| BACKGROUNDLung cancer is a leading cause of cancer-related mortality and a common disease of the elderly. Surgical resection is a conventional treatment for the early stage of lung cancer [1、2] especially for the early stage non-small-cell lung cancer. However, in much time, most of patients have lose chances for surgical operation because of diagnose terminal stage. The statistics of National Cancer Institute have shown that the lung cancer mainly occurs in those aged between 75 and 79 and the peak mortality rate is between 75 and 84 years, depending on gender [3] The technique of video-assisted thoracic surgery (VATS) is a well-established technique in the armamentarium of the thoracic surgeon and currently indicated for a wide spectrum of pulmonary diseases, including primary lung cancer [9-12] Pulmonary lobectomy is the removal of one of the five lobes of the lung and Anatomic pulmonary segments is the removal of the lung tumor and a rim of healthy lung tissue around the tumor [4] Pulmonary lobectomy combined with systematic lymphadenectomy or sampling is the gold standard for lung cancer for the moment.Nakanura reported that [8] 411 patients were followed up for 5 years of research, according to the results of patients with stage IA NSCLC, The 5-year survival rate of lung segment resection and lobectomy resection was the same. Trodell L [9] reported that there were no statistically significant difference in treatment of stage IA for non-small cell lung cancer with lung segment resection or lobectomy resection.This confirms feasibility and efficacy of segment resection in treatment of stage IA(for diameter< 2 cm of the patients with lung cancer) for non-small cell lung cancer.However, a lot of elderly patients usually have severe cardiopulmonary and other system dysfunctions and are unable to tolerate the pulmonary lobectomy. Therefore, patients who severely compromised pulmonary function, advanced age or other extensive comorbidity cannot tolerate a full lobectomy, a more limited operation is recommended [5-7].Segmental resection has also been considered for the treatment of patients with primary lung cancer and poor cardiopulmonary function [13]. Moreover, the risk of operation is gradually rising along with the rise of age [14]. It could only be a local excision though these elderly high-risk patients treated with VATS. And the systematic lymphadenectomy or sampling might be simplified or omitted because of the operative risk. Some clinical, socioeconomic, and surgeon factors were statistically significantly associated with the choice of surgical resection for early-stage NSCLC [15]. Compared with lobectomy, anatomic pulmonary segments better preserves lung functions while removing small nodules [6]. On the other hand, the risk of pulmonary lobectomy for elderly patients is greatly reduced along with the maturity of thoracoscopic lobectomy and lymphadenectomy, and advanced age is no longer a barrier of the VATS radical resection [16]. But there still not sufficient evidence to support the efficacy and long term survival rate of lung segment resection in treatment of stage IB NSCLC (for tumor diameter>2 to<3cm of the patients with lung cancerTherefore, we designed this study to evaluate the long term outcomes and efficacy of thoracoscopic anatomic resections and systematic lymphadenectomy for elderly high-risk patients with stage IB (pT status:>2 to≤3) non-small-cell lung cancer.Methods:242 elderly patients (≥65 years) were divided into two groups, which were defined high-risk group and conventional risk group from August 2008 to December 2010, who were performed by the same surgical team. All patients were diagnosed in stage IB (pT status:>2 to≤3) NSCLC by biopsy before operation.The high-risk patients were identified with severe cardiopulmonary and other system dysfunctions as follow up criteria. They were treated with VATS anatomic pulmonary segments and systematic lymphadenectomy.The conventional risk patients with adequate cardiopulmonary reserve were treated with VATS radical lobectomy and systematic lymphadenectomy. We had recorded all the clinical and pathological data.Outcomes were stratified for tumor size and American Joint Committee on Cancer seventh edition TNM stage for NSCLC. The total survival, five years survival, tumor-free survival, rocal tumor recurrence time and character of patients were recorded as followed up.Appropriate statistical analyses involved the x2 test and Kaplan-Meier estimates of total survival and tumor-free survival.The patients were identified to be high-risk if one of the following descriptions had conformed to the medical history and preliminary results. Otherwise, the patients were subjected into the conventional risk group. The criteria for high-risk were shown as follows:All patients were diagnosed stage IB NSCLC by biopsy before operation. The conventional risk group were received the VAST radical resection and the systematic lymphadenectomy. The high-risk group were received the VAST Anatomic pulmonary segments and the systematic lymphadenectomy.By the end of December 2010, the cases of the elderly high-risk group with the treatment of VAST Anatomic pulmonary segments and the elderly conventional risk group with the treatment of VAST radical resection were 116 and 126 respectively.Operative procedureThe VAST radical resection group:The patients were required with conventional lateral position. The incision for observation is 1.2 cm in length and is located at the midaxillary line or anterior-axillary line of the 7th or 8th intercostal space. The incision for the main operation is generally located between the anterior-axillary line and mid-nipple line at the 4th or 5th intercostal space. The length of this incision differs with different minimally invasive styles. The length for c-VATS (complete-VATS) is between 3 and 5 cm. A 1.2-cm incision for the auxiliary operation is made between the posterior-axillary line and the scapular line of the same intercostal space as used for the incision for observation. Bronchia, pulmonary vasculature and inter-lobar fissure were cut off or sutured by the corresponding endoscopic cut stapler respectively. Then systematic lymphadenectomy was performed. The VAST anatomic pulmonary segments group:The operative incision was the same as the previous group or the incision in the 8th rib under scapula was omitted, and the patients were required with conventional lateral position. Wedge-shaped excision of lung was performed 2 cm from the edge of the tumor using endoscopic cut stapler after the location of the tumor was determinate by palpation and video.Results:A total of 242 patients had underwent surgical resection during our study period: Anatomic pulmonary segments in 116 patients and lobectomy in 126. The operative time and blood loss of the VATS anatomic pulmonary segments group (78.0±35.0 min,95.6±30.4 ml) were significantly less than those of the VATS radical resection group (108.0±25.0min,165.6±58.4ml). Neither groups had postoperative death. The overall and tumor-free survival rate of the VATS anatomic pulmonary segments group within five years were 62.07% and 29.31%, and those of the VATS radical resection group were 63.49% and 33.33%,there was without significant difference (P>0.5). The recurrence rates of the VATS Anatomic pulmonary segment group and VATS radical resection group were 13.79% and 12.70%, there was without significant difference (P>0.5).Data collectingThe age, gender, site of the tumor, operative time, blood loss, postoperative complications, Dissected lymph nodes, hospital stay, postoperative deaths within 30 days, size of the tumor, pleural invasion, T stage and pathological stage of the 242 cases were collected. And the histological type and differentiation of tumor were determinate by histological sections. Postoperative complications were the symptoms that occurred within 30 days post operation including:Air leak (lasting≥7 days), Atrial fibrillation, Serous drainage (requiring drainage≥7 days),Pneumonia, Anastomotic fistula, Myocardial infarction, Empyema, Atelectasis, Subcutaneous air (requiring reinsertion of chest tube or subcutaneous catheter).The Patient characteristics and operative data were shown in Table 1 and Table 2.There was no significant difference in the age, gender, position of the tumor, tumor size, histological type, Smoking status, T stage and pathological stage between the two groups. The histological types of VAST anatomic pulmonary segments group were 70cases of Non-squamous cell carcinoma,46cases of squamous carcinoma. The histological types of VATS radical resection group were 74cases of Non-squamous cell carcinoma,52cases of squamous carcinoma. Dissected nodal stations Dissected lymph nodesa of VAST anatomic pulmonary segments group were: 7.5±1.5,12.5±5.5,Dissected nodal stations and Dissected lymph nodesa of VATS radical resection group were:7.5±1.5,13.5±5.5,Though the patient characteristics and operative data of the two groups had no obvious difference. The operative time and blood loss and Chest tube duration, days and Postoperative hospital stay, days of the VATS anatomic pulmonary segments group (78.0±35.0 min,95.6±30.4 ml, 6.5±2.5days,2.2±1.2days) were significantly less than those of the VATS radical resection group (108.0±25.0min,165.6±58.4ml8.5±2.5days,3.2±1.9days). Neither groups had postoperative death.The overall survival, tumor-free survival, time and patterns of recurrence of all patients were collected by follow-up visits. It was necessary to provide pathological evidence of the recurrence and metastasis of tumor as much as possible in principle, such as, lymph node biopsies or needle biopsy of lung. It could be inferred as recurrence or metastasis when more than two different imaging examinations had demonstrated the possibility of metastasis in the condition that unable to obtain pathology.Statistical analysisComparison of the postoperative recovery and follow-up visits The postoperative recovery and follow-up visits of the two groups were shown in Table 3. The Anastomotic fistula,Atrial fibrillation,Serous drainage (requiring drainage≥7 days),Pneumonia,Subcutaneous air (requiring reinsertion of chest tube or subcutaneous catheter),Myocardial infarction,Empyema,Atelectasis,Air leak (lasting ≥7 days), Anastomotic fistula, Atelectasis of the VATS anatomic pulmonary segmentsgroup(4(3.45%),2(1.72%),2(1.72%),2(1.72%),2(1.72%),2(1.72%),2(1.72%)0(0%),0(0 %))were significantly less than those of the VATS radical resection group (8(6.35%),4(3.17%),8(6.35%),4(3.17%),4(3.17%),2(1.59%),2(1.59%), 2(1.59%)2(3.17%)).The recurrence rates and 5-year actuarial survival and 5-year tumor free survival of the VATS anatomic pulmonary segments group and VATS radical resection group were 13.79%,62.07%,29.31% and 12.70%, 63.49%,33.33% without significant difference (P>0.5).Data were entered in Excel and imported into PASW Statistics (SPSS Inc.) for analysis. Statistical analysis was performed by the SPSS version 20.0 statistical software. The measurement data were expressed as X---±SD and analyzed by T-test. Meanwhile,x2-test was used to analyze the enumeration data. The method of Kaplan-Meier was applied to analyze the overall survival and the tumor-free survival, and the statistical evaluation was conducted by Log-Rank test. There is significantly statistical difference when P<0.05.ConclusionsThroacoscopic segmentectomy under anesthesia and systematic lymphadenectomy is a safe and minimally invasive and effective to treat a selected group of patients with stage IB NSCLC. |
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