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Abstract

 
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OBJECTIVES

Prognosis after segmentectomy for early-stage non-small cell lung cancer (NSCLC) with a high consolidation tumour ratio (CTR) and [18F]-fluoro-2-deoxy-d-glucose (FDG) accumulation on positron emission tomography/computed tomography is unclear.

METHODS

Participants of this study were 465 patients who underwent lobectomy or segmentectomy for clinical N0 NSCLC presenting solid component predominant tumour (CTR >50%) with a whole size ≤3 cm. Accumulations of FDG on positron emission tomography/computed tomography scans were scored according to the Deauville criteria, a 5-point visual evaluating method (Deauville score). The correlations between Deauville score, prognosis, and procedures were analysed.

RESULTS

Characteristics of pathological invasiveness, such as lymphatic invasion (P < 0.001), vascular invasion (P < 0.001) and pleural invasion (P < 0.001), and non-adenocarcinoma histologies (P < 0.001) were more common in patients with Deauville scores of 3–5. The cumulative incidence of recurrence (CIR) was higher in patients with Deauville scores of 3–5 (P < 0.001). The CIR after lobectomy and segmentectomy did not differ significantly among patients with Deauville scores of 1 or 2 (P = 0.598) or those with Deauville scores of 3–5 (P = 0.322). In the analysis of propensity score matched cohort, the CIR after lobectomy and segmentectomy did not differ significantly between patients with Deauville scores of 1 or 2 and Deauville scores of 3–5.

CONCLUSIONS

Segmentectomy may be feasible for NSCLC with high CTR (>50%) and accumulation of FDG. This finding should be confirmed in larger prospective studies.

FDG-PET/CT, Deauville criteria, NSCLC, segmentectomy

INTRODUCTION

Positron emission tomography (PET) with [18F]-fluoro-2-deoxy-d-glucose (FDG) is one of the recent radiological advances. FDG-PET/computed tomography (CT) is widely used to determine the strategy of treating non-small-cell lung cancer (NSCLC). However, because imaging protocols, equipment and measurement methods vary among institutions, maximum standardized uptake values (SUVmaxs) have differed, and comparison among different studies is difficult. To eliminate the discrepancies in SUVmax between institutions and to avoid the restriction of using FDG-PET/CT in clinical trials, Barrington et al. [1] advocated use of the Deauville criteria, a 5-point visual scale for evaluating the accumulation of FDG. Although this criterion was initially used solely for Hodgkin lymphoma, it is now employed in the treatment of various lymphoma types [2, 3], and the use of FDG-PET/CT as an inclusion criterion for large clinical trials of lymphoma was made possible by Deauville criteria [4, 5].

We demonstrated that Deauville criteria are useful in predicting lymph node metastasis [6] and prognosis [7] of patients with clinical N0 lung adenocarcinoma for whole tumour sizes of 3 cm or less. In those studies, most patients with a low (≤50%) consolidation tumour ratio (CTR) had low Deauville scores and rarely experienced recurrence or died of lung cancer [7]. On the other hand, in patients with a high CTR (>50%) tumour, which is known as unfavourable prognostic factor of resected NSCLC [8], the incidences of recurrence and death from lung cancer were significantly higher in patients with high Deauville scores than those with low Deauville scores. However, the relationship of recurrence and death from lung cancer with surgical method has remained unknown. Moreover, non-adenocarcinoma histologies were not included to these studies [6, 7]. Therefore, the aim of the present study was to investigate relationships among prognosis, Deauville score, and surgical method in patients with NSCLC, including non-adenocarcinoma, presented as a solid component predominant tumour (CTR >50%) in preoperative CT.

PATIENTS AND METHODS

Patients

This retrospective study was approved by the Institutional Review Board of Hiroshima University Hospital, which waived the requirement for informed consent from patients. We analysed the clinicopathological data and prognosis of patients who underwent curative intent lobectomy or segmentectomy for NSCLC presented as a node-negative solid component predominant tumour (CTR >50%) in preoperative CT with a whole tumour size of 3 cm or less between April 2007 and March 2019 at Hiroshima University Hospital. Patients who underwent wedge resection, patients with small cell lung cancer or carcinoid, whole tumour size larger than 3 cm, and suspicious lymph node metastasis (enlargement over 1 cm in preoperative CT or significant accumulation of FDG on PET/CT) before surgery were excluded from this study. Patients who could not archive complete resection and patients with obvious tumour progression after FDG-PET/CT were also excluded from the study. Flow chart of the patient selection is shown in Fig. 1.

Flow chart of patient selection. Totally 465 patients were included to this study.
Figure 1:

Flow chart of patient selection. Totally 465 patients were included to this study.

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FDG-PET/CT

The imaging protocol of this study is the same as that in previous studies at our institute [6, 7] and is described in Supplementary Material 1.

Evaluation of FDG-PET/CT using the Deauville criteria

The FDG-PET/CT scans were evaluated visually using the Deauville 5-point scale criteria [1]. The scoring method is shown in Supplementary Material 2. Representative images of each score are presented in Supplementary Material, Fig. S1. The Deauville scores were assessed and shared among thoracic surgeons of authors group.

Surgical procedure and complication

In our institute, segmentectomy was selected for patients with peripherally (located in the outer third of the lung field) located tumour whose preoperative CT and FDG-PET/CT showed no lymph node metastases and sufficient surgical margin greater than the maximum tumour diameter or 2 cm. Radical segmentectomy was performed with hybrid video-assisted thoracic surgery [8]. Postoperative complications were defined based on the Clavien-Dindo classification [9].

Histological and pathological evaluations

The determination of clinical and pathological stages was based on the 8th edition of the TNM classification of malignant tumours [10]. The determination of the histological subtype was based on the World Health Organization’s classification [11]. The diagnosis of lymphatic invasion was based on pathological examination using immunostaining for D2-40 to clarify the location of lymphatic ducts. The presence of vascular invasion and pleural invasion were evaluated using elastic van Gieson staining to determine tumour invasion above the elastic layer of the vessels and the visceral pleura.

Follow-up evaluation

Postoperative follow-up procedures, including physical examination and chest CT scans every 6 months, were performed for 5–10 years after surgical resection.

Statistical analysis

The results were presented as medians and interquartile ranges for continuous variables and as numbers and percentages for categorical variables. Categorical variables were compared using a chi-square test. Continuous variables were analysed using the unpaired t-test. McNemar’s test for categorical variables and paired t tests for continuous variables were used to analyse propensity-matched patient pairs. The included patients were divided into two groups according to the results of our former studies: patients with Deauville scores of 1 or 2, Deauville scores of 3–5 [6, 7]. The risk of recurrence (defined as the cumulative incidence of recurrence; CIR) was estimated using a cumulative incidence function, which accounted for death without recurrence as a competing event. Patients were censored if they were alive and without recurrence at the time of the last follow-up. The risk of lung cancer-specific death (defined as cumulative incidence of lung cancer-specific death; CILSD) was estimated using a cumulative incidence function, which accounted for death from other than lung cancer as a competing event. Differences in CIR and CILSD between groups were assessed using the methods of Gray. Cumulative incidence of all death (CIAD) was calculated by the Kaplan–Meier method and compared by the log rank test. Background variables of patients who underwent lobectomy and segmentectomy were adjusted for by Cox regression analysis and propensity score, which were calculated to balance potential differences in the baseline clinical characteristics between groups using age, sex, pulmonary function (% predicted vital capacity and % forced exploratory volume % in one second), radiological whole and solid component tumour size, and Deauville score. These were multiplied by a coefficient that was calculated by logistic regression, and the sum of the values was taken as the propensity score. Matched cohorts were formed using this propensity score; segmentectomy and lobectomy group pairs with an equivalent propensity score were selected by a 1-to-1 match with a calliper width of 0.05 of standard deviation. Propensity score matching was performed only for patients with peripherally located tumour because tumour location affects the selection of procedure.

All statistical analyses were performed with EZR version 1.51 (Saitama Medical Center, Jichi Medical University, Saitama, Japan) [12], which is a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria).

RESULTS

In total, 465 patients were included in this study (Fig. 1). Patient characteristics are shown in Supplementary Material, Table S1. Invasive characteristics, such as lymphatic invasion (P < 0.001), vascular invasion (P < 0.001), pleural invasion (P < 0.001) and subtype other than adenocarcinoma (P < 0.001), were detected more frequently in patients with Deauville scores of 3–5 than in those with Deauville scores of 1 or 2. Pathological stage (P < 0.001) and incidence of lymph node metastasis (P < 0.001) were also higher in patients with Deauville scores of 3–5 than in those with Deauville scores of 1 or 2. CTR was higher in patients with high Deauville score (Supplementary Material, Fig. S2). The median duration of follow-up was 47 (interquartile range, 24–73) months. The CIR was higher in patients with Deauville scores of 3–5 [5-year CIR rate, 19.7%; 95% confidence interval (CI), 14.6–25.4%] than in those with Deauville scores of 1 or 2 (5-year CIR, 2.4%; 95% CI, 0.6–6.3%; P < 0.001, Fig. 2). CILSD was higher in patients with Deauville scores of 3–5 (5-year CIAD rate, 8.4%; 95% CI, 4.8–13.2%) than in those with Deauville scores of 1 or 2 (5-year CIAD, 0%; P < 0.001, Supplementary Material, Fig. S3A). There was no death from lung cancer in patients with Deauville scores of 1 or 2. CIAD was also higher in patients with Deauville scores of 3–5 (5-year CIAD rate, 24.6%; 95% CI, 18.8–31.9%) than in those with Deauville scores of 1 or 2 (5-year CIAD, 4.4%; 95% CI, 2.0–9.5%; P < 0.001, Supplementary Material, Fig. S3B).

Cumulative incidence of recurrence of all included patients. The cumulative incidence of recurrence was higher in patients with Deauville scores of 3–5 (5-year cumulative incidence of recurrence rate, 19.7%; 95% confidence interval, 14.6–25.4%) than in those with Deauville scores of 1 or 2 (5-year cumulative incidence of recurrence rate, 2.4%; 95% confidence interval, 0.6–6.3%; P < 0.001).
Figure 2:

Cumulative incidence of recurrence of all included patients. The cumulative incidence of recurrence was higher in patients with Deauville scores of 3–5 (5-year cumulative incidence of recurrence rate, 19.7%; 95% confidence interval, 14.6–25.4%) than in those with Deauville scores of 1 or 2 (5-year cumulative incidence of recurrence rate, 2.4%; 95% confidence interval, 0.6–6.3%; P < 0.001).

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Among patients with Deauville scores of 1 or 2 (their characteristics are shown in Table 1), there was not a difference in CIR of patients who underwent lobectomy (5-year CIR rate, 3.3%; 95% CI, 0.6–10.3%) and segmentectomy (5-year CIR rate, 1.2%; 95% CI, 0.1–5.9%; P = 0.598, Fig. 3A). There was no significant difference in CIAD of patients who underwent lobectomy (5-year CIAD rate, 4.2%; 95% CI, 1.4–12.5%) and segmentectomy (5-year CIAD, 4.6%; 95% CI, 1.5–13.7%; P = 0.691, Supplementary Material, Fig. S4).

Cumulative incidence of recurrence of all patients for each procedure. (A) Among patients with Deauville scores of 1 or 2, there was not a significant difference in cumulative incidence of recurrence of patients who underwent lobectomy (5-year cumulative incidence of recurrence rate, 3.3%; 95% confidence interval, 0.6–10.3%) and segmentectomy (5-year cumulative incidence of recurrence rate, 1.2%; 95% confidence interval, 0.1–5.9%; P = 0.598). (B) Among patients with Deauville scores of 3–5, there was no significant difference in cumulative incidence of recurrence of patients who underwent lobectomy (5-year cumulative incidence of recurrence rate, 21.3%; 95% confidence interval, 15.2–28.2%) and segmentectomy (5-year cumulative incidence of recurrence rate, 15.7%; 95% confidence interval, 7.6–26.5%; P = 0.322).
Figure 3:

Cumulative incidence of recurrence of all patients for each procedure. (A) Among patients with Deauville scores of 1 or 2, there was not a significant difference in cumulative incidence of recurrence of patients who underwent lobectomy (5-year cumulative incidence of recurrence rate, 3.3%; 95% confidence interval, 0.6–10.3%) and segmentectomy (5-year cumulative incidence of recurrence rate, 1.2%; 95% confidence interval, 0.1–5.9%; P = 0.598). (B) Among patients with Deauville scores of 3–5, there was no significant difference in cumulative incidence of recurrence of patients who underwent lobectomy (5-year cumulative incidence of recurrence rate, 21.3%; 95% confidence interval, 15.2–28.2%) and segmentectomy (5-year cumulative incidence of recurrence rate, 15.7%; 95% confidence interval, 7.6–26.5%; P = 0.322).

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Table 1:
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Patient characteristics of each Deauville score group

VariablesDeauville score 1 or 2
Deauville score 3–5
Lobectomy, n = 85Segmentectomy, n = 93P-valueLobectomy, n = 200Segmentectomy, n = 87P-value
Age, median (IQR)68 (63–75)69 (64–74)0.53368 (62–75)71 (66–74)0.044
Sex, n (%)0.1720.285
 Male37 (43.5)50 (53.8)137 (68.5)65 (74.7)
 Female48 (56.5)43 (46.2)63 (31.5)22 (25.3)
Pulmonary function, median (IQR)
 %VC102.0 (91.2–109.7)100.0 (87.9–112.4)0.98198.1 (87.7–109.6)97.2 (82.7–108.4)0.202
 FEV1.0%76.7 (71.7–80.0)75.8 (69.0–81.0)0.74875.4 (69.0–79.6)71.2 (58.1–78.9)<0.001
Location, n (%)0.001<0.001
 Central7 (8.2)0 (0)32 (16.0)0 (0)
 Peripheral78 (91.8)93 (100)168 (84.0)87 (100)
Tumour size
 Whole tumour size (mm), median (IQR)19 (15–25)15 (12–19)<0.00123 (19–27)16 (14–21)<0.001
 Solid component size (mm), median (IQR)15 (12–19)12 (9–15)<0.00122 (18–26)16 (13–20)<0.001
 CTR, median (IQR)0.84 (0.66–1.00)0.80 (0.62–1.00)0.5771.0 (1.0–1.0)1.0 (1.0–1.0)0.702
 Pure solid (CTR, 1.0), n (%)33 (38.8)38 (40.9)0.782166 (83.0)77 (88.5)0.224
Deauville score, n (%)0.0160.013
 110 (11.8)24 (25.8)
 275 (88.2)69 (74.2)
 341 (20.5)30 (34.5)
 433 (16.5)18 (20.7)
 5126 (63.0)39 (44.8)
SUVmax, median (IQR)1.3 (1.0–1.7)1.2 (0.8–1.6)0.1884.8 (2.8–6.9)3.4 (2.6–4.6)0.003
Clinical stage (%), n (%)0.7920.374
 IA114 (16.5)12 (12.9)30 (15.0)15 (17.2)
 IA252 (61.2)60 (64.5)108 (54.0)52 (59.8)
 IA319 (22.4)21 (22.6)62 (31.0)20 (23.0)
Classification of segmentectomy, n (%)
 Simple segmentectomy35 (37.6)47 (54.0)
 Complex segmentectomy58 (62.3)40 (46.0)
Complication (severer than grade IIIa) , n (%)10 (11.8)11 (11.8)0.99027 (13.5)12 (13.8)0.947
Histological subtype (%), n (%)0.2010.589
 Adenocarcinoma77 (90.6)86 (92.5)141 (70.5)56 (64.4)
 Squamous cell carcinoma5 (5.9)7 (7.5)41 (20.5)20 (23.0)
 Adenosquamous carcinoma2 (2.4)0 (0)6 (3.0)2 (2.3)
 LCNEC0 (0)0 (0)7 (3.5)7 (8.1)
 Pleomorphic carcinoma0 (0)0 (0)4 (2.0)2 (2.3)
 Other subtypes of NSCLC1 (1.2)0 (0)1 (0.5)0 (0)
LY, n (%)8 (9.4)4 (4.3)0.17263 (31.5)24 (27.6)0.505
V, n (%)7 (8.2)7 (7.5)0.86189 (44.5)33 (37.9)0.299
PL, n (%)8 (9.4)4 (4.3)0.17257 (28.5)14 (16.1)0.021
Pathological stage (%), n (%)0.1210.001
 06 (7.1)11 (11.9)0 (0)0 (0)
 IA129 (34.1)38 (40.9)10 (5.0)10 (11.5)
 IA229 (34.1)34 (36.6)56 (28.0)43 (49.4)
 IA311 (12.9)4 (4.3)40 (20.0)11 (12.6)
 IB7 (8.2)4 (4.3)53 (26.5)16 (18.4)
 IIA0 (0)0 (0)2 (1.0)1 (1.2)
 IIB1 (1.2)2 (2.2)28 (14.0)5 (5.8)
 IIIA2 (2.4)0 (0)11 (5.5)1 (1.2)
Lymph node metastasis, n (%)2 (2.4)1 (1.1)0.50633 (16.5)5 (5.8)0.008
Prognosis, n (%)
 Recurrence2 (2.4)1 (1.1)0,50635 (17.5)10 (11.5)0.188
 Death from any cause3 (3.5)4 (4.3)0.79134 (17.0)19 (21.8)0.337
 Death from lung cancer0 (0)0 (0)NA16 (8.0)4 (4.6)0.281
VariablesDeauville score 1 or 2
Deauville score 3–5
Lobectomy, n = 85Segmentectomy, n = 93P-valueLobectomy, n = 200Segmentectomy, n = 87P-value
Age, median (IQR)68 (63–75)69 (64–74)0.53368 (62–75)71 (66–74)0.044
Sex, n (%)0.1720.285
 Male37 (43.5)50 (53.8)137 (68.5)65 (74.7)
 Female48 (56.5)43 (46.2)63 (31.5)22 (25.3)
Pulmonary function, median (IQR)
 %VC102.0 (91.2–109.7)100.0 (87.9–112.4)0.98198.1 (87.7–109.6)97.2 (82.7–108.4)0.202
 FEV1.0%76.7 (71.7–80.0)75.8 (69.0–81.0)0.74875.4 (69.0–79.6)71.2 (58.1–78.9)<0.001
Location, n (%)0.001<0.001
 Central7 (8.2)0 (0)32 (16.0)0 (0)
 Peripheral78 (91.8)93 (100)168 (84.0)87 (100)
Tumour size
 Whole tumour size (mm), median (IQR)19 (15–25)15 (12–19)<0.00123 (19–27)16 (14–21)<0.001
 Solid component size (mm), median (IQR)15 (12–19)12 (9–15)<0.00122 (18–26)16 (13–20)<0.001
 CTR, median (IQR)0.84 (0.66–1.00)0.80 (0.62–1.00)0.5771.0 (1.0–1.0)1.0 (1.0–1.0)0.702
 Pure solid (CTR, 1.0), n (%)33 (38.8)38 (40.9)0.782166 (83.0)77 (88.5)0.224
Deauville score, n (%)0.0160.013
 110 (11.8)24 (25.8)
 275 (88.2)69 (74.2)
 341 (20.5)30 (34.5)
 433 (16.5)18 (20.7)
 5126 (63.0)39 (44.8)
SUVmax, median (IQR)1.3 (1.0–1.7)1.2 (0.8–1.6)0.1884.8 (2.8–6.9)3.4 (2.6–4.6)0.003
Clinical stage (%), n (%)0.7920.374
 IA114 (16.5)12 (12.9)30 (15.0)15 (17.2)
 IA252 (61.2)60 (64.5)108 (54.0)52 (59.8)
 IA319 (22.4)21 (22.6)62 (31.0)20 (23.0)
Classification of segmentectomy, n (%)
 Simple segmentectomy35 (37.6)47 (54.0)
 Complex segmentectomy58 (62.3)40 (46.0)
Complication (severer than grade IIIa) , n (%)10 (11.8)11 (11.8)0.99027 (13.5)12 (13.8)0.947
Histological subtype (%), n (%)0.2010.589
 Adenocarcinoma77 (90.6)86 (92.5)141 (70.5)56 (64.4)
 Squamous cell carcinoma5 (5.9)7 (7.5)41 (20.5)20 (23.0)
 Adenosquamous carcinoma2 (2.4)0 (0)6 (3.0)2 (2.3)
 LCNEC0 (0)0 (0)7 (3.5)7 (8.1)
 Pleomorphic carcinoma0 (0)0 (0)4 (2.0)2 (2.3)
 Other subtypes of NSCLC1 (1.2)0 (0)1 (0.5)0 (0)
LY, n (%)8 (9.4)4 (4.3)0.17263 (31.5)24 (27.6)0.505
V, n (%)7 (8.2)7 (7.5)0.86189 (44.5)33 (37.9)0.299
PL, n (%)8 (9.4)4 (4.3)0.17257 (28.5)14 (16.1)0.021
Pathological stage (%), n (%)0.1210.001
 06 (7.1)11 (11.9)0 (0)0 (0)
 IA129 (34.1)38 (40.9)10 (5.0)10 (11.5)
 IA229 (34.1)34 (36.6)56 (28.0)43 (49.4)
 IA311 (12.9)4 (4.3)40 (20.0)11 (12.6)
 IB7 (8.2)4 (4.3)53 (26.5)16 (18.4)
 IIA0 (0)0 (0)2 (1.0)1 (1.2)
 IIB1 (1.2)2 (2.2)28 (14.0)5 (5.8)
 IIIA2 (2.4)0 (0)11 (5.5)1 (1.2)
Lymph node metastasis, n (%)2 (2.4)1 (1.1)0.50633 (16.5)5 (5.8)0.008
Prognosis, n (%)
 Recurrence2 (2.4)1 (1.1)0,50635 (17.5)10 (11.5)0.188
 Death from any cause3 (3.5)4 (4.3)0.79134 (17.0)19 (21.8)0.337
 Death from lung cancer0 (0)0 (0)NA16 (8.0)4 (4.6)0.281

CTR: consolidation tumour ratio; FEV1.0: forced exploratory volume in 1 s; IQR: interquartile range; LCNEC: large cell neuroendocrine carcinoma; NSCLC: non-small-cell lung cancer; LY: lymphatic invasion; PL: pleural invasion; SUVmax: maximum standardized uptake value; V: vascular invasion; VC: vital capacity.

Table 1:
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Patient characteristics of each Deauville score group

VariablesDeauville score 1 or 2
Deauville score 3–5
Lobectomy, n = 85Segmentectomy, n = 93P-valueLobectomy, n = 200Segmentectomy, n = 87P-value
Age, median (IQR)68 (63–75)69 (64–74)0.53368 (62–75)71 (66–74)0.044
Sex, n (%)0.1720.285
 Male37 (43.5)50 (53.8)137 (68.5)65 (74.7)
 Female48 (56.5)43 (46.2)63 (31.5)22 (25.3)
Pulmonary function, median (IQR)
 %VC102.0 (91.2–109.7)100.0 (87.9–112.4)0.98198.1 (87.7–109.6)97.2 (82.7–108.4)0.202
 FEV1.0%76.7 (71.7–80.0)75.8 (69.0–81.0)0.74875.4 (69.0–79.6)71.2 (58.1–78.9)<0.001
Location, n (%)0.001<0.001
 Central7 (8.2)0 (0)32 (16.0)0 (0)
 Peripheral78 (91.8)93 (100)168 (84.0)87 (100)
Tumour size
 Whole tumour size (mm), median (IQR)19 (15–25)15 (12–19)<0.00123 (19–27)16 (14–21)<0.001
 Solid component size (mm), median (IQR)15 (12–19)12 (9–15)<0.00122 (18–26)16 (13–20)<0.001
 CTR, median (IQR)0.84 (0.66–1.00)0.80 (0.62–1.00)0.5771.0 (1.0–1.0)1.0 (1.0–1.0)0.702
 Pure solid (CTR, 1.0), n (%)33 (38.8)38 (40.9)0.782166 (83.0)77 (88.5)0.224
Deauville score, n (%)0.0160.013
 110 (11.8)24 (25.8)
 275 (88.2)69 (74.2)
 341 (20.5)30 (34.5)
 433 (16.5)18 (20.7)
 5126 (63.0)39 (44.8)
SUVmax, median (IQR)1.3 (1.0–1.7)1.2 (0.8–1.6)0.1884.8 (2.8–6.9)3.4 (2.6–4.6)0.003
Clinical stage (%), n (%)0.7920.374
 IA114 (16.5)12 (12.9)30 (15.0)15 (17.2)
 IA252 (61.2)60 (64.5)108 (54.0)52 (59.8)
 IA319 (22.4)21 (22.6)62 (31.0)20 (23.0)
Classification of segmentectomy, n (%)
 Simple segmentectomy35 (37.6)47 (54.0)
 Complex segmentectomy58 (62.3)40 (46.0)
Complication (severer than grade IIIa) , n (%)10 (11.8)11 (11.8)0.99027 (13.5)12 (13.8)0.947
Histological subtype (%), n (%)0.2010.589
 Adenocarcinoma77 (90.6)86 (92.5)141 (70.5)56 (64.4)
 Squamous cell carcinoma5 (5.9)7 (7.5)41 (20.5)20 (23.0)
 Adenosquamous carcinoma2 (2.4)0 (0)6 (3.0)2 (2.3)
 LCNEC0 (0)0 (0)7 (3.5)7 (8.1)
 Pleomorphic carcinoma0 (0)0 (0)4 (2.0)2 (2.3)
 Other subtypes of NSCLC1 (1.2)0 (0)1 (0.5)0 (0)
LY, n (%)8 (9.4)4 (4.3)0.17263 (31.5)24 (27.6)0.505
V, n (%)7 (8.2)7 (7.5)0.86189 (44.5)33 (37.9)0.299
PL, n (%)8 (9.4)4 (4.3)0.17257 (28.5)14 (16.1)0.021
Pathological stage (%), n (%)0.1210.001
 06 (7.1)11 (11.9)0 (0)0 (0)
 IA129 (34.1)38 (40.9)10 (5.0)10 (11.5)
 IA229 (34.1)34 (36.6)56 (28.0)43 (49.4)
 IA311 (12.9)4 (4.3)40 (20.0)11 (12.6)
 IB7 (8.2)4 (4.3)53 (26.5)16 (18.4)
 IIA0 (0)0 (0)2 (1.0)1 (1.2)
 IIB1 (1.2)2 (2.2)28 (14.0)5 (5.8)
 IIIA2 (2.4)0 (0)11 (5.5)1 (1.2)
Lymph node metastasis, n (%)2 (2.4)1 (1.1)0.50633 (16.5)5 (5.8)0.008
Prognosis, n (%)
 Recurrence2 (2.4)1 (1.1)0,50635 (17.5)10 (11.5)0.188
 Death from any cause3 (3.5)4 (4.3)0.79134 (17.0)19 (21.8)0.337
 Death from lung cancer0 (0)0 (0)NA16 (8.0)4 (4.6)0.281
VariablesDeauville score 1 or 2
Deauville score 3–5
Lobectomy, n = 85Segmentectomy, n = 93P-valueLobectomy, n = 200Segmentectomy, n = 87P-value
Age, median (IQR)68 (63–75)69 (64–74)0.53368 (62–75)71 (66–74)0.044
Sex, n (%)0.1720.285
 Male37 (43.5)50 (53.8)137 (68.5)65 (74.7)
 Female48 (56.5)43 (46.2)63 (31.5)22 (25.3)
Pulmonary function, median (IQR)
 %VC102.0 (91.2–109.7)100.0 (87.9–112.4)0.98198.1 (87.7–109.6)97.2 (82.7–108.4)0.202
 FEV1.0%76.7 (71.7–80.0)75.8 (69.0–81.0)0.74875.4 (69.0–79.6)71.2 (58.1–78.9)<0.001
Location, n (%)0.001<0.001
 Central7 (8.2)0 (0)32 (16.0)0 (0)
 Peripheral78 (91.8)93 (100)168 (84.0)87 (100)
Tumour size
 Whole tumour size (mm), median (IQR)19 (15–25)15 (12–19)<0.00123 (19–27)16 (14–21)<0.001
 Solid component size (mm), median (IQR)15 (12–19)12 (9–15)<0.00122 (18–26)16 (13–20)<0.001
 CTR, median (IQR)0.84 (0.66–1.00)0.80 (0.62–1.00)0.5771.0 (1.0–1.0)1.0 (1.0–1.0)0.702
 Pure solid (CTR, 1.0), n (%)33 (38.8)38 (40.9)0.782166 (83.0)77 (88.5)0.224
Deauville score, n (%)0.0160.013
 110 (11.8)24 (25.8)
 275 (88.2)69 (74.2)
 341 (20.5)30 (34.5)
 433 (16.5)18 (20.7)
 5126 (63.0)39 (44.8)
SUVmax, median (IQR)1.3 (1.0–1.7)1.2 (0.8–1.6)0.1884.8 (2.8–6.9)3.4 (2.6–4.6)0.003
Clinical stage (%), n (%)0.7920.374
 IA114 (16.5)12 (12.9)30 (15.0)15 (17.2)
 IA252 (61.2)60 (64.5)108 (54.0)52 (59.8)
 IA319 (22.4)21 (22.6)62 (31.0)20 (23.0)
Classification of segmentectomy, n (%)
 Simple segmentectomy35 (37.6)47 (54.0)
 Complex segmentectomy58 (62.3)40 (46.0)
Complication (severer than grade IIIa) , n (%)10 (11.8)11 (11.8)0.99027 (13.5)12 (13.8)0.947
Histological subtype (%), n (%)0.2010.589
 Adenocarcinoma77 (90.6)86 (92.5)141 (70.5)56 (64.4)
 Squamous cell carcinoma5 (5.9)7 (7.5)41 (20.5)20 (23.0)
 Adenosquamous carcinoma2 (2.4)0 (0)6 (3.0)2 (2.3)
 LCNEC0 (0)0 (0)7 (3.5)7 (8.1)
 Pleomorphic carcinoma0 (0)0 (0)4 (2.0)2 (2.3)
 Other subtypes of NSCLC1 (1.2)0 (0)1 (0.5)0 (0)
LY, n (%)8 (9.4)4 (4.3)0.17263 (31.5)24 (27.6)0.505
V, n (%)7 (8.2)7 (7.5)0.86189 (44.5)33 (37.9)0.299
PL, n (%)8 (9.4)4 (4.3)0.17257 (28.5)14 (16.1)0.021
Pathological stage (%), n (%)0.1210.001
 06 (7.1)11 (11.9)0 (0)0 (0)
 IA129 (34.1)38 (40.9)10 (5.0)10 (11.5)
 IA229 (34.1)34 (36.6)56 (28.0)43 (49.4)
 IA311 (12.9)4 (4.3)40 (20.0)11 (12.6)
 IB7 (8.2)4 (4.3)53 (26.5)16 (18.4)
 IIA0 (0)0 (0)2 (1.0)1 (1.2)
 IIB1 (1.2)2 (2.2)28 (14.0)5 (5.8)
 IIIA2 (2.4)0 (0)11 (5.5)1 (1.2)
Lymph node metastasis, n (%)2 (2.4)1 (1.1)0.50633 (16.5)5 (5.8)0.008
Prognosis, n (%)
 Recurrence2 (2.4)1 (1.1)0,50635 (17.5)10 (11.5)0.188
 Death from any cause3 (3.5)4 (4.3)0.79134 (17.0)19 (21.8)0.337
 Death from lung cancer0 (0)0 (0)NA16 (8.0)4 (4.6)0.281

CTR: consolidation tumour ratio; FEV1.0: forced exploratory volume in 1 s; IQR: interquartile range; LCNEC: large cell neuroendocrine carcinoma; NSCLC: non-small-cell lung cancer; LY: lymphatic invasion; PL: pleural invasion; SUVmax: maximum standardized uptake value; V: vascular invasion; VC: vital capacity.

Among patients with Deauville scores of 3–5 (their characteristics are also shown in Table 1), there was not a significant difference in CIR of patients who underwent lobectomy (5-year CIR rate, 21.3%; 95% CI, 15.2–28.2%) and segmentectomy (5-year CIR rate, 15.7%; 95% CI, 7.6–26.5%; P = 0.322, Fig. 3B). There was not a significant difference in CILSD of patients who underwent lobectomy (5-year CILSD rate, 8.4%; 95% CI, 4.4–14.2%) and segmentectomy (5-year CILSD, 7.9%; 95% CI, 2.1–18.6%; P = 0.648, Supplementary Material, Fig. S5A). CIAD was higher in patients who underwent segmentectomy (5-year CIAD rate, 31.2%; 95% CI, 19.6–47.2%) than lobectomy (5-year CIAD, 21.7%; 95% CI, 15.4–30.2%; P = 0.047, Supplementary Material, Fig. S5B). Among patients with whole tumour size 2 cm or less, there were no differences in CIR and CIAD in patients with Deauville scores of 1 or 2 (Supplementary Material, Fig. S6A and B). In patients with Deauville scores of 3–5, there was also no significant difference in CIR, CILSD and CIAD (Supplementary Material, Fig. S7A–C).

The characteristics of matched patients are shown in Table 2. Among patients with Deauville scores of 1 or 2, there was not a significant difference in CIR of patients who underwent lobectomy (5-year CIR, rate 2.6%; 95% CI, 0.2–12.0%) and segmentectomy (5-year CIR rate, 0%; P = 0.984, Fig. 4A). There was no significant difference in CIAD of patients who underwent lobectomy (5-year CIAD rate, 7.4%; 95% CI, 2.4–21.3%) and segmentectomy (5-year CIAD, 2.6%; 95% CI, 0.4–16.8%; P = 0.601, Supplementary Material, Fig. S8). Among patients with Deauville scores of 3–5, there was not a significant difference in CIR of patients who underwent lobectomy (5-year CIR rate, 15.6%; 95% CI, 7.1–27.1%) and segmentectomy (5-year CIR rate, 16.0%; 95% CI, 6.4–29.3%; P = 0.740, Fig. 4B). There was not a significant difference in CILSD of patients who underwent lobectomy (5-year CILSD rate, 6.5%; 95% CI, 1.6–16.7%) and segmentectomy (5-year CILSD, 9.2%; 95% CI, 2.7–20.8%; P = 0.833, Supplementary Material, Fig. S9A). There was not a significant difference in CIAD of patients who underwent lobectomy (5-year CIAD rate, 18.1%; 95% CI, 8.8–25.3%) and segmentectomy (5-year CIAD, 32.6%; 95% CI, 19.6–54.7%; P = 0.170, Supplementary Material, Fig. S9B).

Cumulative incidence of recurrence of matched patients for each procedure. (A) Among patients with Deauville scores of 1 or 2, there was not a significant difference in cumulative incidence of recurrence of patients who underwent lobectomy (5-year cumulative incidence of recurrence rate, 2.6%; 95% confidence interval 0.2–12.0%) and segmentectomy (5-year cumulative incidence of recurrence rate, 0%; P = 0.984). (B) Among patients with Deauville scores of 3–5, there was not a significant difference in cumulative incidence of recurrence of patients who underwent lobectomy (5-year cumulative incidence of recurrence rate 15.6%, 95% confidence interval 7.1–27.1%) and segmentectomy (5-year cumulative incidence of recurrence rate 16.0%, 95% confidence interval 6.4–29.3%, P = 0.740).
Figure 4:

Cumulative incidence of recurrence of matched patients for each procedure. (A) Among patients with Deauville scores of 1 or 2, there was not a significant difference in cumulative incidence of recurrence of patients who underwent lobectomy (5-year cumulative incidence of recurrence rate, 2.6%; 95% confidence interval 0.2–12.0%) and segmentectomy (5-year cumulative incidence of recurrence rate, 0%; P = 0.984). (B) Among patients with Deauville scores of 3–5, there was not a significant difference in cumulative incidence of recurrence of patients who underwent lobectomy (5-year cumulative incidence of recurrence rate 15.6%, 95% confidence interval 7.1–27.1%) and segmentectomy (5-year cumulative incidence of recurrence rate 16.0%, 95% confidence interval 6.4–29.3%, P = 0.740).

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Table 2:
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Characteristics of matched patients of each Deauville score group

VariablesDeauville score 1 or 2
Deauville score 3–5
Lobectomy, n = 47Segmentectomy, n = 47P-valueSDLobectomy, n = 60Segmentectomy, n = 60P-valueSD
Age, median (IQR)66 (63–76)69 (65–73)0.482−0.14669 (62–77)71 (65–74)0.476−0.131
Sex, n (%)0.4090.1710.1770.248
 Male21 (44.7)25 (53.2)36 (60.0)43 (71.7)
 Female26 (55.3)21 (44.7)24 (40.0)17 (28.3)
Pulmonary function, median (IQR)
 %VC102.0 (92.1–110.0)102.8 (97.6–115.2)0.317−0.20897.4 (85.8–107.7)102.5 (85.9–111.2)0.868−0.031
 FEV1.0%76.7 (73.0–79.8)75.8 (68.5–84.1)0.8070.05174.2 (69.6–78.2)72.0 (63.4–78.8)0.1620.257
Tumour size
Whole tumour size (mm), median (IQR)17 (15–23)18 (13–19)0.2590.23420 (16–25)18 (15–22)0.1950.238
Solid component size (mm), median (IQR)14 (11–16)14 (11–16)0.9710.00818 (15–23)17 (14–21)0.6000.057
CTR, median (IQR)0.75 (0.60–1.0)0.80 (0.67–1.0)0.3961.0 (0.96–1.0)1.0 (1.0–1.0)0.083
Pure solid (CTR, 1.0), n (%)15 (31.9)16 (34.0)0.82645 (75.0)52 (86.7)0.102
Deauville score, n (%)0.5350.1280.6560.158
 17 (14.9)5 (10.6)
 240 (85.1)42 (89.4)
 314 (23.3)17 (28.3)
 411 (18.3)13 (21.7)
 535 (58.3)30 (50.0)
SUVmax, median (IQR)1.3 (1.0–1.6)1.3 (1.0–1.6)0.4573.8 (2.6–5.9)3.8 (2.5–5.1)0.546
Clinical stage (%), n (%)0.4840.757
 IA18 (17.0)7 (14.9)2 (3.3)1 (1.7)
 IA239 (83.0)39 (83.0)37 (61.7)40 (66.7)
 IA30 (0)1 (2.1)21 (35.0)19 (31.7)
Classification of segmentectomy, n (%)NA
 Simple segmentectomy18 (38.3)36 (60.0)
 Complex segmentectomy29 (61.7)24 (40.0)
Complication (severer than Grade IIIa)5 (10.6)8 (17.0)0.36811 (18.3)7 (11.7)0.305
Histological subtype (%), n (%)1.0000.814
 Adenocarcinoma44 (93.6)44 (93.6)37 (61.7)43 (71.7)
 Squamous cell carcinoma3 (6.4)3 (6.4)14 (23.3)10 (16.7)
 Adenosquamous carcinoma0 (0)0 (0)2 (3.3)1 (1.7)
 LCNEC0 (0)0 (0)5 (8.3)4 (6.7)
 Pleomorphic carcinoma0 (0)0 (0)2 (3.3)2 (3.3)
LY3 (6.4)1 (2.1)0.29621 (35.0)19 (31.7)0.696
V2 (4.3)4 (8.5)0.39523 (38.3)22 (36.7)0.850
PL3 (6.4)4 (8.5)0.6949 (15.0)12 (20.0)0.470
Pathological stage (%), n (%)0.6270.851
 03 (6.4)4 (8.5)0 (0)0 (0)
 IA120 (42.6)15 (31.9)5 (8.3)6 (10.0)
 IA216 (34.0)20 (42.6)25 (41.7)28 (46.7)
 IA34 (8.5)3 (6.4)13 (21.7)6 (10.0)
 IB3 (6.4)4 (8.5)8 (13.3)14 (23.3)
 IIA0 (0)0 (0)1 (1.7)1 (1.7)
 IIB0 (0)1 (2.1)6 (10.0)4 (6.7)
 IIIA1 (2.1)0 (0)2 (3.3)1 (1.7)
Lymph node metastasis, n (%)1 (2.0)1 (2.1)1.0006 (10.0)4 (6.7)0.508
Prognosis, n (%)
 Recurrence1 (2.1)1 (2.1)1.0009 (15.0)7 (11.7)0.591
 Death from any cause3 (6.4)2 (4.3)0.6459 (15.0)13 (21.7)0.344
 Death from lung cancer0 (0)0 (0)NA4 (6.7)4 (6.7)1.000
VariablesDeauville score 1 or 2
Deauville score 3–5
Lobectomy, n = 47Segmentectomy, n = 47P-valueSDLobectomy, n = 60Segmentectomy, n = 60P-valueSD
Age, median (IQR)66 (63–76)69 (65–73)0.482−0.14669 (62–77)71 (65–74)0.476−0.131
Sex, n (%)0.4090.1710.1770.248
 Male21 (44.7)25 (53.2)36 (60.0)43 (71.7)
 Female26 (55.3)21 (44.7)24 (40.0)17 (28.3)
Pulmonary function, median (IQR)
 %VC102.0 (92.1–110.0)102.8 (97.6–115.2)0.317−0.20897.4 (85.8–107.7)102.5 (85.9–111.2)0.868−0.031
 FEV1.0%76.7 (73.0–79.8)75.8 (68.5–84.1)0.8070.05174.2 (69.6–78.2)72.0 (63.4–78.8)0.1620.257
Tumour size
Whole tumour size (mm), median (IQR)17 (15–23)18 (13–19)0.2590.23420 (16–25)18 (15–22)0.1950.238
Solid component size (mm), median (IQR)14 (11–16)14 (11–16)0.9710.00818 (15–23)17 (14–21)0.6000.057
CTR, median (IQR)0.75 (0.60–1.0)0.80 (0.67–1.0)0.3961.0 (0.96–1.0)1.0 (1.0–1.0)0.083
Pure solid (CTR, 1.0), n (%)15 (31.9)16 (34.0)0.82645 (75.0)52 (86.7)0.102
Deauville score, n (%)0.5350.1280.6560.158
 17 (14.9)5 (10.6)
 240 (85.1)42 (89.4)
 314 (23.3)17 (28.3)
 411 (18.3)13 (21.7)
 535 (58.3)30 (50.0)
SUVmax, median (IQR)1.3 (1.0–1.6)1.3 (1.0–1.6)0.4573.8 (2.6–5.9)3.8 (2.5–5.1)0.546
Clinical stage (%), n (%)0.4840.757
 IA18 (17.0)7 (14.9)2 (3.3)1 (1.7)
 IA239 (83.0)39 (83.0)37 (61.7)40 (66.7)
 IA30 (0)1 (2.1)21 (35.0)19 (31.7)
Classification of segmentectomy, n (%)NA
 Simple segmentectomy18 (38.3)36 (60.0)
 Complex segmentectomy29 (61.7)24 (40.0)
Complication (severer than Grade IIIa)5 (10.6)8 (17.0)0.36811 (18.3)7 (11.7)0.305
Histological subtype (%), n (%)1.0000.814
 Adenocarcinoma44 (93.6)44 (93.6)37 (61.7)43 (71.7)
 Squamous cell carcinoma3 (6.4)3 (6.4)14 (23.3)10 (16.7)
 Adenosquamous carcinoma0 (0)0 (0)2 (3.3)1 (1.7)
 LCNEC0 (0)0 (0)5 (8.3)4 (6.7)
 Pleomorphic carcinoma0 (0)0 (0)2 (3.3)2 (3.3)
LY3 (6.4)1 (2.1)0.29621 (35.0)19 (31.7)0.696
V2 (4.3)4 (8.5)0.39523 (38.3)22 (36.7)0.850
PL3 (6.4)4 (8.5)0.6949 (15.0)12 (20.0)0.470
Pathological stage (%), n (%)0.6270.851
 03 (6.4)4 (8.5)0 (0)0 (0)
 IA120 (42.6)15 (31.9)5 (8.3)6 (10.0)
 IA216 (34.0)20 (42.6)25 (41.7)28 (46.7)
 IA34 (8.5)3 (6.4)13 (21.7)6 (10.0)
 IB3 (6.4)4 (8.5)8 (13.3)14 (23.3)
 IIA0 (0)0 (0)1 (1.7)1 (1.7)
 IIB0 (0)1 (2.1)6 (10.0)4 (6.7)
 IIIA1 (2.1)0 (0)2 (3.3)1 (1.7)
Lymph node metastasis, n (%)1 (2.0)1 (2.1)1.0006 (10.0)4 (6.7)0.508
Prognosis, n (%)
 Recurrence1 (2.1)1 (2.1)1.0009 (15.0)7 (11.7)0.591
 Death from any cause3 (6.4)2 (4.3)0.6459 (15.0)13 (21.7)0.344
 Death from lung cancer0 (0)0 (0)NA4 (6.7)4 (6.7)1.000

CTR: consolidation tumour ratio; FEV1.0: forced exploratory volume in 1 s; IQR: interquartile range; LCNEC: large cell neuroendocrine carcinoma; LY: lymphatic invasion; NSCLC: non-small-cell lung cancer; PL: pleural invasion; SD: standardized differences; SUVmax: maximum standardized uptake value; V: vascular invasion; VC: vital capacity.

Table 2:
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Characteristics of matched patients of each Deauville score group

VariablesDeauville score 1 or 2
Deauville score 3–5
Lobectomy, n = 47Segmentectomy, n = 47P-valueSDLobectomy, n = 60Segmentectomy, n = 60P-valueSD
Age, median (IQR)66 (63–76)69 (65–73)0.482−0.14669 (62–77)71 (65–74)0.476−0.131
Sex, n (%)0.4090.1710.1770.248
 Male21 (44.7)25 (53.2)36 (60.0)43 (71.7)
 Female26 (55.3)21 (44.7)24 (40.0)17 (28.3)
Pulmonary function, median (IQR)
 %VC102.0 (92.1–110.0)102.8 (97.6–115.2)0.317−0.20897.4 (85.8–107.7)102.5 (85.9–111.2)0.868−0.031
 FEV1.0%76.7 (73.0–79.8)75.8 (68.5–84.1)0.8070.05174.2 (69.6–78.2)72.0 (63.4–78.8)0.1620.257
Tumour size
Whole tumour size (mm), median (IQR)17 (15–23)18 (13–19)0.2590.23420 (16–25)18 (15–22)0.1950.238
Solid component size (mm), median (IQR)14 (11–16)14 (11–16)0.9710.00818 (15–23)17 (14–21)0.6000.057
CTR, median (IQR)0.75 (0.60–1.0)0.80 (0.67–1.0)0.3961.0 (0.96–1.0)1.0 (1.0–1.0)0.083
Pure solid (CTR, 1.0), n (%)15 (31.9)16 (34.0)0.82645 (75.0)52 (86.7)0.102
Deauville score, n (%)0.5350.1280.6560.158
 17 (14.9)5 (10.6)
 240 (85.1)42 (89.4)
 314 (23.3)17 (28.3)
 411 (18.3)13 (21.7)
 535 (58.3)30 (50.0)
SUVmax, median (IQR)1.3 (1.0–1.6)1.3 (1.0–1.6)0.4573.8 (2.6–5.9)3.8 (2.5–5.1)0.546
Clinical stage (%), n (%)0.4840.757
 IA18 (17.0)7 (14.9)2 (3.3)1 (1.7)
 IA239 (83.0)39 (83.0)37 (61.7)40 (66.7)
 IA30 (0)1 (2.1)21 (35.0)19 (31.7)
Classification of segmentectomy, n (%)NA
 Simple segmentectomy18 (38.3)36 (60.0)
 Complex segmentectomy29 (61.7)24 (40.0)
Complication (severer than Grade IIIa)5 (10.6)8 (17.0)0.36811 (18.3)7 (11.7)0.305
Histological subtype (%), n (%)1.0000.814
 Adenocarcinoma44 (93.6)44 (93.6)37 (61.7)43 (71.7)
 Squamous cell carcinoma3 (6.4)3 (6.4)14 (23.3)10 (16.7)
 Adenosquamous carcinoma0 (0)0 (0)2 (3.3)1 (1.7)
 LCNEC0 (0)0 (0)5 (8.3)4 (6.7)
 Pleomorphic carcinoma0 (0)0 (0)2 (3.3)2 (3.3)
LY3 (6.4)1 (2.1)0.29621 (35.0)19 (31.7)0.696
V2 (4.3)4 (8.5)0.39523 (38.3)22 (36.7)0.850
PL3 (6.4)4 (8.5)0.6949 (15.0)12 (20.0)0.470
Pathological stage (%), n (%)0.6270.851
 03 (6.4)4 (8.5)0 (0)0 (0)
 IA120 (42.6)15 (31.9)5 (8.3)6 (10.0)
 IA216 (34.0)20 (42.6)25 (41.7)28 (46.7)
 IA34 (8.5)3 (6.4)13 (21.7)6 (10.0)
 IB3 (6.4)4 (8.5)8 (13.3)14 (23.3)
 IIA0 (0)0 (0)1 (1.7)1 (1.7)
 IIB0 (0)1 (2.1)6 (10.0)4 (6.7)
 IIIA1 (2.1)0 (0)2 (3.3)1 (1.7)
Lymph node metastasis, n (%)1 (2.0)1 (2.1)1.0006 (10.0)4 (6.7)0.508
Prognosis, n (%)
 Recurrence1 (2.1)1 (2.1)1.0009 (15.0)7 (11.7)0.591
 Death from any cause3 (6.4)2 (4.3)0.6459 (15.0)13 (21.7)0.344
 Death from lung cancer0 (0)0 (0)NA4 (6.7)4 (6.7)1.000
VariablesDeauville score 1 or 2
Deauville score 3–5
Lobectomy, n = 47Segmentectomy, n = 47P-valueSDLobectomy, n = 60Segmentectomy, n = 60P-valueSD
Age, median (IQR)66 (63–76)69 (65–73)0.482−0.14669 (62–77)71 (65–74)0.476−0.131
Sex, n (%)0.4090.1710.1770.248
 Male21 (44.7)25 (53.2)36 (60.0)43 (71.7)
 Female26 (55.3)21 (44.7)24 (40.0)17 (28.3)
Pulmonary function, median (IQR)
 %VC102.0 (92.1–110.0)102.8 (97.6–115.2)0.317−0.20897.4 (85.8–107.7)102.5 (85.9–111.2)0.868−0.031
 FEV1.0%76.7 (73.0–79.8)75.8 (68.5–84.1)0.8070.05174.2 (69.6–78.2)72.0 (63.4–78.8)0.1620.257
Tumour size
Whole tumour size (mm), median (IQR)17 (15–23)18 (13–19)0.2590.23420 (16–25)18 (15–22)0.1950.238
Solid component size (mm), median (IQR)14 (11–16)14 (11–16)0.9710.00818 (15–23)17 (14–21)0.6000.057
CTR, median (IQR)0.75 (0.60–1.0)0.80 (0.67–1.0)0.3961.0 (0.96–1.0)1.0 (1.0–1.0)0.083
Pure solid (CTR, 1.0), n (%)15 (31.9)16 (34.0)0.82645 (75.0)52 (86.7)0.102
Deauville score, n (%)0.5350.1280.6560.158
 17 (14.9)5 (10.6)
 240 (85.1)42 (89.4)
 314 (23.3)17 (28.3)
 411 (18.3)13 (21.7)
 535 (58.3)30 (50.0)
SUVmax, median (IQR)1.3 (1.0–1.6)1.3 (1.0–1.6)0.4573.8 (2.6–5.9)3.8 (2.5–5.1)0.546
Clinical stage (%), n (%)0.4840.757
 IA18 (17.0)7 (14.9)2 (3.3)1 (1.7)
 IA239 (83.0)39 (83.0)37 (61.7)40 (66.7)
 IA30 (0)1 (2.1)21 (35.0)19 (31.7)
Classification of segmentectomy, n (%)NA
 Simple segmentectomy18 (38.3)36 (60.0)
 Complex segmentectomy29 (61.7)24 (40.0)
Complication (severer than Grade IIIa)5 (10.6)8 (17.0)0.36811 (18.3)7 (11.7)0.305
Histological subtype (%), n (%)1.0000.814
 Adenocarcinoma44 (93.6)44 (93.6)37 (61.7)43 (71.7)
 Squamous cell carcinoma3 (6.4)3 (6.4)14 (23.3)10 (16.7)
 Adenosquamous carcinoma0 (0)0 (0)2 (3.3)1 (1.7)
 LCNEC0 (0)0 (0)5 (8.3)4 (6.7)
 Pleomorphic carcinoma0 (0)0 (0)2 (3.3)2 (3.3)
LY3 (6.4)1 (2.1)0.29621 (35.0)19 (31.7)0.696
V2 (4.3)4 (8.5)0.39523 (38.3)22 (36.7)0.850
PL3 (6.4)4 (8.5)0.6949 (15.0)12 (20.0)0.470
Pathological stage (%), n (%)0.6270.851
 03 (6.4)4 (8.5)0 (0)0 (0)
 IA120 (42.6)15 (31.9)5 (8.3)6 (10.0)
 IA216 (34.0)20 (42.6)25 (41.7)28 (46.7)
 IA34 (8.5)3 (6.4)13 (21.7)6 (10.0)
 IB3 (6.4)4 (8.5)8 (13.3)14 (23.3)
 IIA0 (0)0 (0)1 (1.7)1 (1.7)
 IIB0 (0)1 (2.1)6 (10.0)4 (6.7)
 IIIA1 (2.1)0 (0)2 (3.3)1 (1.7)
Lymph node metastasis, n (%)1 (2.0)1 (2.1)1.0006 (10.0)4 (6.7)0.508
Prognosis, n (%)
 Recurrence1 (2.1)1 (2.1)1.0009 (15.0)7 (11.7)0.591
 Death from any cause3 (6.4)2 (4.3)0.6459 (15.0)13 (21.7)0.344
 Death from lung cancer0 (0)0 (0)NA4 (6.7)4 (6.7)1.000

CTR: consolidation tumour ratio; FEV1.0: forced exploratory volume in 1 s; IQR: interquartile range; LCNEC: large cell neuroendocrine carcinoma; LY: lymphatic invasion; NSCLC: non-small-cell lung cancer; PL: pleural invasion; SD: standardized differences; SUVmax: maximum standardized uptake value; V: vascular invasion; VC: vital capacity.

DISCUSSION

In this study, we presented that Deauville criteria can be used for NSCLC presenting radiologically solid predominant tumour in preoperative CT. CIR was significantly higher in patients with high Deauville scores. However, the CIR after segmentectomy did not differ significantly from that after lobectomy, even in the matched cohort. This suggests that segmentectomy is feasible for early-stage NSCLC, even if they are hypermetabolic tumours.

Recurrence free survival (RFS) and overall survival (OS) are often used as end points of this kind of retrospective study. Recurrence and death from other than lung cancer are treated as events in the analysis using RFS. In the analysis using OS, all death is equally treated as events regardless of cause of death. To clarify oncological outcome, we set CIR as a primary end-point.

According to some recent reports, patients with small NSCLC can be candidates for sublobar resection because the prognosis is favourable [13–15]. This possibility is being investigated in large prospective, randomized controlled trials [16, 17]. On the other hand, tumours with high accumulations of FDG have invasive characteristics and carry a poor prognosis [18], and it is unclear whether sublobar resection can confer a prognosis equal to that of lobectomy for small tumours with high FDG accumulation. However, FDG-PET/CT is not included as inclusion criteria of these trials [16, 17] and the value of SUVmax varies among institutions; therefore, this question has yet to be answered. In our study with Deauville scores, which may allow for prospective studies involving FDG-PET/CT, patients experienced few recurrences and the CIR did not differ among patients with low Deauville scores. This may mean that even if the CTR is high, tumours with weak FDG accumulation have a low invasiveness and cure can be achieved with appropriate resection, regardless of procedure. Even in patients with high Deauville scores, the CIR after lobectomy also did not differ significantly from that after segmentectomy. This may mean that tumours with strong FDG accumulation are highly invasive and surgery alone may not achieve a definite cure. Patients with such tumours may be potential candidates for additional perioperative treatment.

Limitations

First, this was a retrospective study and participants were from a single institution. Second, because standard procedure for solid predominant tumour is currently lobectomy and because it is known that NSCLC with high accumulation of FDG has invasive characteristics, lobectomy was performed in many patients with high Deauville scores in this study. Therefore, even after propensity score matching, some bias may have affected the results. For example, in our cohort, although there are no differences in CIR and CILSD, CIAD tend to be higher in patients who underwent segmentectomy. This is probably because of differences in background other than oncological factor and segmentectomy for compromised patients is contained. To confirm results of this study, a prospective study is necessary. Until now, it has been difficult to conduct prospective studies using FDG-PET/CT in the field of lung cancer surgery because imaging protocols vary among institutions, but the Deauville criteria may enable such studies.

CONCLUSION

The evaluation of FDG accumulation with the Deauville criteria, a 5-point visual scale was useful in predicting prognosis and invasiveness of early-stage, solid predominant NSCLC. Patients with low Deauville scores experienced few recurrences regardless of procedure. Even in patients with high Deauville scores, CIR after lobectomy did not differ statistically from that after segmentectomy. These results indicate that segmentectomy for NSCLC with high CTR and accumulation of FDG may be feasible and should be confirmed in larger prospective studies.

SUPPLEMENTARY MATERIAL

Supplementary material is available at EJCTS online.

Funding

There was no external funding.

Conflict of interest: none declared.

Author contributions

Atsushi Kagimoto: Conceptualization; Data curation; Formal analysis; Investigation; Writing—original draft. Yasuhiro Tsutani: Conceptualization; Supervision; Writing—review & editing. Takahiro Mimae: Conceptualization; Supervision; Writing—review & editing. Yoshihiro Miyata: Supervision; Writing—review & editing. Morihito Okada: Supervision.

Reviewer information

European Journal of Cardio-Thoracic Surgery thanks Haruhisa Matsuguma, Piergiorgio Muriana and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.

REFERENCES

1

Barrington
SF
,
Qian
W
,
Somer
EJ
,
Franceschetto
A
,
Bagni
B
,
Brun
E
  et al.  
Concordance between four European centres of PET reporting criteria designed for use in multicentre trials in Hodgkin lymphoma
.
Eur J Nucl Med Mol Imaging
 
2010
;
37
:
1824
–
33
.

Google Scholar

Crossref
Search ADS
PubMed

 
2

Li
X
,
Sun
X
,
Li
J
,
Liu
Z
,
Mi
M
,
Zhu
F
  et al.  
Interim PET/CT based on visual and semiquantitative analysis predicts survival in patients with diffuse large B-cell lymphoma
.
Cancer Med
 
2019
;
8
:
5012
–
1
.

Google Scholar

Crossref
Search ADS
PubMed

 
3

Zhou
Y
,
Zhao
Z
,
Li
J
,
Zhang
B
,
Sang
S
,
Wu
Y
  et al.  
Prognostic values of baseline, interim and end-of therapy 18F-FDG PET/CT in patients with follicular lymphoma
.
Cancer Manag Res
 
2019
;
11
:
6871
–
85
.

Google Scholar

Crossref
Search ADS
PubMed

 
4

Johnson
P
,
Federico
M
,
Kirkwood
A
,
Fosså
A
,
Berkahn
L
,
Carella
A
  et al.  
Adapted treatment guided by interim PET-CT scan in advanced Hodgkin’s lymphoma
.
N Engl J Med
 
2016
;
374
:
2419
–
29
.

Google Scholar

Crossref
Search ADS
PubMed

 
5

Borchmann
P
,
Goergen
H
,
Kobe
C
,
Lohri
A
,
Greil
R
,
Eichenauer
DA
  et al.  
PET-guided treatment in patients with advanced-stage Hodgkin’s lymphoma (HD18): final results of an open-label, international, randomised phase 3 trial by the German Hodgkin Study Group
.
Lancet
 
2017
;
390
:
2790
–
802
.

Google Scholar

Crossref
Search ADS
PubMed

 
6

Kagimoto
A
,
Tsutani
Y
,
Izaki
Y
,
Handa
Y
,
Mimae
T
,
Miyata
Y
  et al.  
Prediction of lymph node metastasis using semiquantitative evaluation of PET for lung adenocarcinoma
.
Ann Thorac Surg
 
2020
;
110
:
1036
–
42
.

Google Scholar

Crossref
Search ADS
PubMed

 
7

Kagimoto
A
,
Tsutani
Y
,
Handa
Y
,
Mimae
T
,
Miyata
Y
,
Okada
M.
  
Patient selection of sublobar resection using visual evaluation of PET for early stage lung adenocarcinoma
.
Ann Surg Oncol
 
2021
;
28
:
2068
–
75
.

Google Scholar

Crossref
Search ADS
PubMed

 
8

Okada
M
,
Sakamoto
T
,
Yuki
T
,
Mimura
T
,
Miyoshi
K
,
Tsubota
N.
  
Hybrid surgical approach of video-assisted minithoracotomy for lung cancer: significance of direct visualization on quality of surgery
.
Chest
 
2005
;
128
:
2696
–
701
.

Google Scholar

Crossref
Search ADS
PubMed

 
9

Clavien
PA
,
Barkun
J
,
de Oliveira
ML
,
Vauthey
JN
,
Dindo
D
,
Schulick
RD
  et al.  
The Clavien-Dindo classification of surgical complications: five-year experience
.
Ann Surg
 
2009
;
250
:
187
–
96
.

Google Scholar

Crossref
Search ADS
PubMed

 
10

Goldstraw
P
,
Chansky
K
,
Crowley
J
,
Rami-Porta
R
,
Asamura
H
,
Eberhardt
WE
  et al. ; International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee Advisory Boards and Participating Institutions.
The IASLC Lung Cancer Staging Project: proposals for Revision of the TNM Stage Groupings in the Forthcoming (Eighth) Edition of the TNM Classification for Lung Cancer
.
J Thorac Oncol
 
2016
;
11
:
39
–
51
.

Google Scholar

Crossref
Search ADS
PubMed

 
11

Travis
WD
,
Brambilla
E
,
Nicholson
AG
,
Yatabe
Y
,
Austin
JHM
,
Beasley
MB
  et al. ; WHO Panel.
The 2015 World Health Organization Classification of Lung Tumors: impact of genetic, clinical and radiologic advances since the 2004 classification
.
J Thorac Oncol
 
2015
;
10
:
1243
–
60
.

Google Scholar

Crossref
Search ADS
PubMed

 
12

Kanda
Y.
 
Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics
.
Bone Marrow Transplant
 
2013
;
48
:
452
–
8
.

Google Scholar

Crossref
Search ADS
PubMed

 
13

Asamura
H
,
Hishida
T
,
Suzuki
K
,
Koike
T
,
Nakamura
K
,
Kusumoto
M
  et al.  
Radiographically determined noninvasive adenocarcinoma of the lung: survival outcomes of Japan Clinical Oncology Group 0201
.
J Thorac Cardiovasc Surg
 
2013
;
146
:
24
–
30
.

Google Scholar

Crossref
Search ADS
PubMed

 
14

Okada
M
,
Koike
T
,
Higashiyama
M
,
Yamato
Y
,
Kodama
K
,
Tsubota
N.
  
Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study
.
J Thorac Cardiovasc Surg
 
2006
;
132
:
769
–
75
.

Google Scholar

Crossref
Search ADS
PubMed

 
15

Tsutani
Y
,
Miyata
Y
,
Nakayama
H
,
Okumura
S
,
Adachi
S
,
Yoshimura
M
  et al.  
Appropriate sublobar resection choice for ground glass opacity-dominant clinical stage IA lung adenocarcinoma: wedge resection or segmentectomy
.
Chest
 
2014
;
145
:
66
–
71
.

Google Scholar

Crossref
Search ADS
PubMed

 
16

Nakamura
K
,
Saji
H
,
Nakajima
R
,
Okada
M
,
Asamura
H
,
Shibata
T
  et al.  
A phase III randomized trial of lobectomy versus limited resection for small-sized peripheral non-small cell lung cancer (JCOG0802/WJOG4607L)
.
Jpn J Clin Oncol
 
2010
;
40
:
271
–
4
.

Google Scholar

Crossref
Search ADS
PubMed

 
17

Aokage
K
,
Saji
H
,
Suzuki
K
,
Mizutani
T
,
Katayama
H
,
Shibata
T
  et al. ; Lung Cancer Surgical Study Group of the Japan Clinical Oncology Group.
A non-randomized confirmatory trial of segmentectomy for clinical T1N0 lung cancer with dominant ground glass opacity based on thin-section computed tomography (JCOG1211)
.
Gen Thorac Cardiovasc Surg
 
2017
;
65
:
267
–
72
.

Google Scholar

Crossref
Search ADS
PubMed

 
18

Hattori
A
,
Matsunaga
T
,
Takamochi
K
,
Oh
S
,
Suzuki
K.
  
Clinical significance of positron emission tomography in subcentimeter non-small cell lung cancer
.
Ann Thorac Surg
 
2017
;
103
:
1614
–
21
.

Google Scholar

Crossref
Search ADS
PubMed

 

ABBREVIATIONS

     
  • CI

    Confidence interval

    •  
  • CT

    Computed tomography

    •  
  • CTR

    Consolidation tumour ratio

    •  
  • CIAD

    Cumulative incidence of all death

    •  
  • CILSD

    Cumulative incidence of lung cancer-specific death

    •  
  • CIR

    Cumulative incidence of recurrence

    •  
  • FDG

    [18F]-fluoro-2-deoxy-d-glucose

    •  
  • NSCLC

    Non-small-cell lung cancer

    •  
  • PET

    Positron emission tomography

    •  
  • SUVmax

    Maximum standardized uptake value

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