2 or <3 cm Non-solid nodule or AIS histology Evidence of long doubling time

25. Segmentectomy VATS versus open – no difference Nodal staging paramount Adequate margins Segment versus wedge Similar principles May be adequate for select tumors SBRT may become a reasonable alternative