What is the treatment approach for disease affecting bronchopulmonary segments?

Treatment of Disease Affecting Bronchopulmonary Segments

For malignant disease confined to bronchopulmonary segments, anatomical segmentectomy is the preferred surgical approach in patients with impaired pulmonary reserve (FEV1 <65%) or small peripheral tumors <2 cm, though it carries a 5-10% higher local recurrence rate and decreased long-term survival compared to lobectomy. 1

Surgical Decision Algorithm

For Malignant Disease (Lung Cancer)

Primary approach based on patient fitness:

• Standard candidates (FEV1 >65%, adequate cardiopulmonary reserve): Lobectomy remains the gold standard with 2-4% mortality and superior oncologic outcomes 1, 2

• Compromised pulmonary reserve (FEV1 30-65%): Anatomical segmentectomy is acceptable for stage I disease, particularly for tumors <2 cm without nodal involvement 1

• Severely impaired function (FEV1 <30%): Consider non-surgical options including SABR (stereotactic ablative body radiotherapy) or RFA (radiofrequency ablation) 1

Critical Patient Selection Criteria

Preoperative assessment must include: 1

• FEV1 and DLCO measurements with predicted postoperative values (ppo-FEV1 and ppo-DLCO) both >30% for segmentectomy
• Exercise testing with peak VO2 >10 mL/kg/min if either FEV1 or DLCO <80%
• Cardiac risk stratification using recalibrated thoracic RCRI

Proceed with segmentectomy when: 1

• Predicted postoperative FEV1 and DLCO >40% (ideal)
• Both ppo values >30% (acceptable with caution)
• Patient cannot tolerate lobectomy due to comorbidities

Oncologic Considerations for Segmentectomy

Key limitations to acknowledge: 1

• Local recurrence rates: 14-23% (versus lower rates with lobectomy)
• Stage III lesions have 59% local recurrence with sublobar resection
• Long-term survival decreased by 5-10% compared to lobectomy
• Operative mortality remains acceptable at 1.4-3.5%

Optimal candidates for segmentectomy: 1, 2

• Nodules <2 cm diameter without nodal disease
• Pure ground-glass nodules (pGGNs) requiring resection due to excellent prognosis
• Stage I disease (cT1N0, cT2N0) in patients unfit for lobectomy
• Peripheral location allowing adequate parenchymal margins

Technical Requirements

Surgical margins: 3

• Minimum 2 cm parenchymal safety margin required
• Three-dimensional CT reconstruction demonstrates feasibility of adequate margins for tumors up to 26-59 mm depending on segment location
• Largest resectable tumors with 3 cm margins: 59.8 mm in left apical segments, 26.1 mm in right segments 7+8

Surgical approach: 1

• VATS (video-assisted thoracoscopic surgery) preferred over open approach
• Anatomical segmentectomy (not wedge resection) for oncologic cases
• Systematic mediastinal lymph node sampling or clearance mandatory 2
• Localization techniques may be needed for small, deep nodules

Non-Malignant Indications

Segmentectomy is ideally suited for: 4, 5

• Inflammatory lesions (bronchiectasis causing suppuration, superinfection, or hemoptysis)
• Pulmonary metastases
• Multidrug-resistant tuberculosis with localized disease in a segment
• Pulmonary aspergilloma (often TB sequela)
• Destroyed lung segments from infectious sequelae

For these conditions, segmentectomy offers: 4, 5

• Preservation of maximum pulmonary function
• Lower recurrence concerns than with malignancy
• Definitive treatment of localized suppurative disease

Critical Pitfalls to Avoid

Do not perform segmentectomy when: 1

• Patient is fit for lobectomy and has primary lung cancer (accept inferior survival)
• Stage II or III disease is present (59% local recurrence rate)
• Adequate margins cannot be achieved anatomically
• Frozen section analysis unavailable during surgery for nodules

Common errors: 1

• Failing to calculate predicted postoperative values before surgery
• Performing wedge resection instead of anatomical segmentectomy for cancer
• Omitting systematic lymph node assessment
• Not considering SABR/RFA in patients with FEV1 <30%

Intraoperative Decision-Making

If malignancy confirmed on frozen section during segmentectomy: 1

• Proceed to completion lobectomy during same anesthetic if patient fit enough
• Accept segmentectomy only if lobectomy would create unacceptable risk
• Ensure systematic mediastinal lymph node sampling completed

If frozen section unavailable or non-diagnostic: 1

• Consider diagnostic anatomical segmentectomy for nodules <2 cm
• Plan staged completion lobectomy if malignancy confirmed on final pathology
• Alternative: proceed directly to lobectomy for highly suspicious lesions