Sublobar Resection for Clinical Stage IA Non-small-cell Lung Cancer in the United States

The Role of Sublobar Resection in Early-Stage Non-Small-Cell Lung Cancer

The results of a prospective, multi-institutional randomized trial developed to assess the equality of sublobar resection versus standard lobectomy were first published in 1995. They concluded that, compared with lobectomy, sublobar resections did not show any significant improvement either in terms of postoperative morbidity and mortality nor in terms of late post-resectional cardiorespiratory function. Moreover, due to the higher mortality and local recurrence rate related to sublobar resection, lobectomy had to be judged as the best surgical option for patients diagnosed with peripheral early-stage non-small-cell lung cancer. Since then, lobectomy has been considered the best surgical option for fit patients suffering from early-stage non-small cell lung cancer. In 2022 and 2023, three non-inferiority randomized trials were published, comparing lobectomy with the sublobar resection in T1a N0 patients whose tumors were up to 2 cm in size. Although presenting some important differences, all three trials met their primary endpoints, disclosing the non-inferiority of sublobar resections in terms of overall and disease-free survival. This narrative review aims to compare the newly published results of these trials as well as to report results from recent non-randomized studies on this topic.

Survival and pulmonary function in stage IA non-small cell lung cancer after sublobar resection versus lobectomy: An updated meta-analysis

Traditionally, lobectomy was standard for stage IA non-small-cell lung cancer (NSCLC). Recent RCTs suggest sublobar resection's comparable outcomes. Our meta-analysis, incorporating 30 studies (including four RCTs), assessed sublobar resection's efficacy. Employing a random-effects model and I2 statistics for heterogeneity, we found sublobar resection reduced DFS (HR 1.31, p < 0.01) and OS (HR 1.27, p < 0.01) overall. However, RCT subgroup analysis showed no significant differences in DFS (p = 0.28) or OS (p = 0.62). Sublobar resection is a viable option for well-selected patients.

Sublobar Resection vs Lobectomy for Stage IA Non-Small Cell Lung Carcinoma-Takeaways From Modern Randomized Trials

Sublobar resection for early-stage non-small cell lung cancer has been an emerging topic of great interest to thoracic surgeons. However, data regarding the efficacy and safety of sublobar resection vs lobectomy was lacking until now. Recently, 3 published randomized controlled trials (Cancer and Leukemia Group B [CALGB]140503/Alliance, Japan Clinical Oncology Group [JCOG]0802 and Das Deutsche Register Klinischer Studien [DRKS]00004897) confirmed the noninferiority of sublobar resection for early-stage non-small cell lung cancer in carefully selected populations. This review aims to summarize and compare these 3 landmark trials and inform surgeons of new best practices.

Wedge resection, segmentectomy, and lobectomy: oncologic outcomes based on extent of surgical resection for ≤2 cm stage IA non-small cell lung cancer

Background

Long-standing controversy has existed over whether sublobar resection is an adequate oncological procedure for clinical stage IA non-small cell lung cancer (NSCLC) ≤2 cm, despite the recent randomized trial reports of Japanese Clinical Oncology Group (JCOG) 0802 and Cancer and Leukemia Group B (CALGB) 140503 demonstrating non-inferior outcomes with sublobar resection compared to lobectomy. As practice patterns shift, we sought to compare oncologic outcomes in patients with these early-stage tumors after wedge resection, segmentectomy, or lobectomy in a contemporary, real-world, cohort.

Methods

A retrospective review of a prospectively maintained database from a single institution was conducted from 2011 to 2020 to identify all patients with clinically staged IA1 or IA2 NSCLC (tumors ≤2 cm with no nodal involvement). The primary outcomes of interest were overall survival (OS) and disease-free survival (DFS), with secondary outcomes of lung cancer-specific survival (LCSS), recurrence patterns, and perioperative morbidity and mortality.

Results

A total of 480 patients were identified; 93 (19.4%) patients underwent wedge resection, 90 (18.7%) received segmentectomy, and 297 (61.9%) underwent lobectomy. Patients who underwent wedge resection had worse Eastern Cooperative Oncology Group (ECOG) performance status (23.7% ECOG 1 or 2 vs. 5.6% among segmentectomy and 5.4% among lobectomy, P<0.05). Both wedge resection and segmentectomy patients had lower preoperative mean percentage of predicted forced expiratory volume in one second (%FEV1) compared to the lobectomy group (81.8% and 82.6% vs. 89.6%, P=0.002), a higher proportion of patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD), and a higher Charlson Comorbidity Index. There were no statistically significant differences in 5-year OS, DFS, or LCSS between groups: 90%, 61%, 78% for wedge resections compared with 85%, 75%, 86% for segmentectomy, and 87%, 77%, 87% for lobectomy, respectively. Recurrence was observed in 17 patients who underwent wedge resection (18.3%, 8 local, 9 distant), 12 patients who received segmentectomy (13.4%, 6 local, 6 distant), and 38 patients who underwent lobectomy (12.8%, 11 local, 27 distant), which was not significantly different (P=0.36).

Conclusions

Patients with inferior performance status or lower baseline pulmonary function are more likely to receive wedge resection for clinical stage IA NSCLC ≤2 cm in size. For these small tumors, lobectomy, segmentectomy, and wedge resection provide comparable oncologic outcomes.

Resectable non-stage IV nonsmall cell lung cancer: the surgical perspective

Surgery remains an essential element of the multimodality radical treatment of patients with early-stage nonsmall cell lung cancer. In addition, thoracic surgery is one of the key specialties involved in the lung cancer tumour board. The importance of the surgeon in the setting of a multidisciplinary panel is ever-increasing in light of the crucial concept of resectability, which is at the base of patient selection for neoadjuvant/adjuvant treatments within trials and in real-world practice. This review covers some of the topics which are relevant in the daily practice of a thoracic oncological surgeon and should also be known by the nonsurgical members of the tumour board. It covers the following topics: the pre-operative selection of the surgical candidate in terms of fitness in light of the ever-improving nonsurgical treatment alternatives unfit patients may benefit from; the definition of resectability, which is so important to include patients into trials and to select the most appropriate radical treatment; the impact of surgical access and surgical extension with the evolving role of minimally invasive surgery, sublobar resections and parenchymal-sparing sleeve resections to avoid pneumonectomy.

Lobectomy, segmentectomy, or wedge resection for peripheral clinical T1aN0 non-small cell lung cancer: A post hoc analysis of CALGB 140503 (Alliance)

BACKGROUND

We have recently reported the primary results of CALGB 140503 (Alliance), a randomized trial in patients with peripheral cT1aN0 non-small cell lung cancer (American Joint Committee on Cancer seventh) treated with either lobar resection (LR) or sublobar resection (SLR). Here we report differences in disease-free survival (DFS), overall survival (OS) and lung cancer-specific survival (LCSS) between LR, segmental resection (SR), and wedge resection (WR). We also report differences between WR and SR in terms of surgical margins, rate of locoregional recurrence (LRR), and expiratory flow rate at 6 months postoperatively.

METHODS

Between June 2007 and March 2017, a total of 697 patients were randomized to LR (n = 357) or SLR (n = 340) stratified by clinical tumor size, histology, and smoking history. Ten patients were converted from SLR to LR, and 5 patients were converted from LR to SLR. Survival endpoints were estimated using the Kaplan-Maier estimator and tested by the stratified log-rank test. The Kruskal-Wallis test was used to compare margins and changes in forced expiratory volume in 1 second (FEV1) between groups, and the χ2 test was used to test the associations between recurrence and groups.

RESULTS

A total of 362 patients had LR, 131 had SR, and 204 had WR. Basic demographic and clinical and pathologic characteristics were similar in the 3 groups. Five-year DFS was 64.7% after LR (95% confidence interval [CI], 59.6%-70.1%), 63.8% after SR (95% CI, 55.6%-73.2%), and 62.5% after WR (95% CI, 55.8%-69.9%) (P = .888, log-rank test). Five-year OS was 78.7% after LR, 81.9% after SR, and 79.7% after WR (P = .873, log-rank test). Five-year LCSS was 86.8% after LR, 89.2% after SR, and 89.7% after WR (P = .903, log-rank test). LRR occurred in 12% after SR and in 14% after WR (P = .295). At 6 months postoperatively, the median reduction in % FEV1 was 5% after WR and 3% after SR (P = .930).

CONCLUSIONS

In this large randomized trial, LR, SR, and WR were associated with similar survival outcomes. Although LRR was numerically higher after WR compared to SR, the difference was not statistically significant. There was no significant difference in the reduction of FEV1 between the SR and WR groups.

Is wedge a dirty word? Demographic and facility-level variables associated with high-quality wedge resection

Objectives

Although sublobar resections have gained traction, wedge resections vary widely in quality. We seek to characterize the demographic and facility-level variables associated with high-quality wedge resections.

Methods

The National Cancer Database was queried from 2010 to 2018. Patients with T1/T2 N0 M0 non-small cell lung cancer 2 cm or less who underwent wedge resection without neoadjuvant therapy were included. A wedge resection with no nodes sampled or with positive margins was categorized as a low-quality wedge. A wedge resection with 4 or more nodes sampled and negative margins was categorized as a high-quality wedge. Facility-specific variables were investigated via quartile analysis based on the overall volume and proportion of high-quality wedge or low-quality wedge resections performed.

Results

A total of 21,742 patients met inclusion criteria, 6390 (29.4%) of whom received a high-quality wedge resection. Factors associated with high-quality wedge resection included treatment at an academic center (3005 [47.0%] vs low-quality wedge 6279 [40.9%]; P < .001). The 30- and 90-day survivals were similar, but patients who received a high-quality wedge resection had improved 5-year survival (4902 [76.7%] vs 10,548 [68.7%]; P < .001). Facilities in the top quartile by volume of high-quality wedge resections performed 69% (4409) of all high-quality wedge resections, and facilities in the top quartile for low-quality wedge resections performed 67.6% (10,378) of all low-quality wedge resections. A total of 113 facilities were in the top quartile by volume for both high-quality wedge and low-quality wedge resections.

Conclusions

High-quality wedge resections are associated with improved 5-year survival when compared with low-quality wedge resections. By volume, high-quality wedge and low-quality wedge resections cluster to a minority of facilities, many of which overlap. There is discordance between best practice guidelines and current practice patterns that warrants additional study.

Wedge resection versus lobectomy in T1 lung cancer patients: a propensity matched analysis

OBJECTIVES

Performing wedge resection rather than lobectomy for primary lung cancer remains controversial. Recent studies demonstrate no survival advantage for non-anatomical resection compared to lobectomy in patients with early-stage lung cancer. The objective of this study was to investigate whether in patients with T1 tumours, non-anatomical wedge resection is associated with equivalent survival to lobectomy.

METHODS

This was a retrospective cohort study of patients who underwent lung resection at the Lancashire Cardiac Centre between April 2005 and April 2018. Patients were subjected to multidisciplinary team discussion. The extent of resection was decided by the team based on British Thoracic Society guidelines. The primary outcome was overall survival. Propensity matching of patients with T1 tumours was also performed to determine whether differences in survival rates exist in a subset of these patients with balanced pre-operative characteristics.

RESULTS

There were 187 patients who underwent non-anatomical wedge resection and 431 patients who underwent lobectomy. Cox modelling demonstrated no survival difference between groups for the first 1.6 years then a risk of death 3-fold higher for wedge resection group after 1.6 years (HR 3.14, CI 1.98-4.79). Propensity matching yielded 152 pairs for which 5-year survival was 66.2% for the lobectomy group and 38.5% for the non-anatomical wedge group (SMD = 0.58, p = 0.003).

CONCLUSIONS

Non-anatomical wedge resection was associated with significantly reduced 5-year survival compared to lobectomy in matched patients. Lobectomy should remain the standard of care for patients with early-stage lung cancer who are fit enough to undergo surgical resection.

Outcomes after sublobar resection versus lobectomy in non-small cell carcinoma in situ

OBJECTIVE

Guidelines for treatment of non-small cell lung cancer identify patients with tumors ≤2 cm and pure carcinoma in situ histology as candidates for sublobar resection. Although the merits of lobectomy, sublobar resection, and lymphoid (LN) sampling, have been investigated in early-stage non-small cell lung cancer, evaluation of these modalities in patients with IS disease can provide meaningful clinical information. This study aims to compare these operations and their relationship with regional LN sampling in this population.

METHODS

The National Cancer Database was used to identify patients diagnosed with non-small cell lung cancer clinical Tis N0 M0 with a tumor size ≤2 cm from 2004 to 2017. The χ2 tests were used to examine subgroup differences by type of surgery. Kaplan-Meier method and Cox proportional hazard model were used to compare overall survival.

RESULTS

Of 707 patients, 56.7% (401 out of 707) underwent sublobar resection and 43.3% (306 out of 707) underwent lobectomy. There was no difference in 5-year overall survival in the sublobar resection group (85.1%) compared with the lobectomy group (88.9%; P = .341). Multivariable survival analyses showed no difference in overall survival (hazard ratio, 1.044; P = .885) in the treatment groups. LN sampling was performed in 50.9% of patients treated with sublobar resection. In this group, LN sampling was not associated with improved survival (84.9% vs 85.0%; P = .741).

CONCLUSIONS

We observed no difference in overall survival between sublobar resection and lobectomy in patients with cTis N0 M0 non-small cell lung cancer with tumors ≤2 cm. Sublobar resection may be an appropriate surgical option for this population. LN sampling was not associated with improved survival in patients treated with sublobar resection.

The efficacy and safety of wedge resection for peripheral stage IA lung adenocarcinoma: a real-world study based on a single center

Background

The effectiveness of segmentectomy for stage IA lung adenocarcinoma (IA-LUAD) has been well-documented. However, the efficacy and safety of wedge resection for peripheral IA-LUAD remains controversial. This study evaluated the feasibility of wedge resection in patients with peripheral IA-LUAD.

Methods

Patients with peripheral IA-LUAD who underwent wedge resection by video-assisted thoracoscopic surgery (VATS) at Shanghai Pulmonary Hospital were reviewed. Cox proportional hazards modeling was performed to identify predictors of recurrence. Receiver operating characteristic (ROC) curve analysis was used to calculate the optimal cutoffs of identified predictors.

Results

A total of 186 patients (female/male, 115/71; mean age, 59.9 years) were included. Mean maximum dimension of consolidation component (MCD) was 5.6 mm, consolidation-to-tumor ratio (CTR) was 37%, and mean computed tomography value of tumor (CTVt) was -285.4 HU. With a median follow-up of 67 months (interquartile range, 52-72 months), the 5-year recurrence rate was 4.84%. Ten patients occurred recurrence postoperatively. No recurrence was observed adjacent to the surgical margin. Increasing MCD, CTR, and CTVt were associated with a higher risk of recurrence, with corresponding hazard ratios (HRs) of 1.212 [95% confidence interval (CI): 1.120-1.311], 1.054 (95% CI: 1.018-1.092), and 1.012 (95% CI: 1.004-1.019) with optimal cutoffs for predicting recurrence of 10 mm, 60%, and -220 HU, respectively. When a tumor had characteristics under these respective cutoffs, no recurrence was observed.

Conclusions

Wedge resection can be considered to be a safe and efficacious management strategy for patients with peripheral IA-LUAD, especially for MCD less than 10 mm, CTR less than 60% and CTVt less than -220 HU.

Chronic Obstructive Pulmonary Disease and Lung Cancer: A Review for Clinicians

Chronic obstructive pulmonary disease (COPD) and lung cancer are common global causes of morbidity and mortality. Because both diseases share several predisposing risks, the 2 diseases may occur concurrently in susceptible individuals. The diagnosis of COPD has important implications for the diagnostic approach and treatment options if lesions concerning for lung cancer are identified during screening. Importantly, the presence of COPD has significant implications on prognosis and management of patients with lung cancer. In this monograph, we review the mechanistic linkage between lung cancer and COPD, the impact of lung cancer screening on patients at risk, and the implications of the presence of COPD on the approach to the diagnosis and treatment of lung cancer. This manuscript succinctly reviews the epidemiology and common pathogenetic factors for the concurrence of COPD and lung cancer. Importantly for the clinician, it summarizes the indications, benefits, and complications of lung cancer screening in patients with COPD, and the assessment of risk factors for patients with COPD undergoing consideration of various treatment options for lung cancer.

Surgical Options for Resectable Lung Adenosquamous Carcinoma: A Propensity Score-Matched Analysis

Background

Surgery is the primary treatment option for Lung adenosquamous carcinoma (ASC) patients. However, no study compares the benefits of lobectomy and sublobar resection in ASC patients.

Methods

A total of 1379 patients in the Surveillance, epidemiology, and End Results (SEER) database and 466 patients in Shanghai Pulmonary Hospital (SPH) were enrolled. Survival benefits were evaluated after possible confounders were eliminated by propensity score matching (PSM).

Results

After 1:3 PSM, 463 SEER database patients and 244 SPH patients were enrolled. Lobectomy was associated with better overall survival (OS) and disease-free survival (DFS) than sublobar resection for ASC patients (5-year OS of SEER: 46.9% vs. 33.3%, P =0.017; 5-year OS of SPH: 35.0% vs. 16.4%, P =0.002; 5-year DFS of SPH: 29.5% vs. 14.8%, P =0.002). Similar results were observed in stage I patients. Univariate and multivariate Cox regression analyses showed that sublobar resection was an adverse prognostic factor independently (SEER: HR: 1.40, 95%CI: 1.08-1.81, P =0.012; SPH: HR: 1.73, 95%CI: 1.11-2.70, P =0.015). Subgroup analysis showed that all of the ASC patient subtypes tended to benefit more from lobectomy than sublobar resection.

Conclusions

Lobectomy remains the primary option for ASC patients compared to sublobar resection, including stage I.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 2: systematic review of evidence regarding resection extent in generally healthy patients

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, stereotactic body radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in generally healthy patients is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons with at least some adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In healthy patients there is no short-term benefit to sublobar resection vs. lobectomy in randomized and non-randomized comparisons. A detriment in long-term outcomes is demonstrated by adjusted non-randomized comparisons, more marked for wedge than segmentectomy. Quality-of-life data is confounded by the use of video-assisted approaches; evidence suggests the approach has more impact than the resection extent. Differences in pulmonary function tests by resection extent are not clinically meaningful in healthy patients, especially for multi-segmentectomy vs. lobectomy. The margin distance is associated with the risk of recurrence.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in healthy patients with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation on which to build a framework for individualized clinical decision-making.

Bibliometric Analysis of 50 Most Cited Articles Comparing Lobectomy with Sublobar Resection

BACKGROUND

 Recent years have seen an increase in the number of studies of the sublobar resection approach in non-small cell lung cancer (NSCLC) surgery. The purpose of this bibliometric analysis is to assess the significance and impact of articles comparing sublobar resection and lobectomy in NSCLC surgery.

MATERIAL AND METHODS

 The Web of Science database was searched to identify studies comparing sublobar resection and lobectomy in NSCLC surgery published between 2005 and 2020 (accessed: September 11, 2020). The 50 most cited articles were analyzed by years, countries, authors, authors' affiliations, journals, journals' addresses, and impact factors.

RESULTS

 The bibliometric analysis revealed that the most cited article had 443 citations, while the total number of citations of all articles was 2,820. The mean number of citations, in turn, was 56.4 ± 75.62 (1-443) times. The highest number of publications over the past 15 years was in 2016, with eight articles. The Annals of Thoracic Surgery (n = 10; 20%) had the highest number of publications on the list. The articles included in the present study were mostly (n = 35, 70%) published in U.S. journals. While multiple subject matters and analyses were presented by many studies, survival was the topic of greatest interest, with 37 (74%) studies.

CONCLUSION

 This study revealed that interest in studies comparing sublobar resection with lobectomy has increased in recent years. It also presents both quantitative and qualitative analyses of the most cited articles in the literature on this topic. Therefore, it can serve as a guide for researchers.

Women and Lung Cancer

The world is witnessing a global epidemic of lung cancer in women. Cigarette smoking remains the dominant risk factor in both sexes, but multiple observations suggest that important sex-related distinctions in lung cancer exist. These include differences in histologic distribution, prevalence in never-smokers, frequency of activating EGFR mutations, likelihood of DNA adduct accumulation, and survival outcomes. Important questions such as whether women are more susceptible to carcinogenic effects of smoking or derive more benefit from lung cancer screening merit more study. A deeper understanding of sex-related differences in lung cancer may lead to improved outcomes for both women and men.

Survival and Recurrence Following Wedge Resection Versus Lobectomy for Early-Stage Non-Small Cell Lung Cancer

To determine if wedge resection is equivalent to lobectomy for Stage I Non-Small Cell Lung Cancer (NSCLC) and to evaluate the impact of radiologic and pathologic variables not available in large national databases. Records were reviewed from 2010-2016 for patients with pathologic Stage I NSCLC who underwent wedge resection or lobectomy. Propensity score matching was performed on pre-operative variables and patients with ≥1 lymph node removed. Clinical variables were compared. Kaplan-Meier curves and multivariable Cox proportional hazard models for 5-year overall survival (OS), disease-free (DFS), and locoregional-recurrence-free survival (LRFS) were created. A total of 1086 patients met inclusion criteria; 391 lobectomies and 695 wedge resections. Propensity score matching yielded 167 pairs of lobectomy and wedge resection patients. Complications were fewer for wedge resections than lobectomies, 19.2% for wedge resection patients vs 34.1% for lobectomy patients, p < 0.01. OS was equivalent between groups, 86.2% for lobectomy patients vs 83.4% for wedge resection patients p = 0.47. DFS was similar, 79.0% for lobectomy patients vs 72.5% for wedge resection patients p = 0.10. Overall LRFS was worse in wedge resection patients vs lobectomy patients, 82.0% vs 93.4% p < 0.01. However, in the matched wedge resection patients with a margin >10 mm the LRFS was equal to that of lobectomy patients, 86.4% for wedge resection patients vs 91.8% for lobectomy patients p = 0.140. Patients with Stage I NSCLC can experience similar OS, DFS, and LRFS with wedge resection as compared to lobectomy, when wedge resection margins are >10 mm and appropriate lymph node dissection is performed.

The Evolving Concept of Complete Resection in Lung Cancer Surgery

Simple Summary

In the surgical treatment of lung cancer, the complete removal of the portion of the lung where the cancer is and of the involved adjacent structures is of paramount importance to achieve long-term survival. The International Association for the Study of Lung Cancer (IASLC) proposed a definition of complete resection that included a well-defined type of removal of the regional lymph nodes as a fundamental step. The lymph nodes may contain cancer cells and, if left behind, cancer will soon progress. The IASLC also defined incomplete resection when there is any evidence of persistent cancer after the operation. It also defined an intermediate condition, uncertain resection, when no evidence of residual disease can be proved, but all the conditions of complete resection are not fulfilled. Four validations of the definitions have proved their prognostic value and, therefore, the definitions should be followed when a surgical resection of lung cancer is planned.

Abstract

Different definitions of complete resection were formulated to complement the residual tumor (R) descriptor proposed by the American Joint Committee on Cancer in 1977. The definitions went beyond resection margins to include the status of the visceral pleura, the most distant nodes and the nodal capsule and the performance of a complete mediastinal lymphadenectomy. In 2005, the International Association for the Study of Lung Cancer (IASLC) proposed definitions for complete, incomplete and uncertain resections for international implementation. Central to the IASLC definition of complete resection is an adequate nodal evaluation either by systematic nodal dissection or lobe-specific systematic nodal dissection, as well as the integrity of the highest mediastinal node, the nodal capsule and the resection margins. When there is evidence of cancer remaining after treatment, the resection is incomplete, and when all margins are free of tumor, but the conditions for complete resection are not fulfilled, the resection is defined as uncertain. The prognostic relevance of the definitions has been validated by four studies. The definitions can be improved in the future by considering the cells spread through air spaces, the residual tumor cells, DNA or RNA in the blood, and the determination of the adequate margins and lymphadenectomy in sublobar resections.

Travelling to a High-Volume Center Confers Improved Survival in Stage I Non-small Cell Lung Cancer

BACKGROUND

The association of hospital volume with outcomes has been assessed previously for patients with non-small cell lung cancer (NSCLC), but there are limited data on the cumulative effect of travel burden and hospital volume on treatment decisions and survival outcomes. We used the National Cancer Database to evaluate this relationship in early-stage NSCLC.

METHODS

Outcomes of interest were compared between 2 propensity-matched groups with stage I NSCLC: patients in the bottom quartile of distance travelled who underwent surgery at low-volume centers (Local) and those in the top quartile of distance travelled who received surgery at high-volume centers (Distant). Outcomes included type of resection (anatomic or nonanatomic), time to resection (< or ≥8 weeks), number of lymph nodes examined (< or ≥10 nodes) and R0 resection.

RESULTS

We identified 3325 Local patients who travelled 2.3 miles (interquartile range [IQR]: 1.4-3.3 miles) to centers that treated 10.5 (IQR: 6.5-16.5) stage I NSCLCs/year and 3361 Distant patients who travelled 40.0 miles (IQR: 29.1-63.4 miles) to centers treating 56.9 (IQR: 40.1-84.7) stage I NSCLCs/year. Local patients were less likely to receive surgery <8 weeks post-diagnosis, have ≥10 lymph nodes examined during surgery, and undergo an R0 resection (all P < .01). Distant patients had shorter hospital stays and superior median survival, both P < .01.

CONCLUSIONS

Patients travelling longer distances to high-volume centers receive better and more timely surgical care, leading to shorter hospital stays and improved survival outcomes. Regionalization of lung cancer care by improving travel support to larger treatment facilities may help improve early-stage NSCLC outcomes.

Association of Survival With Adjuvant Chemotherapy Among Patients With Early-Stage Non-Small Cell Lung Cancer With vs Without High-Risk Clinicopathologic Features

Importance

Tumor size larger than 4 cm is accepted as an indication for adjuvant chemotherapy in patients with node-negative non-small cell lung cancer (NSCLC). Treatment guidelines suggest that high-risk features are also associated with the efficacy of adjuvant chemotherapy among patients with early-stage NSCLC, yet this association is understudied.

Objective

To assess the association between adjuvant chemotherapy and survival in the presence and absence of high-risk pathologic features in patients with node-negative early-stage NSCLC.

Design, Setting, and Participants

This retrospective cohort study using data from the National Cancer Database included 50 814 treatment-naive patients with a completely resected node-negative NSCLC diagnosed between January 1, 2010, and December 31, 2015. The study was limited to patients who survived at least 6 weeks after surgery (ie, estimated median time to initiate adjuvant chemotherapy after surgery) to mitigate immortal time bias. Statistical analysis was performed from December 1, 2018, to February 29, 2020.

Exposures

Adjuvant chemotherapy use vs observation, stratified according to the presence or absence of high-risk pathologic features (visceral pleural invasion, lymphovascular invasion, and high-grade histologic findings), sublobar surgery, and tumor size.

Main Outcomes and Measures

The association of high-risk pathologic features with survival after adjuvant chemotherapy vs observation was evaluated using Cox proportional hazards regression models.

Results

Overall, 50 814 eligible patients with NSCLC (27 365 women [53.9%]; mean [SD] age, 67.4 [9.5] years]) were identified, including 4220 (8.3%) who received adjuvant chemotherapy and 46 594 (91.7%) who did not receive adjuvant chemotherapy. Among patients with tumors 3 cm or smaller, chemotherapy was not associated with improved survival (hazard ratio [HR], 1.10; 95% CI, 0.96-1.26; P = .17). For patients with tumors larger than 3 cm to 4 cm, adjuvant chemotherapy was associated with a survival benefit among patients who underwent sublobar surgery (HR, 0.72; 95% CI, 0.56-0.93; P = .004). For tumors larger than 4 cm to 5 cm, a survival benefit was associated with adjuvant chemotherapy only in patients with at least 1 high-risk pathologic feature (HR, 0.67; 95% CI, 0.56-0.80; P = .02). For tumors larger than 5 cm, adjuvant chemotherapy was associated with a survival benefit irrespective of the presence of high-risk pathologic features (HR, 0.75; 95% CI, 0.61-0.91; P = .004).

Conclusions and Relevance

In this cohort study, tumor size alone was not associated with improved efficacy of adjuvant chemotherapy in patients with early-stage (node-negative) NSCLC. High-risk clinicopathologic features and tumor size should be considered simultaneously when evaluating patients with early-stage NSCLC for adjuvant chemotherapy.

Impact of tumor disappearance ratio on the prognosis of lung adenocarcinoma ≤2 cm in size: A retrospective cohort study

BACKGROUND/PURPOSE

Lung cancer patients can have advanced-stages at diagnosis, even the tumor size is ≤2 cm. We aimed to study the relationship between image characteristics, clinical, and patholoigcal results.

METHODS

We retrospectively enrolled patients with lung adenocarcinoma at Taichung Veterans General Hospital and Chang Gung Memorial Hospital from 2007 to 2015, who were diagnosed with treatment naïve primary tumor lesions at sizes less than 2 cm, as measured by computed tomography (CT) scans. The patient was analyzed for lymph node (LN) and distant metastasis evaluation, with clinicopathological characteristics, including tumor-disappearance ratio (TDR) (tumor diameter at the mediastinal/lung window) over chest CT scans, pathological diagnosis, disease-free survival (DFS), and overall survival (OS).

RESULTS

Totally 280 patients were surveyed initially and showed significantly increase of clinical LN involvement and distant metastasis when TDR ≤75% compared with >75% (21.6% vs 0% for LN involvement; 27.1% vs 0% for distant metastasis; both p < 0.001). We included 199 patients having surgical treatment and follow-up for the survival analysis. With a TDR ≤75%, significantly worse DFS (HR, 19.23; 95% CI, 2.60-142.01; p = 0.004) and a trend of worse OS (HR, 4.97; 95% CI, 0.61-40.61; p = 0.134) were noted by Kaplan-Meier method. TDR ≤75% revealed more advanced pathological stage, and more tumors containing micropapillary or solid subtypes when diagnosed adenocarcinoma.

CONCLUSION

For lung cancer patients with primary tumor ≤2 cm, TDR ≤75% was related to more advanced stages, the presence of micropapillary or solid components of adenocarcinoma subtypes, worse DFS, and a trend of worse OS.

Lobectomy versus sublobar resection in patients with non-small cell lung cancer: a systematic review

Surgery is the gold standard treatment of lung cancer. The minimally invasive technique does not only concern access to the chest but also the limits of parenchymal resection. The study debates on the safety and oncological adequacy of sublobar resections in bronchogenic carcinoma patients. A systematic analysis of the data in the literature was carried out, comparing the outcomes of patients with resectable non-small lung cancer (NSCLC) who underwent lobectomy or sublobar resection. These last interventions include both segmentectomies and wedge resections taking into consideration the following parameters: complications, relapse rate and overall survival. The complication rate is higher in patients underwent lobectomy compared to sublobar resection, especially in presence of high comorbidity index or octogenarian patients (overall values respectively between 0 and 48% and 0 and 46.6%). Contrarily, the relapse rate (6.2% to 32% vs. 3.6% to 53.4%) and overall survival (50.2% to 93.8% vs. 38.6% to 100%) are more favorable in patients undergoing lobectomy. Sublobar resections are particularly indicated in elderly patients and in patients with high comorbidity index or reduced respiratory functional reserve. However, pulmonary lobectomy still remains the safest and oncologically correct method in patients with good performance status or higher risk of recurrence.

Comparison between radiofrequency ablation and sublobar resections for the therapy of stage I non-small cell lung cancer: a meta-analysis

Background

Sublobar resection (SLR) and radiofrequency ablation (RFA) are the two minimally invasive procedures performed for treating stage I non-small cell lung cancer (NSCLC). This study aimed to compare SLR and RFA for the treatment of stage I NSCLC using the meta-analytical method.

Methods

We searched PubMed and Embase for articles published till December 2019 to evaluate the comparative studies and assess the survival and progression-free survival rates and postoperative complications (PROSPERO registration number: CRD42018087587). A meta-analysis was performed by combining the outcomes of the reported incidences of short-term morbidity and long-term mortality. The fixed or random effects model was utilized to calculate the pooled odds ratios (OR) and the 95% confidence intervals.

Results

Four retrospective studies were considered in the course of this study. The studies included a total of 309 participants; 154 were assigned to the SLR group, and 155 were assigned to the RFA group. Moreover, there were statistically significant differences between the one- and three-year survival rates and one- and three-year progression-free survival rates for the two groups, which were in favor of the SLR group. Among the post-surgical complications, pneumothorax and pleural effusion were more common for the SLR group, while cardiac abnormalities were prevalent in the RFA group. There was no difference in prevalence of hemoptysis between SLR and RFA groups, which might be attributed to the limited study sample size.

Conclusion

Considering the higher survival rates and disease control in the evaluated cases, surgical resection is the preferred treatment method for stage I NSCLC. RFA can be considered a valid alternative in patients not eligible for surgery and in high-risk patients as it is less invasive and requires shorter hospital stay.

Comparison of prognostic impact of lymphovascular invasion in stage IA non-small cell lung cancer after lobectomy versus sublobar resection: A propensity score-matched analysis

OBJECTIVES

Lymphovascular invasion (LVI) is a well-known poor prognostic factor after lobectomy for non-small cell lung cancer. However, the prognostic effect of LVI in patients who undergo sublobar resection has not been fully evaluated. Thus, we compared the prognostic impact of LVI in stage IA patients who underwent lobectomy or sublobar resection.

MATERIALS AND METHODS

We retrospectively reviewed the data from patients with stage IA NSCLC who underwent surgical resection between 2007 and 2016. The prognostic impact of LVI was calculated by the Cox proportional hazard regression model. To adjust for the differences in confounding variables between LVI-positive and LVI-negative patients, propensity score matching (PSM) was carried out in patients who underwent lobectomy or sublobar resection.

RESULTS

Among the stage IA NSCLC patients (n = 2134), 184 (8.6%) had been diagnosed with LVI, of whom 144 (8.9%) were in the lobectomy group (n = 1614) and 40 (7.7%) were in the sublobar resection group (n = 520). In multivariable analysis, LVI was a significant risk factor for both overall survival (OS) (hazard ratio [HR], 2.03; 95% confidence interval [CI], 1.39-2.96; p < 0.001) and recurrence-free survival (RFS) (HR, 2.31; 95% CI, 1.68-3.17; p < 0.001). After PSM, the prognostic impact of LVI was greater in the sublobar resection group (HR = 4.93 and 4.25 for OS and RFS, respectively) than in the lobectomy group (HR = 1.77 and 2.51 for OS and RFS, respectively).

CONCLUSIONS

The presence of LVI was significantly associated with worse OS and RFS in stage IA NSCLC patients. The prognostic impact of LVI was more pronounced in the sublobar resection group than in the lobectomy group.

Oncologic Outcomes of Surgery Versus SBRT for Non-Small-Cell Lung Carcinoma: A Systematic Review and Meta-analysis

BACKGROUND

The optimal treatment of stage I non-small-cell lung carcinoma is subject to debate. The aim of this study was to compare overall survival and oncologic outcomes of lobar resection (LR), sublobar resection (SR), and stereotactic body radiotherapy (SBRT).

METHODS

A systematic review and meta-analysis of oncologic outcomes of propensity matched comparative and noncomparative cohort studies was performed. Outcomes of interest were overall survival and disease-free survival. The inverse variance method and the random-effects method for meta-analysis were utilized to assess the pooled estimates.

RESULTS

A total of 100 studies with patients treated for clinical stage I non-small-cell lung carcinoma were included. Long-term overall and disease-free survival after LR was superior over SBRT in all comparisons, and for most comparisons, SR was superior to SBRT. Noncomparative studies showed superior long-term overall and disease-free survival for both LR and SR over SBRT. Although the papers were heterogeneous and of low quality, results remained essentially the same throughout a large number of stratifications and sensitivity analyses.

CONCLUSION

Results of this systematic review and meta-analysis showed that LR has superior outcomes compared to SBRT for cI non-small-cell lung carcinoma. New trials are underway evaluating long-term results of SBRT in potentially operable patients.

The Year in Thoracic Anesthesia: Selected Highlights from 2019

THIS special article is the 4th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan; the associate editor-in-chief, Dr. Augoustides; and the editorial board for the opportunity to expand this series, the research highlights of the year that specifically pertain to the specialty of thoracic anesthesia. The major themes selected for 2019 are outlined in this introduction, and each highlight is reviewed in detail in the main body of the article. The literature highlights in this specialty for 2019 include updates in the preoperative assessment and optimization of patients undergoing lung resection and esophagectomy, updates in one lung ventilation (OLV) and protective ventilation during OLV, a review of recent meta-analyses comparing truncal blocks with paravertebral catheters and the introduction of a new truncal block, meta-analyses comparing nonintubated video-assisted thoracoscopic surgery (VATS) with those performed using endotracheal intubation, a review of the Society of Thoracic Surgeons (STS) recent composite score rating for pulmonary resection of lung cancer, and an update of the Enhanced Recovery After Surgery (ERAS) guidelines for both lung and esophageal surgery.

Lymphadenectomy is Unnecessary for Pure Ground-Glass Opacity Pulmonary Nodules

BACKGROUND

Lobectomy plus lymph node dissection is the standard treatment of early-stage lung cancer, but the low lymph node metastasis rate with ground-glass opacity (GGO) makes surgeons not perform lymphadenectomy. This study aimed to re-evaluate the lymph node metastasis rate of GGO to help make a clinical judgment.

METHODS

We performed this retrospective study to enroll patients who received lung cancer surgery from 2011 to 2016. Patient characteristics collected included tumor size, solid part size and lymph node metastasis rate. These patients were categorized into pure GGO and part solid GGO groups to undergo analysis.

RESULTS

Lymph node metastasis rates were 0%, 3.8% and 6.9% in order of the pure GGO group, the GGO predominant group and the solid predominant group. In the lobectomy patients, the solid predominant group still showed to have the highest lymph node metastasis rate and recurrence rate (8.3% and 10.1%).

CONCLUSION

It is unnecessary to perform lymphadenectomy for patients with pure GGO in view of the 0% lymph node metastasis rate. The higher lymph node metastasis rate in the patients with the solid predominant group, 6.9%, suggested that surgeons should choose a rational lymphadenectomy method according to their GGO property and clinical judgment.

Equivalent Survival Between Lobectomy and Segmentectomy for Clinical Stage IA Lung Cancer

BACKGROUND

The oncologic efficacy of segmentectomy is controversial. We compared long-term survival in clinical stage IA (T1N0) Medicare patients undergoing lobectomy and segmentectomy in The Society of Thoracic Surgeons database.

METHODS

The Society of Thoracic Surgeons General Thoracic Surgery Database was linked to Medicare data in 14,286 lung cancer patients who underwent segmentectomy (n = 1654) or lobectomy (n = 12,632) for clinical stage IA disease from 2002 to 2015. Cox regression was used to create a long-term survival model. Patients were then propensity matched on demographic and clinical variables to derive matched pairs.

RESULTS

In Cox modeling segmentectomy was associated with survival similar to lobectomy in the entire cohort (hazard ratio, 1.04; 95% confidence interval, 0.89-1.20; P = .64) and in the matched subcohort. A subanalysis restricted to the 2009 to 2015 population (n = 11,811), when T1a tumors were specified and positron emission tomography results and mediastinal staging procedures were accurately recorded in the database, also showed that segmentectomy and lobectomy continue to have similar survival (hazard ratio, 1.00; 95% confidence interval, 0.87-1.16). Subanalysis of the pathologic N0 patients demonstrated the same results.

CONCLUSIONS

Lobectomy and segmentectomy for early-stage lung cancer are equally effective treatments with similar survival. Surgeons from The Society of Thoracic Surgeons database appear to be selecting patients appropriately for sublobar procedures.

Sublobar resection is associated with decreased survival for patients with early stage large-cell neuroendocrine carcinoma of the lung

OBJECTIVES

Sublobar resection (SLR) for early non-small-cell lung carcinoma (NSCLC) has been shown to have a survival rate similar to that of lobectomy. Large-cell neuroendocrine carcinoma (LCNEC) of the lung, although treated like an NSCLC, has a poor prognosis compared to NSCLC. We sought to determine if outcomes are poor in patients with early stage LCNEC treated with SLR versus lobectomy.

METHODS

We searched for patients with pathological stage I LCNEC ≤3 cm within the National Cancer Database between 2004 and 2014. Propensity score matching was used to compare the 5-year overall survival rate of patients having SLR (wedge or segmentectomy) to that of patients having a lobectomy. Patients were matched for age, node sampling, comorbidity score, tumour size, insurance status and other factors. Patients who received neoadjuvant therapy were excluded. Kaplan-Meier methods were used for analysis.

RESULTS

A total of 1011 patients met the inclusion criteria: 263 were treated with SLR (223 wedges and 40 segmentectomies) and 748 patients, with lobectomy. Patients who received SLR were older, had more comorbidities and smaller tumours. On unadjusted Kaplan-Meier analysis, patients who had SLR had decreased 5-year overall survival compared to those who had a lobectomy (37.9% vs 56.6%, P < 0.001). Propensity score matching (1:1) across 12 demographic and tumour variables yielded 185 patients per group with 34 segmentectomies and 151 wedge resections in the SLR cohort. On Kaplan-Meier analysis of the matched cohort, patients who had SLR had a worse 5-year overall survival rate compared to those who had a lobectomy (41.5% vs 60.3%; P = 0.001).

CONCLUSIONS

SLR for early stage LCNEC is associated with a lower 5-year overall survival rate compared to lobectomy on unadjusted and propensity matched analyses.

Surgeons' preference sublobar resection for stage I NSCLC less than 3 cm

Background

This study aimed to compare survival between standard lobectomy and surgeons' preference sublobar resection among patients with stage I non‐small cell lung cancer (NSCLC).

Methods

Medical records of patients undergoing pulmonary resection between 2006 and 2016 were reviewed retrospectively. Differences in disease‐free survival (DFS) and DFS‐associated factors between patients receiving lobectomy and surgeons' preference sublobar resection were analyzed after 1‐1 propensity score‐matching (n = 119 per group).

Results

In total, 1064 pathological stage I NSCLC patients were identified, including 816 (76.7%) who underwent lobectomy, 111 (10.4%) who underwent sublobar resection as a compromised procedure (medically unfit), and 137 (12.9%) who underwent surgeons' preference sublobar resection. Rates of five‐year DFS for patients undergoing lobectomy, medically unfit, and surgeons' preference sublobar resection were 88.7%, 71.0%, and 93.4%, respectively (P < 0.001). Multivariable Cox regression analysis demonstrated that radiological solid‐appearance (adjusted hazard [aHR] = 2.908, P = 0.003), PL2 invasion (aHR = 1.970, P = 0.024), and angiolymphatic invasion (aHR = 2.202, P = 0.005) were significantly associated with lower DFS after adjusting for surgeons' preference sublobar resection (aH = 1.031, P = 0.939). Subgroup analysis of all 403 solid‐dominant patients demonstrated equivalent five‐year DFS between surgeons' preference sublobar resection and lobectomy (87.7% and 84.1%, respectively, P = 0.721). Propensity‐matched analysis showed no differences in five‐year DFS in stage I NSCLC patients undergoing lobectomy or surgeons' preference sublobar resection (90.5% vs. 93.4% P = 0.510), and DFS for surgeons' preference sublobar resection remained an insignificant factor (aHR = 0.894, P = 0.834).

Conclusions

Carefully selected patients who have undergone surgeons' preference sublobar resection have comparable outcomes to those receiving lobectomy for stage I NSCLC <3 cm.

Key points

Significant findings of the study Intended sublobar resection has a good outcome. What this study adds Sublobar resection is applicable for stage I NSCLC <3 cm.

New T1 classification

The IASLC staging and Prognostic Factor Committee proposed new changes to the descriptors for the 8th edition of the Tumour Node Metastasis Staging for Lung Cancer. The T1 descriptor changes include (1) T1 tumours are subclassified into T1a (< 1 cm), T1b (> 1 to < 2 cm), T1c (> 2 to < 3 cm). The corresponding changes are introduced to the overall staging: T1aN0M0 = Stage IA1; T1bN0M0 = Stage IA2; T1cN0M0 = Stage IA3. (2) The introduction of the pathological entities Adenocarcinoma-In-Situ (AIS), Minimally Invasive Adenocarcinoma, and Lepidic Predominant Adenocarcinoma. The corresponding changes on the T descriptor are as follows: Adenocarcinoma-in situ is coded as Tis (AIS); Minimally Invasive Adenocarcinoma is coded as T1a(mi). In this review, the basis for these changes will be described, and the implications on clinical practice will be discussed.

Propensity-Matched Analysis Comparing Survival After Sublobar Resection and Lobectomy for cT1N0 Lung Adenocarcinoma

BACKGROUND

The optimal surgical method for cT1N0 lung adenocarcinoma remains controversial.

OBJECTIVE

The aim of this study was to evaluate the differences in clinical outcomes of sublobar resection and lobectomy for cT1N0 lung adenocarcinoma patients.

METHODS

We included 1035 consecutive patients with cT1N0 lung adenocarcinoma who underwent surgery at our institute from January 2011 to December 2016. The surgical approach, either sublobar resection or lobectomy, was determined at the discretion of each surgeon. A propensity-matched analysis incorporating total tumor diameter, solid component diameter, consolidation-to-tumor (C/T) ratio, and performance status was used to compare the clinical outcomes of the sublobar resection and lobectomy groups.

RESULTS

Sublobar resection and lobectomy were performed for 604 (58.4%; wedge resection/segmentectomy: 470/134) and 431 (41.6%) patients, respectively. Patients in the sublobar resection group had smaller total tumor diameters, smaller solid component diameters, lower C/T ratios, and better performance status. More lymph nodes were dissected in the lobectomy group. Patients in the sublobar resection group had better perioperative outcomes. A multivariable analysis revealed that the solid component diameter and serum carcinoembryonic antigen level are independent risk factors for tumor recurrence. After propensity matching, 284 paired patients in each group were included. No differences in overall survival (OS; p = 0.424) or disease-free survival (DFS; p = 0.296) were noted between the two matched groups.

CONCLUSIONS

Sublobar resection is not inferior to lobectomy regarding both DFS and OS for cT1N0 lung adenocarcinoma patients. Sublobar resection may be a feasible surgical method for cT1N0 lung adenocarcinoma.

A nomogram for the prediction of overall survival in patients with stage II and III non-small cell lung cancer using a population-based study

As a malignant tumor with poor prognosis, accurate and effective treatment of non-small cell lung cancer (NSCLC) is crucial. To predict overall survival in patients with stage II and III NSCLC, a nomogram was constructed using data from the Surveillance, Epidemiology and End Results database. Eligible patients with NSCLC with available clinical information diagnosed between January 1, 2010 and November 31, 2015 were selected from the database, and the data were randomly divided into a training set and a validation set. Univariate and multivariate Cox regression analyses were used to identify prognostic factors with a threshold of P<0.05, and a nomogram was constructed. Harrell's concordance indexes and calibration plots were used to verify the predictive power of the model. Risk group stratification by stage was also performed. A total of 15,344 patients with stage II and III NSCLC were included in the study. The 3- and 5-year survival rates were 0.382 and 0.278, respectively. The training and validation sets comprised 10,744 and 4,600 patients, respectively. Age, sex, race, marital status, histology, grade, Tumor-Node-Metastasis T and N stage, surgery type, extent of lymph node dissection, radiation therapy and chemotherapy were identified as prognostic factors for the construction of the nomogram. The nomogram exhibited a clinical predictive ability of 0.719 (95% CI, 0.718–0.719) in the training set and 0.721 (95% CI, 0.720–0.722) in the validation set. The predicted calibration curve was similar to the standard curve. In addition, the nomogram was able to divide the patients into groups according to stage IIA, IIB, IIIA, and IIIB NSCLC. Thus, the nomogram provided predictive results for stage II and III NSCLC patients and accurately determined the 3- and 5-year overall survival of patients.

The probability of nodal metastasis in novel T-factor: the applicability of sublobar resection

Background

Recently sublobar resection is often indicated for small-sized peripheral lung cancer according to size or the consolidation/tumor ratio on CT; however, the T-factor classification drastically changed in the 8^th version. We investigated the relationship between a novel clinical T-factor classification, which includes other clinical information and the pathologic N-factor, to evaluate the applicability of the novel T-factor classification to sublobar resection.

Methods

From January 2013 to October 2017, 545 patients with cTis or cT1 lung cancer underwent surgery. Patients with non-peripheral type, induction treatment, cN≥1, cM1, and those without nodal dissection, preoperative evaluation by thin-sliced CT or FDG-PET were excluded. Finally, 325 patients were eligible for inclusion. All clinical parameters were prospectively collected and retrospectively analyzed. The 8^th edition of TNM classification was utilized.

Results

Nodal metastasis was detected in 38 (11.7%) patients. Among cTis/1mi/1a/1b/1c patients (n=10/11/51/146/107), pN1 and pN2 were observed in 0/0/2/9/10 and 0/0/1/8/8, respectively. cT1b/c patients showed a significantly higher rate of nodal metastasis (P=0.024). Among 253 cT1b/c patients, solid-type tumors (n=177) were more frequently associated with nodal metastasis. A ROC curve analysis revealed that SUVmax 1.9 was the cutoff value (AUC=0.827) for the presence of nodal metastasis. Using the 2 parameters of solid-type or SUVmax ≥1.9, we could successfully exclude patients with nodal metastasis, for whom sublobar resection is not indicated.

Conclusions

In terms of nodal metastasis, sublobar resection can be applicable for all cTis/1mi tumors; patients with cT1a/b/c tumors with mixed GGO and low SUVmax are candidates for sublobar resection.

Impact of Different Types of Lymphadenectomy Combined With Different Extents of Tumor Resection on Survival Outcomes of Stage I Non-small-cell Lung Cancer: A Large-Cohort Real-World Study

Background: To investigate the prognostic impact of different types of lymphadenectomy with different extents of tumor resection on the outcomes of stage I non-small-cell lung cancer (NSCLC).

Methods: Patients were classified into lobectomy and sublobectomy groups, and then each group was subdivided according to the types of lymphadenectomy. The end points of the study were overall survival (OS) and disease-free survival (DFS). Propensity score matched (PSM) comparative analysis and univariate and multivariate Cox regression analyses were performed.

Result: A total of 1,336 patients were included in the current study. Lobectomy was associated with better OS and DFS. In the lobectomy group, lobectomy with bilateral mediastinal lymphadenectomy (BML) was associated with better OS than lobectomy with systematic nodal dissection (SND) or lobe-specific systematic node dissection (L-SND). Lobectomy with SND or L-SND was associated with better OS than lobectomy with systematic nodal sampling (SNS) or selected lymph node biopsy (SLNB). Additionally, lobectomy with BML or SND was associated with better DFS than lobectomy with L-SND or SNS or SLNB. After PSM, compared with lobectomy with SNS or SLNB, lobectomy with SND resulted in more favorable OS and DFS. There was no survival difference between different types of lymphadenectomy for patients who underwent sublobectomy. A multivariable analysis revealed independent associations of lobectomy with BML or SND with better OS and DFS compared with those of lobectomy with SNS or SLNB.

Conclusion: This study reveals an association of lobectomy with more systematic and complete lymph node dissection, such as BML or SND, with better prognosis in stage I NSCLC patients.

Sublobar resection is associated with better perioperative outcomes in elderly patients with clinical stage I non-small cell lung cancer: a multicenter retrospective cohort study

BACKGROUND

Sublobar resection has emerged as an alternative to lobectomy for management of early-stage non-small cell lung cancer (NSCLC). However, controversy remains as to whether it is adequate for elderly patients. The present study aimed to comparatively study the perioperative outcomes and overall survival of sublobar resection vs. lobectomy for management of elderly patients (≥65 years) with clinical stage I NSCLC.

METHODS

This is a multicenter retrospective cohort study. Clinical stage I NSCLC patients who underwent lobar or sublobar resection (segmentectomy and wedge resection) at the Department of Thoracic Surgery of 10 tertiary hospitals between January 2014 and September 2017 were retrospectively reviewed from the national collaborative prospective lung cancer database (LinkDoc Technology Co, Ltd., Beijing, China). Clinical data on demographic and tumor characteristics, surgical details were collected. Perioperative outcomes and overall survival were analyzed by using propensity score matching to adjust for selection bias. Subgroup analysis was further carried out to explore the potential sources of heterogeneity.

RESULTS

Among the 1,579 eligible patients, 1,164 (73.7%) underwent lobectomy and 415 (26.3%) underwent sublobar resection (106 segmentectomy and 309 wedge resection). Sublobar resection was more frequently performed in patients who were elder, had more comorbidities and smaller, left-sided adenocarcinoma (P<0.001). Propensity-matched analysis showed significant association of sublobar resection with less blood loss, shorter operation time, chest drainage and hospital stay, while with less lymph node removal when compared with lobectomy (P<0.001). Short term survival analysis showed comparable results even after adjusted in the matched analysis. Similar results were obtained when limiting patients to those aged >75 years, at pathologic stage I, and those who smoking or undergoing video-assisted thoracoscopic surgery (VATS) or segmentectomy and lobectomy.

CONCLUSIONS

Sublobar resection was associated with significantly better perioperative outcomes without compromising short term survival in elderly patients with clinical stage I NSCLC. However, the importance of patient selection and management process, as well as accurate lymph node staging must be acknowledged when making the surgical decision (clinical registration number: NCT03429673).

Extent of lymphadenectomy is associated with oncological efficacy of sublobar resection for lung cancer ≤2 cm

BACKGROUND

Sublobar resection (SLR) is an alternative to lobectomy for early non-small cell lung cancer. Comparative effectiveness of these 2 approaches might be modified by the extent of lymph node dissection.

METHODS

We utilized the Surveillance, Epidemiology, and End Results Program-Medicare dataset to identify patients with stage I non-small cell lung cancer aged 66 years or older with tumor size ≤2 cm. We compared patient characteristics with t tests for continuous variables and χ² tests for categorical variables. Kaplan-Meier curves were constructed to determine overall survival (OS) and cancer-specific survival (CSS). We evaluated OS and CSS among propensity-matched cohorts undergoing lobectomy versus SLR, particularly as it related to extent of lymphadenectomy.

RESULTS

Among 2757 lobectomies and 1229 SLR procedures performed for stage I tumors ≤2 cm, we propensity-matched 1124 patients from each group. Patients undergoing SLR were more likely to have no lymph nodes sampled (46.9% vs 6.4%; P < .001). OS (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.29-1.69) and CSS (HR, 2.06; 95% CI, 1.41-3.02) were worse following SLR. When propensity-matched cohorts of patients with at least 1 lymph node removed (n = 567 each group) were examined, the HRs for survival for SLR decreased (OS HR, 1.38; 95% CI, 1.12-1.69; CSS HR, 1.58; 95% CI, 0.97-2.57). Finally, when cohorts were propensity matched for ≥9 lymph nodes examined (n = 103 each group), there was no difference in OS (HR, 0.84; 95% CI, 0.50-1.39) or CSS (HR, 1.10; 95% CI, 0.35-3.41).

CONCLUSIONS

SLR leads to fewer lymph node removed and is associated with inferior survival compared with lobectomy. A more extensive lymphadenectomy may be associated with equivalent survival between matched patients undergoing SLR and lobectomy.

Application of intrapulmonary wire combined with intrapleural fibrin glue in preoperative localization of small pulmonary nodules

OBJECTIVE

This study aims to investigate the accuracy of the preoperative localization of small nodules by computerized tomography (CT)-guided placing wire and intrapleural fibrin glue near the nodules at 3 days before the operation.

METHODS

From October 2015 to December 2017, a total of 79 patients, who received preoperative localization of small pulmonary nodules and surgical treatment in the Department of Thoracic Surgery of Hohhot First Hospital, were enrolled into this study. These patients were randomly divided into 2 groups: methylene blue localization group (n = 47), and modified localization group (n = 32), where the patients received preoperative localization of the small nodules by CT-guided placing wire and intrapleural fibrin glue near the nodule at 3 days before the operation. Localization accuracy, operation time and difficulty in postoperative seeking for pathological specimens were compared between these 2 groups.

RESULTS

In the methylene blue localization group, 3 patients had localization failure due to the intrathoracic diffusion of methylene blue, and the success rate was 93.61%. In the modified localization group, all 32 patients succeeded in the localization, and the success rate was 100%. Operation time and difficulty of finding the specimen was significantly lower in the modified localization group than in the methylene blue localization group (P < .05).

CONCLUSION

The application of preoperative localization of small nodules by placing wire and intrapleural fibrin glue improves the success rate of resection, reduces operation time and the risk of the operation, and lowers the difficulty of finding pathological specimens after the operation. Hence this operative procedure is worthy of popularization.

Do the surgical results in the National Lung Screening Trial reflect modern thoracic surgical practice?

INTRODUCTION

Surgical data from the National Lung Screening Trial (NLST) has yet to be closely examined. We sought to analyze surgical procedures and complications from the NLST to determine their relevance to modern surgical practice.

METHODS

The NLST database was queried for patients who underwent surgical resection for confirmed lung cancer, specifically evaluating postoperative complications. Numerical variables were compared using the Mann-Whitney U test. Categorical variables were compared using the χ² test. Logistic regression uni- and multivariable analysis of independent risk factors of postoperative complications was performed.

RESULTS

At operation, 80% of patients (n = 821) had lobectomy, 4.1% (n = 42) had pneumonectomy, and 16.1% (n = 166) had sublobar resection, among whom 69% (n = 114) had wedge resection. Only 29.6% (n = 305) of the cohort had a thoracoscopic resection. Although the overall rate of surgical patients with any complication was 31% (n = 318), only 15.5% of patients (n = 160) had major complications, most commonly prolonged air leaks (n = 67, 6.5%). Respiratory failure (n = 28, 2.7%), prolonged ventilation (n = 9, 0.9%), myocardial infarction or cardiac arrest (n = 7, 0.7%), and stroke (n = 2, 0.2%) were rare events. Overall 30-day mortality in patients undergoing resection was 1.7% (n = 18). On multivariable analysis, greater smoking pack history (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.001-1.01) and pulmonary comorbidities (OR, 1.34; 95% CI, 0.98-1.82) were significant or approached significance for an association with complications/death, whereas sublobar resection (OR, 0.59; 95% CI, 0.38-0.94) and video-assisted thoracoscopic surgery approach (OR, 0.76; 95% CI, 0.56-1.04) were significant or approached significance for an association with decreased rates of complications/death.

CONCLUSIONS

Operative mortality and postoperative morbidity were very low in patients undergoing resection for screen-detected lung cancer. Increased use of sublobar resection and minimally invasive surgical approaches may be associated with fewer complications.

Impact of examined lymph node counts on survival of patients with stage IA non-small cell lung cancer undergoing sublobar resection

Background

The correlation between the number of examined lymph nodes (ELNs) and lung cancer-specific survival (LCSS) of stage IA non-small cell lung cancer (NSCLC) patients, who underwent sublobar resection in which lymph node (LN) sampling was relatively restricted as compared with standard lobectomy remains unclear.

Methods

Patients from the Surveillance, Epidemiology, and End Results database with stage IA NSCLC who underwent sublobar resection were categorized based on ELN count (1-6 vs. ≥7; the cut point 7 was identified by Cox model).

Results

Collectively, 3,219 patients with a median follow-up time of 37 months were included in this study (G1: 1-6 ELN, n=2,410; G2: ≥7 ELN, n=809). The 5-year LCSS rate of the G1 and G2 cohorts were 75% and 83%, respectively. Cox analysis suggested that the LCSS of G1 cohort patients was lower as compared with the G2 cohort [hazard ratio (HR) =1.530; 95% confidence interval (CI): 1.240-1.988, P<0.001). Propensity score analysis also showed decreased survival of the matched G1 cohort (HR =1.499; 95% CI: 1.176-1.911; P=0.001).

Conclusions

The data suggested the ELNs ≤6 were associated with poor prognoses. Adequate LN sampling is essential even for stage IA NSCLC patients undergoing sublobar resection.

Radiologic Criteria in Predicting Pathologic Less Invasive Lung Cancer According to TNM 8th Edition

PURPOSE

The Japan Clinical Oncology Group Study 0201 has proposed radiologic criteria on thin-slice computed tomography to diagnose pathologic less invasive lung adenocarcinoma that could be a candidate for sublobar resection based on the previous tumor, node, metastasis classification system (TNM). The aim of this study was to propose the new radiologic criteria for predicting pathologic less invasive cancer according to the 8th edition TNM.

PATIENTS AND METHODS

We analyzed 744 patients who had peripheral clinical Tis-T1cN0M0 non-small-cell lung cancer of 3 cm or less and underwent complete resection by lobectomy from 2003 to 2011. We defined lung cancer with no nodal involvement and no vessel invasion pathologically as a pathologic less invasive cancer and investigated the radiologic criteria on the basis of the solid component size and by the consolidation-to-tumor (C/T) ratio (calculated with the maximum solid component diameter divided by the maximum tumor diameter) by using preoperative thin-slice computed tomography to predict them with a specificity of 97% or more, and evaluated overall survival.

RESULTS

Patients with clinical Tis/T1mi/T1a disease had no pathologic invasive cancer except for one patient (specificity, 99%). From the investigation with the C/T ratio, only the criterion of C/T ratio 0.5 or less met the standard (specificity, 100%). The final specificity after combining these criteria was 99.6%, and they showed excellent prognosis (5-year overall survival rate, 96.2%).

CONCLUSION

Lung cancer with clinical Tis/T1mi/T1a or a C/T ratio of 0.5 or less can be completely cured by sublobar resection with sufficient margin because of its less invasive nature pathologically.

Perioperative mortality and morbidity after sublobar versus lobar resection for early-stage non-small-cell lung cancer: post-hoc analysis of an international, randomised, phase 3 trial (CALGB/Alliance 140503)

BACKGROUND

Increased detection of small-sized, peripheral, non-small-cell lung cancer has renewed interest in sublobar resection instead of lobectomy, the traditional standard of care for early-stage lung cancer. We aimed to assess morbidity and mortality associated with lobar and sublobar resection for early-stage lung cancer.

METHODS

CALGB/Alliance 140503 is a multicentre, international, non-inferiority, phase 3 trial in patients with peripheral non-small-cell lung cancer clinically staged as T1aN0. Patients were recruited from 69 academic and community-based institutions in Australia, Canada, and the USA. Patients were randomly assigned intraoperatively to either lobar or sublobar resection. The random assignment was based on permuted block randomisation without concealment and was stratified according to radiographic tumour size, histology, and smoking status. The primary endpoint of the trial is disease-free survival; here, we report a post-hoc, exploratory, comparative analysis of perioperative mortality and morbidity associated with lobar and sublobar resection. Perioperative mortality was defined as death from any cause within 30 days and 90 days of surgical intervention and was calculated for all randomised patients. Morbidity was graded using Common Terminology Criteria for Adverse Events version 4.0. All analyses were done on an intention-to-treat basis for randomised patients with data available. This trial is registered with ClinicalTrials.gov, number NCT00499330.

FINDINGS

Between June 15, 2007, and March 13, 2017, 697 patients were randomly allocated to either lobar resection (n=357) or sublobar resection (n=340; 59% wedge resection). Six (0·9%) patients died by 30 days, four (1·1%) after lobar resection and two (0·6%) after sublobar resection; by 90 days, ten (1·4%) patients had died, six (1·7%) after lobar resection and four (1·2%) after sublobar resection (difference at 30 days, 0·5%, 95% CI -1·1 to 2·3; difference at 90 days, 0·5%, 95% CI -1·5 to 2·6). An adverse event of any grade occurred in 193 (54%) of 355 patients after lobar resection and 172 (51%) of 337 patients after sublobar resection. Adverse events of grade 3 or worse occurred in 54 (15%) patients assigned lobar resection and in 48 (14%) patients assigned sublobar resection. No differences between surgical approaches were noted in cardiac or pulmonary complications. Grade 3 haemorrhage (requiring transfusion) occurred in six (2%) patients assigned lobar resection and eight (2%) patients assigned sublobar resection. Prolonged air leak occurred in nine (3%) patients after lobar resection and two (1%) patients after sublobar resection.

INTERPRETATION

Our post-hoc analysis showed that perioperative mortality and morbidity did not seem to differ between lobar and sublobar resection in physically and functionally fit patients with clinical T1aN0 non-small-cell lung cancer. These data may affect the daily choices made by patients and their doctors in establishing the best treatment approach for stage I lung cancer.

FUNDING

National Cancer Institute.