Thirty- and ninety-day outcomes after sublobar resection with and without brachytherapy for non-small cell lung cancer: results from a multicenter phase III study

Treatment of stage I lung cancer in high-risk and inoperable patients: comparison of prospective clinical trials using stereotactic body radiotherapy (RTOG 0236), sublobar resection (ACOSOG Z4032), and radiofrequency ablation (ACOSOG Z4033)

OBJECTIVE

The purpose of the present study was to compare the selection criteria and short-term outcomes among 3 prospective clinical trials using stereotactic body radiotherapy (Radiation Therapy Oncology Group [RTOG] trial 0236), sublobar resection (American College of Surgeons Oncology Group [ACOSOG] trial Z4032), and radiofrequency ablation (ACOSOG trial Z4033).

METHODS

The selection criteria and outcomes were compared among RTOG 0236 (n = 55), ACOSOG Z4032 (n = 211), and ACOSOG Z4033 (n = 51). Age, Eastern Cooperative Oncology Group performance status, percentage of predicted forced expiratory volume in 1 second, and percentage of predicted carbon monoxide diffusing capacity of the lung were used to perform a propensity-matched analysis among patients with clinical stage 1A in RTOG 0236 and ACOSOG Z4032.

RESULTS

The patients in ACOSOG Z4033 undergoing radiofrequency ablation were older (75.6 ± 7.5 years) than those in RTOG 0236 (72.5 ± 8.8 years) and ACOSOG Z4032 (70.2 ± 8.5 years; P = .0003). The pretreatment percentage of predicted forced expiratory volume in 1 second was 61.3% ± 33.4% for RTOG 0236, 53.8% ± 19.6% for ACOSOG Z4032, and 48.8% ± 20.3% for ACOSOG Z4033 (P = .15). The pretreatment percentage of predicted carbon monoxide diffusing capacity of the lung was 61.6% ± 30.2% for RTOG 0236, 46.4% ± 15.6% for ACOSOG Z4032, and 43.7% ± 18.0% for ACOSOG Z4033 (P = .001). The overall 90-day mortality for stereotactic body radiotherapy, surgery, and radiofrequency ablation was 0%, 2.4% (5/211), and 2.0% (1/51), respectively (P = .5). Overall, the unadjusted 30-day grade 3+ adverse events were more common with surgery than with stereotactic body radiotherapy (28% vs 9.1%, P = .004), although no difference was between the 2 groups at 90 days. Among the patients with clinical stage IA in ACOSOG Z4032, 29.3% had a more advanced pathologic stage at surgery. A propensity-matched comparison showed no difference between stereotactic body radiotherapy and surgery for 30-day grade 3+ adverse events (odds ratio, 2.37; 95% confidence interval, 0.75-9.90; P = .18).

CONCLUSIONS

Among appropriately matched patients, no difference was seen in early morbidity between sublobar resection and stereotactic body radiotherapy. These results underscore the need for a randomized trial to delineate the relative survival benefit of each modality and to help stratify patients considered high risk.

Optimal management of patients with stage I non-small-cell lung cancer and compromised cardiopulmonary function

SUMMARY Lobectomy with systematic lymph node evaluation is the standard of care for medically fit patients with stage I non-small-cell lung cancer. The definition of ‘medically inoperable’ has evolved over time as technological advances have reduced the morbidity and mortality associated with surgery. Operability is currently more appropriately described as a gradient of risk, rather than a strict characterization of inoperable versus operable. For patients who cannot tolerate a lobectomy, multiple treatment options exist: sublobar resection, fractionated radiation, stereotactic body radiation therapy (SBRT) and radiofrequency ablation. Ongoing randomized studies will provide direct comparisons of surgery versus SBRT for both standard- and high-risk operable patients. For medically inoperable patients, radiation is the standard of care, and SBRT offers high rates of local control with limited morbidity. Prospective trials will continue to inform, but in the meantime, the best approach is a multidisciplinary one in which treatment is optimized for individual patients.

American College of Surgeons Oncology Group Z4099/Radiation Therapy Oncology Group 1021: a randomized study of sublobar resection compared with stereotactic body radiotherapy for high-risk stage I non-small cell lung cancer

During the past decade, tremendous interest has arisen in the use of nonoperative therapies for patients with non-small cell lung cancer. Of these therapies, stereotactic body radiotherapy has become established as an effective modality for treating peripheral cancer in medically inoperable patients. Toxicity is low, and the treatment is effective, with excellent local control rates. Several investigators have suggested that stereotactic body radiotherapy could be effective for high-risk operable patients (usually treated with sublobar resection) and even perhaps for standard-risk operable patients (usually treated with lobectomy); however, this is less accepted. A direct comparison of stereotactic body radiotherapy and sublobar resection is difficult for a number of reasons. These include different definitions of recurrence, different populations of patients in these studies (with those undergoing stereotactic body radiotherapy tending to be the medically inoperable group), and different methods of classifying morbidity in the surgical and radiation oncology studies. Imaging follow-up has also not been standardized among the studies. Thus, a randomized study is necessary and timely. Investigators from the American College of Surgeons Oncology Group and the Radiation Therapy and Oncology Group have collaborated to develop a phase III randomized study comparing stereotactic body radiotherapy and sublobar resection (with or without brachytherapy) for high-risk operable patients with non-small cell lung cancer. This study (American College of Surgeons Oncology Group Z4099/Radiation Therapy Oncology Group 1021) has recently opened for accrual. It is hoped that this will help to better define the role of these therapies for patients with non-small cell lung cancer.

Current options and controversies in the treatment of high-risk patients with early-stage non-small-cell lung cancer: a surgeon’s perspective

SUMMARY While lobectomy remains the standard of care for stage I non-small-cell lung cancer in low-to-moderate-risk patients, treatment options for the medically inoperable or high-risk population have been more challenging. Understanding what defines this high-risk/inoperable population and what treatment options are currently available are outlined in this perspective. The spectrum of surgical therapy from lobectomy to sublobar resection with or without brachytherapy will also be evaluated. Furthermore, the evolution of stereotactic body radiation therapy (SBRT) in the treatment of stage I non-small-cell lung cancer and other nonsurgical treatment options currently available will be evaluated. This will provide an understanding of comparative studies of these modalities, as well as important clinical trials on the horizon.

Surgical management of early-stage non-small cell lung carcinoma and the present and future roles of adjuvant therapy: a review for the radiation oncologist

We review the evidence for optimal surgical management and adjuvant therapy for patients with stages I and II non-small cell lung cancer (NSCLC) along with factors associated with increased risks of recurrence. Based on the current evidence, we recommend optimal use of mediastinal lymph node dissection, adjuvant chemotherapy, and post-operative radiation therapy, and make suggestions for areas to explore in future prospective randomized clinical trials.

American College of Surgeons Oncology Group and the community surgeon

The American College of Surgeons Oncology Group (ACOSOG) conducts cancer trials that are relevant to surgeons who treat patients with breast, thoracic, and gastrointestinal cancers. ACOSOG is funded by the National Cancer Institute and is charged with conducting prospective clinical trials that address important questions in academic and community practice settings. Examples include role of axillary dissection for microscopic nodal disease, neoadjuvant therapy for organ-conserving surgery, laparoscopic rectal cancer resection, mediastinal nodal staging, and sublobar resection for early-stage non-small cell lung cancer. Such trials are relevant to most practicing surgeons.