Segmentectomy





Definition

Segmentectomy is the excision (removal) of a portion of any organ or gland. The procedure has several variations and many names, including segmental resection, wide excision, lumpectomy , tumorectomy, quadrantectomy , and partial mastectomy.


Purpose

Segmentectomy is the surgical removal of a defined segment or portion of an organ or gland performed as a treatment. In this case, the purpose is the removal of a cancerous tumor. Common organs that have segments are the breasts, lungs, and liver.


Demographics

Segmentectomies are usually performed on patients with lung, liver, or breast cancer.

Lung cancer is the second most common cancer among both men and women, and is the leading cause of cancer death for both genders. Lung cancer kills more people (approximately 157,000 per year) than cancers of the breast, prostate, colon, and pancreas combined. Almost 90% of all lung cancers are caused by cigarette smoking. Other causes include secondhand smoke and exposure to asbestos and other occupation-related substances.

In each of the racial and ethnic groups, the rates among men are about two to three times greater than the rates among women. Among men, age-adjusted lung cancer incidence rates (per 100,000) range from a low of about 14 among American Indians to a high of 117 among African Americans, an eight-fold difference. For women, the rates range from approximately 15 per 100,000 among Japanese to nearly 51 among Alaska Natives, approximately a three-fold difference.

Excluding cancers of the skin, breast cancer is the most common form of cancer among women in the United States. The increase in incidence is primarily due to increased screening by physical examination and mammography . Although breast cancer occurs among both women and men, it is quite rare among men. White non-Hispanic women have the highest rates of breast cancer, over twice the rate for Hispanic women. There are a low number of cases for Alaska Native, American Indian, Korean, and Vietnamese women.

Primary cancers of the liver account for approximately 1.5% of all cancer cases in the United States. About two-thirds of liver cancers are most clearly associated with hepatitis B and hepatitis C viral infections and cirrhosis. This type of liver cancer occurs more frequently in men than in women by a ratio of two to one.


Description

When cancer is confined to a segment of an organ, removal of that portion may offer cancer-control results equivalent to those of more extensive operations. This is especially true for breast and liver cancers. For breast and lung cancers, a segmentectomy is often combined with removal of some or all regional lymph nodes.

Treatment options for lung cancer depend on the stage of the cancer (whether it is in the lung only or has spread to other places in the body); tumor size; the type of lung cancer; presence (or lack) of symptoms; and the patient's general health.

A disease in which malignant (cancer) cells form in the tissues of the lung is called non-small cell lung cancer (NSCLC). There are five types of NSCLC; each consists of different types of cancer cells, which grow and spread in different ways. The types of NSCLC are named for the kinds of cells found in the cancer, and how the cells appear when viewed under a microscope.

Segmentectomy may be the treatment of choice for cancerous tumors in the occult, or hidden stage, as well as in stage 0, stage I, or stage II NSCLC. When the site and nature of the primary tumor is defined in occult stage lung cancer, it is generally removed by segmentectomy.

Segmentectomy is the usual treatment for stage 0 cancers of the lung, as they are limited to the layer of tissue that lines air passages, and have not invaded the nearby lung tissue. Chemotherapy or radiation therapy is not normally required.

Segmentectomy is recommended only for treating the smallest stage I cancers and for patients with other medical conditions that make removing part or the entire lobe of the lung (lobectomy) dangerous. If the patient does not have sufficient pulmonary function to tolerate this more extensive operation, a segmentectomy will be performed. Additional chemotherapy after surgery for stage I NSCLC is not routinely recommended. If a patient has serious medical problems, radiation therapy may be the primary treatment.

A cancerous tumor will be surgically removed by segmentectomy or lobectomy in cases of stage II NSCLC. A wedge resection might be done if the patient cannot withstand lobectomy. Sometimes pneumonectomy (removal of the entire lung) is needed. Radiation therapy may be used to destroy cancer cells left behind after surgery, especially if malignant cells are present at the edge of the tissue removed by surgery. Some doctors may recommend additional radiation therapy even if the edges of the sample have no detectable cancer cells.

Segmentectomy is under investigation for the treatment of small-cell lung cancers.

Because of the need for radiotherapy after segmentectomy, some patients, such as pregnant women and those with syndromes not compatible with radiation treatment, may not be candidates for segmentectomy. As in any surgery, patients should alert their physician about all allergies and any medications they are taking.

Diagnosis/Preparation

The following methods may be used to help diagnose breast cancer:

  • complete physical exam and family medical history
  • clinical breast exam
  • mammography
  • biopsy (incisional, excisional, or needle)
  • ultrasonography
  • fine-needle aspiration

Tests help to determine whether cancer cells have spread within the lungs or to other parts of the body after a diagnosis of lung cancer. The following tests and procedures may be used in the staging process to diagnose lung cancer:

  • complete physical exam, including personal and family medical history
  • chest x ray
  • computed tomography (CT) scan
  • positron emission tomography ( PET ) scan
  • other radiologic exams
  • laboratory tests (tissue, blood, urine, or other substances in the body)
  • bronchoscopy
  • mediastinoscopy
  • anterior mediastinotomy
  • lymph node biopsy

Treatment is determined when the stage of the tumor is known.

Such routine preoperative preparations, as not eating or drinking after midnight on the night before surgery are typically ordered for a segmentectomy. Information about expected outcomes and potential complications is also part of the preparation for this surgery.


Aftercare

After a segmentectomy, patients are usually cautioned against doing moderate lifting for several days. Other activities may be restricted (especially if lymph nodes were removed) according to individual needs. Pain is often enough to limit inappropriate motion, and is generally controlled with medication. If pain medications are ineffective, the patient should contact the physician, as severe pain may be a sign of a complication requiring medical attention. Women who undergo segmentectomy of the breast are often instructed to wear a well-fitting support bra both day and night for approximately one week after surgery.

The length of the hospital stay depends on the specific surgery performed and the extent of organ or tissue removed, as well as other factors.

Radiation therapy usually begins four to six weeks after surgery, and continues for four to five weeks. The timing of additional therapy is specific to each patient.


Risks

The risks for any surgical procedure requiring anesthesia include reactions to the medications and breathing problems. Bleeding and infection are risks for any surgical procedure. Infection in the area affecting a segmentectomy occurs in only 3–4% of patients. Pneumonia is also a risk.


Normal results

Successful removal of the tumor with no major bleeding or infection at the wound site after surgery is considered a normal outcome.


Morbidity and mortality rates

Although the incidence of breast cancer has been rising in the United States for the past two decades, the mortality rate has remained relatively stable since the 1950s. Mortality rates range from 15% of the incidence rate for Japanese women to 33% of the incidence rate for African American women. The highest age-adjusted mortality occurs among African American women, followed by Caucasian and Hawaiian women.

African American women have the highest mortality rates in the age groups 30–54 years and 55–69 years, followed by Hawaiian, and Caucasian non-Hispanic women. The mortality rate for Caucasian women exceeds that for African American women in the 70-year and older age group.

Five-year survival rates for liver cancer patients are usually less than 10% in the United States. The reported statistics for these cancers often include mortality rates that exceed the incidence rates. The discrepancy occurs when the cause of death is misclassified as "liver cancer" for patients whose cancer originated as a primary tumor in another organ and spread to the liver, becoming a secondary cancer.

For primary liver cancer, non-Hispanic white men and women have the lowest age-adjusted mortality rates in the United States, roughly one-half that of the African American and Hispanic populations.

Liver cancer mortality rates for Asian American groups are several times higher than that of the Caucasian population. The highest age-adjusted mortality rates for all groups are among the Chinese population. Alaskan Native and American Indian populations have a very low incidence of liver cancer.

Factors that affect the prognosis (chance of recovery) for lung cancer include:

  • stage of the cancer (whether it is in the lung only or has spread to other places in the body)
  • tumor size
  • type of lung cancer
  • presence of symptoms
  • shortness of breath during activities
  • shortness of breath with less and less activity
  • the patient's general health

Current treatments are not a cure for most patients with non-small cell lung cancer. If it returns after treatment, it is called recurrent non-small cell lung cancer. The cancer may reappear in the brain, lung, or other parts of the body. Further treatment is then required.


Alternatives

Other cancer treatments include:

  • chemotherapy
  • radiation therapy
  • radiosurgery
  • laser therapy
  • photodynamic therapy
  • chemoprevention

Using a segmentectomy to remove breast cancers (as a technique that conserves the aesthetic appearance of a breast) is being investigated for large tumors after several cycles of preoperative chemotherapy.

Cancers in some locations (such as where the windpipe divides into the left and right main bronchi) are difficult to remove completely by surgery without also removing an entire lung.

See also Quadrantectomy .


Resources

BOOKS

Benedet, Rosalind Dolores, and Shannon Abbey (Illustrator). After Mastectomy: Healing Physically and Emotionally. Omaha, NE: Addicus Books, 2003.

Clavien, Pierre-Alain, and Nuria Roca, eds. Malignant Liver Tumors: Current and Emerging Therapies, 2nd edition. Sudbury, MA: Jones & Bartlett Pub., 2003.

Farrell, Susan. Mammograms and Mastectomies: Facing Them With Humor and Prayer. Battle Creek, MI: Acorn Publishing, 2003.

Henschke, Claudia I., Peggy McCarthy, and Sarah Wernick. Lung Cancer: Myths, Facts, Choices—And Hope. New York, NY: W.W. Norton & Company, 2002.

Simone, John. The LCIS & DCIS Breast Cancer Fact Book. Raleigh, NC: Three Pyramids Publishing, 2002.

PERIODICALS

Mahadevia, Parthiv J., Lee A. Fleisher, Kevin D. Frick, John Eng, Steven N. Goodman, and Neil R. Powe. "Lung Cancer Screening with Helical Computed Tomography in Older Adult Smokers: A Decision and Cost-Effectiveness Analysis." Journal of the American Medical Association 289 (2003): 313-22. <http://www.atcs.jp/journal/abstract.php?ac=3&bn=030901& x0026;no=10>

Shimizu J. J., Y. Ishida, T. Kinoshita., T. Terada, Y. Tatsuzawa, Y. Kawaura, et al. "Left Upper Division Sleeve Segmentectomy for Early Stage Squamous Cell Carcinoma of the Segmental Bronchus: Report of Two Cases." Annals of Thoracic Cardiovascular Surgery 9, no.1 (2003): 62-7.

Vastag, Brian. "Consensus Panel Recommendations for Treatment of Early Breast Cancer." Journal of the American Medical Association 284 (2002): 2707-8.

ORGANIZATIONS

American Cancer Society. 1599 Clifton Road, N.E. Atlanta, GA 30329-4251. (800) 227-2345. http://www.cancer.org .

National Alliance of Breast Cancer Organizations (NABCO). 9 East 37th Street, 10th Floor, New York, NY 10016. (888) 80-NABCO. http://www.nabco.org .

National Comprehensive Cancer Network. 50 Huntingdon Pike, Suite 200, Rockledge, PA 19046. (215) 728-4788. Fax: (215) 728-3877. Email: information@nccn.org. http://www.nccn.org/ .

National Institutes of Health (NIH), Department of Health and Human Services. 9000 Rockville Pike. Bethesda, MD 20892. (800) 422-6237.

U.S. Department of Health and Human Services. 200 Independence Avenue, S.W., Washington, D.C. 20201. (877) 696-6775.

Y-ME National Breast Cancer Organization. Suite 500-212 West Van Buren St., Chicago, IL 60607-3908. (800) 986-9505. 312-986-8338. Fax: 312-294-8597. http://www.y-me.org .

OTHER

National Cancer Institute. Types of Cancer. 2003. [cited April 28, 2003] http://www.nci.nih.gov/cancerinfo/types/ .


Laura Ruth, Ph.D. Crystal H. Kaczkowski, M.Sc.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?



Segmentectomies are performed in a hospital by a general surgeon, a medical doctor who specializes in surgery. If there are complicating factors, a specialized surgeon may perform the surgery.

QUESTIONS TO ASK THE DOCTOR



  • Is segmentectomy an option for treatment?
  • When will it be known whether or not all the cancer has been removed?
  • What benefits can be expected from this operation?
  • What is the risk of tumor recurrence after undergoing this procedure?
  • What should be done to prepare for surgery?
  • What happens if this operation does not go as planned?


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