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European Journal of Cardio-Thoracic Surgery 46 (2014) 928 LETTER TO THE EDITOR RESPONSE
doi:10.1093/ejcts/ezu123 Advance Access publication 2 April 2014
Reply to Poullis
Data capture in aortic registries
David H. Tiana and Tristan D. Yana,b,*
a Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
b Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
* Corresponding author. Suite 304, 100 Carillon Avenue, Newtown, NSW 2042, Australia. Tel: +61-2-95501933; fax: +61-2-95506669;
e-mail: (T.D. Yan).
Received 23 February 2014; accepted 26 February 2014
Keywords: Aortic arch surgery • Clinical registry • Neuroprotection
We thank Dr Poullis for his comments [1] on our article [2] and recommendation of his Excel datasheet to record continuous data for
variables such as blood pressure, temperature, glucose, lactate and
haematocrit. The point that Dr Poullis raises is highly pertinent to surgical studies and databases—howmuch data do we need to record?
Continuous data recording during surgery is an admirable goal,
as it does indeed capture variations in surgical parameters that
cannot be extrapolated through simple summary statistics. However,
the utility of such a system is questionablewhen comparedwith the
effort required to obtain such data (for example, the Excel datasheet
that Dr Poullis proposes require data to be inputted manually).
The obstacle with implementing such a system that captures
continuous surgical parameters is not just the difficulty in reaching
a general consensus on its design and format, but ensuring
widespread clinical implementation and usage. Adoption of such
systems can be hastened through acceptance and recommendation by professional societies, as well as robust studies demonstrating the scientific and clinical validation of such schemes. In
the absence of such evidence, we believe that implementation of
these systems may be too much work for too little gain.
[1] Poullis M. Aortic arch surgery: Beyond surgical technique alone. Eur J
Cardiothorac Surg 2014;46:927.
[2] Yan TD, Tian DH, LeMaire SA, Misfeld M, Elefteriades JA, Chen EP et al. The
ARCH Projects: design and rationale (IAASSG 001). Eur J Cardiothorac Surg
European Journal of Cardio-Thoracic Surgery 46 (2014) 928–929 LETTER TO THE EDITOR
doi:10.1093/ejcts/ezu142 Advance Access publication 8 April 2014
A critical analysis of segmentectomy versus lobectomy for
non-small-cell lung cancer
Christopher Caoa,b,c,*, Sunil Guptaa, David Chandrakumara and Tristan D. Yana,d
a The Systematic Review Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia
b Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, Australia
c School of Medical Sciences, University of New South Wales, Sydney, Australia
d Department of Cardiothoracic Surgery, The Royal Prince Alfred Hospital, Sydney, Australia
* Corresponding author. The Systematic Review Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia. Tel: +61-2-91131111;
fax: +61-2-91133393; e-mail: (C. Cao).
Received 31 December 2013; accepted 21 February 2014
Keywords: Segmentectomy • Lobectomy • Non-small-cell lung cancer •Meta-analysis
Bao et al. [1] should be commended for completing a thorough
and timely meta-analysis to compare the survival outcomes of
segmentectomy versus lobectomy for Stage I non-small-cell lung
cancer (NSCLC). This analysis represents the first of its kind to distinguish segmentectomies from wedge resections, an important
distinction from both an oncological and technical perspective
Letters to the Editor / European Journal of Cardio-Thoracic Surgery928
that has been overlooked in previous meta-analyses that compared ‘sublobar resections’ with lobectomy procedures [2, 3]. We
concur with the authors that the current literature lacks robust
high-level evidence on this topic and a meta-analysis of observational studies may provide insightful guidance for clinicians.
Results of this study found that patients who underwent segmentectomy for Stage I, IA and IA (2–3 cm) NSCLC were associated with
inferior combined overall survival (OS) and cancer-specific survival
(CSS) outcomes compared with those who underwent lobectomy.
However, patients with Stage IA (≤2 cm) NSCLC had no statistically
significant difference in survival compared with lobectomy. It is
imperative to analyse these results in detail to avoid misleading
conclusions. In two of the four analysed subgroups, Stage IA and
Stage IA (2–3 cm), OS outcomes were significantly worse after segmentectomy, but CSS was not significant. The combined OS/CSS
were significant in both subgroups, and the authors concluded that
patients who underwent segmentectomy in these cohorts resulted
in inferior outcomes. However, it must be emphasized that patient
baseline characteristics between these two treatment groups differed significantly, and patients were often selected for segmentectomies due to significant comorbidities and limited pulmonary
reserve prohibiting them from lobectomy procedures [4, 5]. In such
cases, differences in OS may be misleading compared with CSS, as
patients died due to causes unrelated to NSCLC and the oncological efficacy of their surgical procedures. Hence, worse OS outcomes
in the segmentectomy group may be a reflection of their patient
characteristics rather than their operative outcome. Similarly, a
combined statistic of OS and CSS may overestimate the adverse survival outcomes of segmentectomy procedures.
To address the issue of differing patient baseline characteristics,
Tsutani et al. [6] recently published a propensity-score analysis
involving 481 patients with clinical Stage IA adenocarcinoma who
were subsequently matched into 81 pairs according to clinicopathological factors. Results of this study demonstrated no differences in regard to OS and recurrence-free survival at 3 years. In
our opinion, it is no longer controversial to perform sublobar
resections for patients with NSCLC who are deemed ineligible for
lobectomy procedures due to comorbidities or limited pulmonary
function. The area of interest lies with the cohort of patients who
can tolerate either a segmentectomy or a lobectomy procedure.
For this growing patient population who are diagnosed with early
stage NSCLC through more aggressive screening programmes,
oncological efficacy needs to be balanced with pulmonary preservation and potentially reduced perioperative complications
associated with segmentectomy. Future analyses should aim to
differentiate data from studies that included ‘compromised’
patients who underwent sublobar resections as a result of their inability to undergo lobectomy, or ‘intentional’ patients who could
have tolerated either procedure.
Conflict of interest: none declared.
[1] Bao F, Ye P, Yang Y, Wang L, Zhang C, Lv X et al. Segmentectomy or lobectomy
for early stage lung cancer: a meta-analysis. Eur J Cardiothorac Surg 2014;46:
[2] Fan J, Wang L, Jiang GN, Gao W. Sublobectomy versus lobectomy for stage I
non-small-cell lung cancer, a meta-analysis of published studies. Ann Surg
Oncol 2012;19:661–8.
[3] Nakamura H, Kawasaki N, Taguchi M, Kabasawa K. Survival following
lobectomy vs limited resection for stage I lung cancer: a meta-analysis.
Br J Cancer 2005;92:1033–7.
[4] Warren WH, Faber LP. Segmentectomy versus lobectomy in patients with
stage I pulmonary carcinoma. Five-year survival and patterns of intrathoracic
recurrence. J Thorac Cardiovasc Surg 1994;107:1087–93; discussion 93–4.
[5] Keenan RJ, Landreneau RJ, Maley RH Jr, Singh D, Macherey R, Bartley S
et al. Segmental resection spares pulmonary function in patients with stage
I lung cancer. Ann Thorac Surg 2004;78:228–33; discussion 28–33.
[6] Tsutani Y, Miyata Y, Nakayama H, Okumura S, Adachi S, Yoshimura M et al.
Oncologic outcomes of segmentectomy compared with lobectomy for
clinical stage IA lung adenocarcinoma: propensity score-matched analysis
in a multicenter study. J Thorac Cardiovasc Surg 2013;146:358–64.
European Journal of Cardio-Thoracic Surgery 46 (2014) 929–930 LETTER TO THE EDITOR RESPONSE
doi:10.1093/ejcts/ezu143 Advance Access publication 8 April 2014
Reply to Cao et al.
Feichao Bao, Peng Ye, Yunhai Yang and Jian Hu*
Department of Thoracic Surgery, First Hospital, College of Medicine, Zhejiang University, Hangzhou, China
* Corresponding author. Department of Thoracic Surgery, First Hospital, College of Medicine, Zhejiang University, No. 79, Qingchun Road, Hangzhou 310003,
Zhejiang, China. Tel: +86-571-87236770; fax: +86-571-87236770; e-mail: ( J. Hu).
Received 9 February 2014; accepted 21 February 2014
Keywords: Segmentectomy • Lobectomy • Non-small-cell lung cancer •Meta-analysis
We thank Cao et al. [1] for their insightful comments on our manuscript recently published in the European Journal of CardioThoracic Surgery [2]. Cao et al. addressed, in their letter to the
editor, two important and controversial aspects of segmentectomy comparing with lobectomy for early stage non-small-cell
lung cancer (NSCLC), which we would like to discuss in detail.
The first issue emphasized by Cao et al. was the rationality of
using combined overall survival (OS) and cancer-specific survival
(CSS) outcomes to compare the two different surgical procedures.
Our study aimed at assessing the survival difference between segmentectomy and lobectomy. We must admit that combining OS
and CSS does have some shortcomings such as it may
Letters to the Editor / European Journal of Cardio-Thoracic Surgery 929

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