Segmentectomy Q&A: How Research Changed the Way Surgeons Treat Lung Cancer

New research is changing the way surgeons approach lung cancer treatment. Peter Ellman, M.D., cardiovascular and thoracic surgeon at FirstHealth’s Reid Heart Center, answers key questions about a procedure called a segmentectomy and what it means for patients. Dr. Ellman joined the FirstHealth & Wellness Podcast to discuss emerging tech and how it is impacting lung cancer treatment. Listen here or read on to learn more about segmentectomies.

Question: First of all, what types of patients are candidates for a segmentectomy?

Dr. Ellman: We are talking about patients who have lung cancer and an early lung cancer. That would be a small cancer, usually in the one-to-two-centimeter range, caught early, usually incidentally or found on a screening CT scan of the chest that is done for people who have a history of smoking.

There is a very small percentage of people who actually get those scans done, so one thing I’d really want to talk about is that if you’re listening to this podcast and have a history of smoking, you should talk to your primary care doctor about getting a screening CAT scan. It's low dose, no contrast and what it will do is see if there's potentially a small cancer there that needs to be dealt with.

Once somebody becomes symptomatic with lung cancer and say you're having shortness of breath or even coughing up a little bit of blood, that's often one of the late stages of cancer where you can't have surgery. At that point, a surgeon like me is kind of out of the game and you would be seeing radiation oncologists or other oncology providers. But if we can catch these things early, in many cases, we can do a resection minimally invasively with small incisions and you go home the next day.

We are really trying to push for this screening program. A research study published about 10 years ago in the New England Journal of Medicine shows that screening CAT scans really do save lives. When we catch these things early and they are about the size of a pea, we can begin talking about surgery. Before a procedure, we would probably do some kind of a biopsy. At FirstHealth, usually Dr. Michael Pritchett, who's a world expert in navigational bronchoscopy, can go in and biopsy very, very small tumors and prove that you have a cancer. And then we would do staging studies, a PET scan, a brain MRI and probably a bronchoscopy maybe at the same time when the biopsy was done to make sure that it hasn't spread to the lymph nodes that are running along your trachea or spread elsewhere. If we feel that the cancer is limited to that one small area of your lung, and you have lung function that would tolerate a resection, then we would want to take it out because that's your best chance at a cure.

Question: Can you describe a segmentectomy? What exactly is being done?

Dr. Ellman: Recent data tells us that a segmentectomy can be as good as a lobectomy, which is the classic operation for lung cancer. There's basically five lobes of your lungs. On the right side, there's three lobes. On the left side, there's two. And so, you can imagine if the lung on the left side, say, is divided into two lobes and you take out one of the lobes for a lung cancer, that's great from the standpoint of the cancer operation, because these cancers can spread in the lung itself, but you've now taken out half of that person's lung on that side, which depending on their lung function, and a lot of people who've smoked don't have totally normal lung function, you may leave them slightly short of breath afterwards. Though we really try to make sure, based on the preoperative lung function studies, that they're not going to feel short of breath afterwards, and they have the lung capacity to stand the resection.

Now, if you're on the borderline and, you know, depending on where the tumor is, there's some areas that are more amenable to a segmentectomy than others. And so, a segmentectomy is just taking part of that lobe out. And if you have that small tumor in one of the segments that's more amenable to it than others, that would make you a candidate for the segmentectomy, either because your lung function would do better without the whole lobectomy or if it's just in the right segment to do it.

Question: Can you tell us more about the research you mentioned and how that might change things down the road?

Dr. Ellman: I think it is a beneficial option in certain cases. If you can do an equal cancer resection and spare some lung tissue, you'd want to do that. So, particularly on the superior segments of the lower lobes, those lend themselves to the segmentectomy. The lingula of the left upper lobe is also one of the areas, one of the segments that lends itself, you know, anatomically. Every segmentectomy and every lobectomy is like a different operation unto itself. In every anatomic lung resection, either a lobectomy or a segmentectomy, you've got to divide in at least one artery and one vein and then an airway, the bronchus.

The research shows that the segmentectomies can be as good a cancer operation. There's also research that shows that even a good wedge resection, which is a non-anatomical, and that's even more of the data that's come out recently, that as long as you can get a good margin, a couple centimeters, let's say you just wedge out that part of the lung that has the cancer, that's also a good option. The main point is to try and get the tumor out with a good amount of lung tissue, so you feel your margins are good.

The segmentectomy, particularly against both the superior segments and the lingula on the left side, those are the places where even if you have normal lung function, it makes sense to do that because why not spare a huge portion of those lobes. If the tumor is in other parts of the lung, it doesn't make quite as much sense to do it. And you might be looking at a lobectomy, which isn't the end of the world. It's still a great cancer operation. It's still done thousands of times every day, all over the world.

But the segmentectomy, most of the research for that has also come looking at something called ground-glass opacities, which is a kind of a lung cancer, not sometimes as aggressive. And some of that research is out of Japan. But we're proud of the fact that we've been moving in the direction of sticking with the things that are being done that are cutting edge and our gold standard all over the world.

Question: What is the recovery like for a segmentectomy?

Dr. Ellman: The main thing here is whether or not an operation is done minimally invasively or open. For years, to have a lung operation done, you would need to have a big incision about 10 centimeters long, made in the side of your body, kind of continuing up underneath your scapula, and then you basically must spread the ribs apart and sometimes cut part of the ribs to do a traditional thoracotomy incision to do a lung resection. Back in 2015 and 2016, I started the robotic program here at this hospital as a means to bring minimally invasive lung resection to our lung cancer program here, because that really is the gold standard now for these early lung cancers.

So, there's two different ways to do a minimally invasive resection for lung cancer, video-assisted thoracoscopy, VATS, which is small incisions, but you're standing at the bedside and you're holding the instruments that you're operating with. The other option is robotic video-assisted thoracoscopy. And so with that, you actually have a robot, a da Vinci robot, which has forearms at the bedside. Those instruments then are placed by the surgeon through trocars that have been placed in the body, which are like little tubes. And then, the surgeon sits in the corner of the room and controls the robot using both his feet and his hands and has stereoscopic vision. That allows you to do that operation that traditionally was done through a very large incision, that would mean you're in the hospital for three or four days and there's more significant pain, longer recovery, through small incisions that many times now I'm sending patients home the next day because we're not making that big incision and we're not spreading the ribs apart.

For the robotic lobectomy and the robotic segmentectomy the real benefit in terms of the short-term recovery in your hospital stay is that you haven't gotten that thoracotomy. From the standpoint of the actual recovery afterwards, it's not significantly different, say, the difference between a segmentectomy and a lobectomy just immediately after you get out of the hospital.

But probably long-term, sparing, you know, that extra part of the lung, I think certainly in certain people who have already had a little bit of limited lung function because of smoking, they would notice a difference compared to how they would've felt with the full lobectomy, because I think they'd have a little bit more wind and a little bit more stamina. But the main thing is whether you can do these operations minimally invasively and without having to convert to an open procedure and getting people home the first day or two after surgery.

To learn more about Dr. Ellman’s work and the team at Reid Heart Center, visit FirstHealth’s website.