A propensity score matching analysis of survival following segmentectomy or wedge resection in early-stage lung invasive adenocarcinoma or squamous cell carcinoma

Limited resection for stage IA radiologically invasive lung cancer: a real-world nationwide database study

OBJECTIVES

Radiologically invasive non-small cell lung cancer, defined as consolidation size to maximum tumour diameter ratio of over 0.5, is associated with pathological invasiveness and worse prognosis. However, there are no real-world, nationwide database studies on limited resections that consider radiological invasiveness. This study aimed to investigate the prognostic validity of limited resection, such as segmentectomy and wedge resection, in cStage IA (TNM 8th edition) radiologically invasive lung cancer.

METHODS

We conducted a retrospective analysis of patients who underwent complete resection according to the Japanese Joint Committee of Lung Cancer Registry Database. The relationship between surgical procedures and prognosis was examined using stratification by cT factor and radiological invasiveness.

RESULTS

Among the 5,692 patients enrolled, lobectomy, segmentectomy, and wedge resection were performed in 4,323 (80.0%), 657 (11.5%), and 712 (12.5%) patients, respectively. Multivariable analysis with or without propensity score matching indicated that older age, poor performance status, and wedge resection were significantly associated with worse prognosis and that patients who underwent segmentectomy showed an equivalent prognosis to those who underwent lobectomy. Subset analyses revealed that segmentectomy showed an equivalent prognosis to lobectomy in patients with cT1b or less, but not in those with cT1c, especially for non-pure radiological invasive cT1c; 5-year overall survival rates were 91.4% vs 90.4% in cT1b with non-pure radiological invasiveness, and 80.0% vs 83.8% in cT1b with pure radiological invasiveness, respectively.

CONCLUSIONS

Segmentectomy can be an alternative to lobectomy in patients with radiologically invasive lung cancer with cT1b or less, but not in those with cT1c.

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.

Prognostic Radiological Tools for Clinical Stage IA Pure Solid Lung Cancer

In this study, we analyzed prognostic radiological tools and surgical outcomes for radiologically pure solid adenocarcinomas (AD) and squamous cell carcinoma (SQ) in clinical stage IA. We retrospectively investigated 130 patients who underwent surgical resections. We assessed the predictive risk factors for recurrence and pathological lymph node metastasis (LNM). There was no statistical difference in recurrence free survival (RFS) or cancer-specific survival (CSS) between AD and SQ groups (p = 0.642 and p = 0.403, respectively). In the whole cohort, tumor size on lung window and mediastinal settings, and tumor disappearance ratio using high-resolution computed tomography (HRCT) were not prognostic parameters (p = 0.127, 0.066, and 0.082, respectively). The maximal standardized uptake value (SUVmax) using positron emission tomography-CT was associated with recurrence (p = 0.016). According to the receiver operating characteristic curve, the cut-off value of SUVmax for recurrence was 4.6 (p = 0.016). The quantitative continuous variables using any radiological tools were not associated with LNM. However, tumor diameter on mediastinal setting ≥8 mm with SUVmax ≥2.4 could be a risk factor for LNM. Pure solid AD and SQ were equivalent for the RFS and CSS. SUVmax was useful to predict recurrence. The tumor diameter on a mediastinal setting and SUVmax were useful in predicting pathological LNM.

Thoracoscopic Wedge Resection Versus Segmentectomy for cT1N0 Lung Adenocarcinoma

BACKGROUND

The choice between wedge resection and segmentectomy as a sublobar resection method for patients with cT1N0 lung cancer remains debatable. This study aimed to evaluate the clinical outcomes after wedge resection and segmentectomy for patients with cT1N0 lung adenocarcinoma.

METHODS

The study enrolled 1002 consecutive patients with cT1N0 lung adenocarcinoma who underwent sublobar resection at the authors' institution between 2011 and 2017. A propensity score-matching analysis was used to compared the clinical outcomes between the wedge resection and segmentectomy groups.

RESULTS

Wedge resection was performed for 810 patients (80.8%), and segmentectomy was performed for 192 patients (19.2%). Wedge resection resulted in better perioperative outcomes than segmentectomy. The multivariate analysis showed that the significant risk factors for poor disease-free survival (DFS) were elevated preoperative serum carcinoembryonic antigen levels, total tumor diameter greater than 2 cm, and a consolidation-to-tumor (C/T) ratio higher than 50%. After propensity-matching, no differences in overall survival or DFS were noted between the two matched groups. However, subgroup analysis showed that segmentectomy was associated with better DFS than wedge resection (p = 0.039) for the patients with a tumor diameter greater than 2 cm and a C/T ratio higher than 50%.

CONCLUSION

Segmentectomy is the appropriate surgical method for sublobar resection in cT1N0 lung adenocarcinoma patients with a tumor diameter greater than 2 cm and a C/T ratio higher than 50%. Wedge resection may be a safe and feasible sublobar resection method for patients with a tumor diameter of 2 cm or smaller or a C/T ratio of 50% or lower.

Comparative Effectiveness of Lobectomy, Segmentectomy, and Wedge Resection for Pathological Stage I Non-small Cell Lung Cancer in Elderly Patients: A Population-Based Study

Introduction: This study was designed to assess the long-term survival of lobectomy, segmentectomy, and wedge resection for pathological stage I non-small cell lung cancer (NSCLC) in patients over 75 years of age.

Patients and methods: Pathological stage I NSCLC patients aged ≥75 years who underwent lobectomy, segmentectomy, or wedge resection were identified from the Surveillance, Epidemiology, and End Results database. Propensity score–matched and competing risks analyses were conducted. The overall survival (OS) rate and lung cancer–specific survival (LCSS) rate were compared among the three groups based on the pathological stage.

Results: A total of 3,345 patients were included. In the full cohort, the OS rate and LCSS rate of lobectomy were superior to wedge resection, but not to segmentectomy, the OS advantage diminished when patients were over 85 years old or when at least one lymph node was examined during the procedure. Stratified analyses showed that there was no significant difference in OS and LCSS rates among the three surgical procedures for patients with tumors smaller than 1.0 cm. The OS and LCSS of wedge resection, not segmentectomy, were inferior to lobectomy in stage IA2–IB tumors.

Conclusion: Lobectomy should be recognized as the “gold standard” procedure for pathological stage I NSCLC in patients over 75 years of age, and segmentectomy could be considered as an effective alternative. Wedge resection could be considered for patients with compromised cardiopulmonary function or tumors smaller than 1.0 cm, and intraoperative lymph node examination should be conducted.

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.

Oncologic outcomes of segmentectomy vs lobectomy in pathologic stage IA (≤2 cm) invasive lung adenocarcinoma: A population-based study

BACKGROUND AND OBJECTIVES

For early-stage invasive lung adenocarcinoma, it remains unclear whether segmentectomy can yield outcomes equivalent to those of lobectomy. This study aimed to compare survival outcomes after segmentectomy and lobectomy among patients with stage IA invasive lung adenocarcinoma.

METHODS

We identified patients with stage IA (≤2 cm) invasive lung adenocarcinoma who underwent segmentectomy or lobectomy from the Surveillance, Epidemiology, and End Results database (2004-2015). Propensity score matching (PSM) was used to balance the baseline characteristics. Overall survival (OS) and lung cancer-specific survival (LCSS) were compared using the Kaplan-Meier method and Cox proportional hazards regression.

RESULTS

A total of 5474 patients were included. Before PSM, the 5-year OS was 78.3% for patients undergoing lobectomy vs 76.5% for patients undergoing segmentectomy (P = .166) while LCSS were 86.8% vs 83.0% (P = .015). After PSM, survival analyses showed that segmentectomy had OS (75.8% vs 76.4%; P = .694) and LCSS (82.7% vs 82.9%; P = .604) equivalent to those of lobectomy. Cox regression demonstrated that segmentectomy was equivalent to lobectomy in terms of OS and LCSS before and after PSM.

CONCLUSION

For stage IA (≤2 cm) invasive lung adenocarcinoma, segmentectomy may have oncologic outcomes equivalent to those of lobectomy.

A nomogram to predict prognosis in patients undergoing sublobar resection for stage IA non-small-cell lung cancer

Introduction

This study aimed to develop a practical nomogram to predict prognosis in patients who are undergoing sublobar resection for stage IA non-small-cell lung cancer (NSCLC). Data from Surveillance, Epidemiology, and End Results (SEER) databases were used to construct the nomogram.

Methods

Data from patients undergoing sublobar resection for stage IA NSCLC diagnosed between 2004 and 2014 were extracted from the SEER database. Factors that may predict the outcome were identified using the Kaplan–Meier method and the Cox proportional-hazards model. A nomogram was constructed to predict the 3- and 5-year overall survival (OS) and lung cancer-specific survival (LCSS) rates of these patients. The predictive accuracy of the nomogram was measured using the concordance index (C-index) and calibration curve.

Results

A total of 4,866 patients were selected for this study. Using univariate and multivariate analyses, eight independent prognostic factors associated with OS were identified, including sex (P<0.001), age (P<0.001), race (P=0.043), marital status (P=0.009), pathology (P=0.004), differentiation (P<0.001), tumor size (P<0.001), and surgery (P=0.001), and five independent prognostic factors associated with LCSS were also identified, including sex (P<0.001), age (P<0.001), differentiation (P<0.001), tumor size (P<0.001), and surgery (P=0.011). A nomogram was established based on these results and validated using the internal bootstrap resampling method. The C-index of the established nomogram for OS and LCSS was 0.649 (95% CI: 0.635–0.663) and 0.640 (95% CI: 0.622–0.658), respectively. The calibration curves for probability of 3-, and 5-year OS and LCSS rates demonstrated good agreement between the nomogram prediction and actual observation.

Conclusion

This innovative nomogram delivered a relatively accurate individual prognostic prediction for patients undergoing sublobar resection for stage IA NSCLC.

Meta-analysis of segmentectomy versus wedge resection in stage IA non-small-cell lung cancer

Background

Although limited resection was once considered the surgical treatment for patients with Phase IA non-small-cell lung cancer (NSCLC), there has been an ongoing controversial surgical indication for wedge resection and segmentectomy in recent years. The objective of this study was to compare overall survival (OS) and disease-free survival (DFS) of segmentectomy and wedge resection for early stage NSCLC, using a meta-analysis.

Methods

Systematic research was conducted using four online databases to search for studies published before 2017. The DFS and OS for early stage NSCLC after segmentectomy and wedge resection were compared. The studies were selected according to rigorous predefined inclusion criteria, and meta-analyzed using the log (hazard ratio; ln[HR]) and its standard error (SE) calculations.

Results

Included in this meta-analysis were nine studies, published from 2006 to 2017, with a total of 7,272 patients. Survival outcome of segmentectomy was comparable to wedge resections for stage IA lung cancer because of OS (similar hazard ratio [HR]: 0.93, 95% confidence interval [CI]: 0.83-1.05, P=0.26) and DFS (similar HR: 0.81, 95% CI: 0.60-1.09, P=0.17). Nevertheless, for stage IA NSCLC with tumor size ≤2 cm, segmentectomy was superior to wedge resection (combined HR: 0.82, 95% CI: 0.70-0.97, P=0.02). However, there were no significant differences in OS rates, 1.07 (95% CI: 0.78-1.46, P=0.68), between segmentectomy and wedge resection for IA NSCLC with a tumor size of ≤1 cm.

Conclusion

This study concluded that segmentectomy could achieve better OS than wedge resection for stage IA NSCLC with a tumor size of ≤2 cm. However, surgeons could conduct segmentectomy and wedge resection for NSCLC ≤1 cm according to patient profile and the location of tumor. These results should be confirmed by further randomized clinical trials.