Câncer de Pulmão Estádio Câncer de Pulmão Estádio IA. Quais os limites da IA. Quais os limites da ressecção sublobar?ressecção sublobar?

Carlos Antônio Stabel DaudtJoinville, Santa Catarina

Ginsberg RJ, Rubenstein LV for the Lung Ginsberg RJ, Rubenstein LV for the Lung Cancer Study Group. Randomized trial of Cancer Study Group. Randomized trial of lobectomy vs. limited ressection for T1N0 lobectomy vs. limited ressection for T1N0 non-small cell lung cancer. Ann Thorac Surg non-small cell lung cancer. Ann Thorac Surg 1995;60:615-231995;60:615-23

Recidiva local 3 vezes maior

O uso de ressecção sub-lobar e O uso de ressecção sub-lobar e segmentectomia é aceito para segmentectomia é aceito para doenças benignas e carcinoma doenças benignas e carcinoma metastático.metastático. Também é aceito como Também é aceito como um procedimento razoável para um procedimento razoável para ressecção em pacientes com câncer e ressecção em pacientes com câncer e função pulmonar comprometida.função pulmonar comprometida.

Qual é a controvérsia?Qual é a controvérsia?Quem ainda acha que a lobectomia é o “padrão ouro” para Estadio IA?

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Pubmed:Pubmed:sublobar resection lung cancersublobar resection lung cancer124 citações

Nakamura H, Kawasaki N, Taguchi M, Nakamura H, Kawasaki N, Taguchi M, Kabasawa K. Survival followingKabasawa K. Survival followinglobectomy vs. limited resection for stage I lobectomy vs. limited resection for stage I lung cancer: a meta-analysis.lung cancer: a meta-analysis.Br J Cancer 2005;92:1033–1037.Br J Cancer 2005;92:1033–1037.

Sem diferença estatisticamente significativa. 2790 pacientes, 1970-2004, 14 estudos, 12 retrospectivos. Muita heterogeneidade no

estudo, pelo longo tempo avaliado, e as diferentes indicações para ressecções sub-lobares.

Lobectomy versus sublobar resection for small (2 cm or less) non-small cell lung cancers. Wolf AS, Richards WG, Jaklitsch MT, Gill R, Chirieac LR, Colson YL, Mohiuddin K, Mentzer SJ, Bueno R, Sugarbaker DJ, Swanson SJ. Ann Thorac Surg. 2011 Nov;92(5):1819-23; discussion 1824-5. Epub 2011 Oct 31.Estudo retrospectivo de 2000 a 2005 – Tendência para maior recidiva local. Pacientes no grupo sub-lobar eram mais velhos e com função pulmonar pior.

J Natl Cancer Inst. 2011 Nov 2;103(21):1621-9. Epub 2011 Sep 29.J Natl Cancer Inst. 2011 Nov 2;103(21):1621-9. Epub 2011 Sep 29.Predictors and outcomes of limited resection for early-stage non-small cell lung cancer.Predictors and outcomes of limited resection for early-stage non-small cell lung cancer.Billmeier SE, Ayanian JZ, Zaslavsky AM, Nerenz DR, Jaklitsch MT, Rogers SO.Billmeier SE, Ayanian JZ, Zaslavsky AM, Nerenz DR, Jaklitsch MT, Rogers SO.SourceSourceDepartment of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, 75 Francis St, Boston, MA Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA. sbillmeier@partners.org02115, USA. sbillmeier@partners.orgAbstractAbstractBACKGROUND: BACKGROUND: Lobectomy is considered the standard treatment for early-stage non-small cell lung cancer (NSCLC); however, more Lobectomy is considered the standard treatment for early-stage non-small cell lung cancer (NSCLC); however, more limited resections are commonly performed. We examined patient and surgeon factors associated with limited resection limited resections are commonly performed. We examined patient and surgeon factors associated with limited resection and compared postoperative and long-term outcomes between sublobar and lobar resections.and compared postoperative and long-term outcomes between sublobar and lobar resections.METHODS: METHODS: A population- and health system-based sample of patients newly diagnosed with stage I or II NSCLC between 2003 and A population- and health system-based sample of patients newly diagnosed with stage I or II NSCLC between 2003 and 2005 in five geographically defined regions, five integrated health-care delivery systems, and 15 Veterans Affairs hospitals 2005 in five geographically defined regions, five integrated health-care delivery systems, and 15 Veterans Affairs hospitals was observed for a median of 55 months, through May 31, 2010. Predictors of limited resection and postoperative was observed for a median of 55 months, through May 31, 2010. Predictors of limited resection and postoperative outcomes were compared using unadjusted and propensity score-weighted analyses. All P values are from two-sided tests.outcomes were compared using unadjusted and propensity score-weighted analyses. All P values are from two-sided tests.RESULTS: RESULTS: One hundred fifty-five (23%) patients underwent limited resection and 524 (77%) underwent lobectomy. In adjusted One hundred fifty-five (23%) patients underwent limited resection and 524 (77%) underwent lobectomy. In adjusted analyses of patient-specific factorsanalyses of patient-specific factors, smaller tumor size (P = .004), coverage by Medicare or Medicaid, no insurance or , smaller tumor size (P = .004), coverage by Medicare or Medicaid, no insurance or unknown insurance (P = .02), more severe lung disease (P < .001), and a history of stroke (P = .049) were associated with unknown insurance (P = .02), more severe lung disease (P < .001), and a history of stroke (P = .049) were associated with receipt of limited resectionreceipt of limited resection. In adjusted analyses of surgeon characteristics. In adjusted analyses of surgeon characteristics, thoracic surgery specialty (P = .02), non-fee-, thoracic surgery specialty (P = .02), non-fee-for-service compensation (P = .008), and National Cancer Institute cancer center designation (P = .006)for-service compensation (P = .008), and National Cancer Institute cancer center designation (P = .006) were associated were associated with higher odds of limited resection. Unadjusted 30-day mortality was higher with limited resection than with lobectomy with higher odds of limited resection. Unadjusted 30-day mortality was higher with limited resection than with lobectomy (7.1% vs 1.9%, difference = 5.2%, 95% confidence interval [CI] = 1.5% to 10.8%, P = .003), and the adjusted difference was (7.1% vs 1.9%, difference = 5.2%, 95% confidence interval [CI] = 1.5% to 10.8%, P = .003), and the adjusted difference was not statistically significant (6.5% vs 2.9%, difference = 3.6%, 95% CI = -.1% to 9.2%, P = .09). Postoperative complications not statistically significant (6.5% vs 2.9%, difference = 3.6%, 95% CI = -.1% to 9.2%, P = .09). Postoperative complications did not differ by type of surgery (all P > .05). Over the course of the study, a non-statistically significant trend toward did not differ by type of surgery (all P > .05). Over the course of the study, a non-statistically significant trend toward improved long-term survival was evident for lobectomy, compared with limited resection, in adjusted analyses (hazard improved long-term survival was evident for lobectomy, compared with limited resection, in adjusted analyses (hazard ratio of death = 1.35 for limited resection, 95% CI = 0.99 to 1.84, P = .05).ratio of death = 1.35 for limited resection, 95% CI = 0.99 to 1.84, P = .05).CONCLUSIONS: CONCLUSIONS: Evidence is statistically inconclusive but suggestive that lobectomy, compared with limited resection, is associated with Evidence is statistically inconclusive but suggestive that lobectomy, compared with limited resection, is associated with increased long-term survival for early-stage lung cancer. Clinical, socioeconomic, and surgeon factors appear to be increased long-term survival for early-stage lung cancer. Clinical, socioeconomic, and surgeon factors appear to be associated with the choice of surgical resection.associated with the choice of surgical resection.

smaller tumor size (P = .004), coverage by smaller tumor size (P = .004), coverage by Medicare or Medicaid, no insurance or unknown Medicare or Medicaid, no insurance or unknown insurance (P = .02), more severe lung disease insurance (P = .02), more severe lung disease (P < .001), and a history of stroke (P = .049) (P < .001), and a history of stroke (P = .049) were associated with receipt of limited were associated with receipt of limited resectionresection. In adjusted analyses of surgeon . In adjusted analyses of surgeon characteristicscharacteristics, thoracic surgery specialty (P , thoracic surgery specialty (P = .02), non-fee-for-service compensation (P = .02), non-fee-for-service compensation (P = .008), and National Cancer Institute cancer = .008), and National Cancer Institute cancer center designation (P = .006)center designation (P = .006) were associated were associated with higher odds of limited resectionwith higher odds of limited resection

Sublobar resection provides an equivalent survival after Sublobar resection provides an equivalent survival after lobectomy in elderly patients with early lung cancer.lobectomy in elderly patients with early lung cancer.Okami J, Ito Y, Higashiyama M, Nakayama T, Tokunaga T, Maeda J, Okami J, Ito Y, Higashiyama M, Nakayama T, Tokunaga T, Maeda J, Kodama K.Kodama K. Ann Thorac Surg. 2010 Nov;90(5):1651-6.Ann Thorac Surg. 2010 Nov;90(5):1651-6.

1990-20072 grupos: idosos (=> 75 anos); jovens (<75 anos) IA

Sublobar resection provides Sublobar resection provides an equivalent survival after lobectomy in elderly patients with early lung an equivalent survival after lobectomy in elderly patients with early lung cancer.cancer.Okami J, Ito Y, Higashiyama M, Nakayama T, Tokunaga T, Maeda J, Kodama K. Okami J, Ito Y, Higashiyama M, Nakayama T, Tokunaga T, Maeda J, Kodama K. Ann Thorac Surg. 2010 Nov;90(5):1651-6Ann Thorac Surg. 2010 Nov;90(5):1651-6

Idosos n: 133 Jovens n:631

79 lobectomias e 54 sub-lobares

74,3% e 67,6% (ns p<0.92)

Recidiva local 1,3% e 11,1%

539 lobectomias e 92 sub-lobares

Sobrevida 90,9% e 64% (p<0.0001)

Recidiva local 12.0% e 1,5%

PAPEL DA RESSECÇÃO LIMITADA NA CIRURGIA DO CÂNCER DE PAPEL DA RESSECÇÃO LIMITADA NA CIRURGIA DO CÂNCER DE PULMÃO PULMÃO

Paulo de BiasiPaulo de BiasiLivro Virtual

Livro 01 - Tópicos de atualização em cirurgia torácicaVários autores - 61 capítulos disponíveis em PDF.

< 2cm.

Does lobectomy achieve better survival and recurrence rates Does lobectomy achieve better survival and recurrence rates than limited pulmonary resection for T1N0M0 non-small cell than limited pulmonary resection for T1N0M0 non-small cell lung cancer patients?lung cancer patients?Chamogeorgakis T, Ieromonachos C, Georgiannakis E, Mallios Chamogeorgakis T, Ieromonachos C, Georgiannakis E, Mallios D. Interact Cardiovasc Thorac Surg. 2009 Mar;8(3):364-72. D. Interact Cardiovasc Thorac Surg. 2009 Mar;8(3):364-72. Epub 2008 Jul 18. Epub 2008 Jul 18.

PMID: 18641014 [PubMed - indexed for MEDLINE] Free full text PMID: 18641014 [PubMed - indexed for MEDLINE] Free full text

4. Search strategyMedline 1950 to May 2008 using OVID interface (Limitedresection.mp OR sublobar.mp OR wedge resection.mp ORlimited pulmonary resection.mp OR limited lung resection.mp OR conservative resection.mp OR conservative pulmonaryresection.mp OR wedge excision.mp OR segmentectomy.mp) AND (Carcinoma, Non-Small-Cell Lungyornon-small cell lung cancer.mp) Resultado: 255 publicações, dos quais 19 apresentavam melhor evidência.

Journal of Thoracic Oncology: Journal of Thoracic Oncology: October 2010 - Volume 5 - Issue 10 - pp October 2010 - Volume 5 - Issue 10 - pp

1583-15931583-1593

Sublobar Resection: A Movement from the Lung Cancer Study Group

Blasberg, Justin D. MD*; Pass, Harvey I. MD†‡¶; Donington, Jessica S. MD†¶

Table 7Table 7

TABLE 7. Tumor, Resection, and Patient Characteristics Associated with Improved Survival After Sublobar Resection for NSCLC

Copyright © 2012 Journal of Thoracic Oncology. Published by Lippincott Williams & Wilkins. 15

Sublobar Resection: A Movement from the Lung Cancer Study GroupBlasberg, Justin D.; Pass, Harvey I.; Donington, Jessica S.Journal of Thoracic Oncology. 5(10):1583-1593, October 2010.doi: 10.1097/JTO.0b013e3181e77604

Qual é a controvérsia?Qual é a controvérsia?Quem ainda acha que a lobectomia é o “padrão ouro” para Estadio IA?

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Phase III Randomized Study of Lobectomy Phase III Randomized Study of Lobectomy Versus Sublobar Resection in Patients With Versus Sublobar Resection in Patients With

Small Peripheral Stage IA Non-Small Cell Small Peripheral Stage IA Non-Small Cell Lung Cancer Lung Cancer

ObjectivesPrimaryCompare the disease-free survival of patients with small (≤ 2 cm) peripheral stage IA non-small cell lung cancer undergoing lobectomy vs sublobar resection (wedge resection or segmentectomy).

Secondary-Compare the overall survival of patients undergoing lobectomy vs sublobar resection.-Compare the rates of loco-regional and systemic recurrence in patients undergoing lobectomy vs sublobar resection.-Compare the pulmonary function of these patients, as measured by expiratory flow rates at 6 months postoperatively.-Explore the relationship between characteristics of the primary lung cancer, as revealed by pre-operative CT scan and positron emission tomography (PET) imaging, and outcomes. -Determine the false-negative rate of preoperative PET scan for identification of involved hilar and mediastinal lymph nodes.-Assess the utility of annual follow-up CT scan after surgical resection in these patients.

Entry CriteriaEntry CriteriaDisease Characteristics:Disease Characteristics:

Suspected or proven non-small cell lung cancer (NSCLC), meeting both Suspected or proven non-small cell lung cancer (NSCLC), meeting both preoperative and intraoperative criteria: preoperative and intraoperative criteria:

Preoperative criteria Preoperative criteria -Peripheral lung nodule ≤ 2 cm by CT scan -Peripheral lung nodule ≤ 2 cm by CT scan -Center of the tumor must be located in the outer third of the lung in either -Center of the tumor must be located in the outer third of the lung in either the transverse, coronal, or sagittal planthe transverse, coronal, or sagittal plan-Tumor location must be suitable for either lobar or sublobar resection (wedge -Tumor location must be suitable for either lobar or sublobar resection (wedge resection or segmentectomy)resection or segmentectomy)-No pure ground opacities or pathologically confirmed N1 or N2 disease-No pure ground opacities or pathologically confirmed N1 or N2 disease

Intraoperative criteria Intraoperative criteria Histologically confirmed NSCLCHistologically confirmed NSCLC-Confirmation of N0 status by frozen section examination of nodal levels 4, 7, -Confirmation of N0 status by frozen section examination of nodal levels 4, 7, and 10 on the right side and 5, 6, 7, and 10 on the left side* and 10 on the right side and 5, 6, 7, and 10 on the left side* -Levels 4 and 7 nodes may be sampled by mediastinoscopy, endobronchial -Levels 4 and 7 nodes may be sampled by mediastinoscopy, endobronchial ultrasound (EBUS), and/or endoscopic ultrasound (EUS), or at the time of ultrasound (EBUS), and/or endoscopic ultrasound (EUS), or at the time of thoracotomy or video-assisted thoracoscopic surgery (VATS) exploration*thoracotomy or video-assisted thoracoscopic surgery (VATS) exploration* [Note: *Nodes previously sampled by mediastinoscopy (or EBUS and/or EUS)  [Note: *Nodes previously sampled by mediastinoscopy (or EBUS and/or EUS) either immediately before or within 6 weeks of the definitive surgical either immediately before or within 6 weeks of the definitive surgical procedure (thoracotomy or VATS) do not need to be resampled]procedure (thoracotomy or VATS) do not need to be resampled]-No evidence of locally advanced or metastatic disease-No evidence of locally advanced or metastatic disease

OutlineOutlineThis is a multicenter, randomized study. Patients are stratified according to This is a multicenter, randomized study. Patients are stratified according to tumor size (< 1 cm vs 1-1.5 cm vs > 1.5-2.0 cm) (based on the maximum tumor size (< 1 cm vs 1-1.5 cm vs > 1.5-2.0 cm) (based on the maximum dimension determined from the preoperative scan), histology (squamous dimension determined from the preoperative scan), histology (squamous cell carcinoma vs adenocarcinoma vs other), and smoking status (never cell carcinoma vs adenocarcinoma vs other), and smoking status (never smoked [smoked < 100 cigarettes over lifetime] vs former smoker [smoked smoked [smoked < 100 cigarettes over lifetime] vs former smoker [smoked > 100 cigarettes AND quit ≥ 1 year ago] vs current smoker [quit < 1 year > 100 cigarettes AND quit ≥ 1 year ago] vs current smoker [quit < 1 year ago or currently smokes]). Patients are randomized to 1 of 2 treatment ago or currently smokes]). Patients are randomized to 1 of 2 treatment arms.arms.

Arm I:Arm I: Patients undergo lobectomy by open thoracotomy or video- Patients undergo lobectomy by open thoracotomy or video-assisted thoracoscopic surgery (VATS).assisted thoracoscopic surgery (VATS). Arm II:Arm II: Patients undergo a wedge resection or anatomical Patients undergo a wedge resection or anatomical segmentectomy by open thoracotomy or VATS. segmentectomy by open thoracotomy or VATS. After completion of study treatment, patients are followed up After completion of study treatment, patients are followed up every 6 months for 2 years and then annually for 5 years.every 6 months for 2 years and then annually for 5 years.

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Aproximadamente 300 randomizados , faltam 392. n: 692.

Novo Estadiamento:Novo Estadiamento:T1a (=< 2cm) e T1b(>2-T1a (=< 2cm) e T1b(>2-3cm). Ambos são 1A3cm). Ambos são 1A