Sublobar resection is comparable to lobectomy for screen-detected lung cancer

doi:10.1016/j.jtcvs.2021.06.056

The Journal of Thoracic and Cardiovascular Surgery

Volume 163, Issue 6, June 2022, Pages 1907-1915

https://doi.org/10.1016/j.jtcvs.2021.06.056 Get rights and content

Abstract

Objective

Sublobar resection is frequently offered to patients with small, peripheral lung cancers, despite the lack of outcome data from ongoing randomized clinical trials. Sublobar resection may be a particularly attractive surgical strategy for screen-detected lung cancers, which have been suggested to be less biologically aggressive than cancers detected by other means. Using prospective data collected from patients undergoing surgery in the National Lung Screening Trial, we sought to determine whether extent of resection affected survival for patients with screen-detected lung cancer.

Methods

The National Lung Screening Trial database was queried for patients who underwent surgical resection for confirmed lung cancer. Propensity score matching analysis (lobectomy vs sublobar resection) was done (nearest neighbor, 1:1, matching with no replacement, caliper 0.2). Demographics, clinicopathologic and perioperative outcomes, and long-term survival were compared in the entire cohort and in the propensity-matched groups. Multivariable logistic regression analysis was done to identify factors associated with increased postoperative morbidity or mortality.

Results

We identified 1029 patients who underwent resection for lung cancer in the National Lung Screening Trial, including 821 patients (80%) who had lobectomy and 166 patients (16%) who had sublobar resection, predominantly wedge resection (n = 114, 69% of sublobar resection). Patients who underwent sublobar resection were more likely to be female (53% vs 41%, P = .004) and had smaller tumors (1.5 cm vs 2 cm, P < .001). The sublobar resection group had fewer postoperative complications (22% vs 32%, P = .010) and fewer cardiac complications (4% vs 9%, P = .033). For stage I patients undergoing sublobar resection, there was no difference in 5-year overall survival (77% for both groups, P = .89) or cancer-specific survival (83% for both groups, P = .96) compared with patients undergoing lobectomy. On multivariable logistic regression analysis, sublobar resection was the only factor associated with lower postoperative morbidity/mortality (odds ratio, 0.63; 95% confidence interval, 0.40-0.98). To compare surgical strategies in balanced patient populations, we propensity matched 127 patients from each group undergoing sublobar resection and lobectomy. There were no differences in demographics or clinical and tumor characteristics among matched groups. There was again no difference in 5-year overall survival (71% vs 65%, P = .40) or cancer-specific survival (75% vs 73%, P = .89) for patients undergoing lobectomy and sublobar resection, respectively.

Conclusions

For patients with screen-detected lung cancer, sublobar resection confers survival similar to lobectomy. By decreasing perioperative complications and potentially preserving lung function, sublobar resection may provide distinct advantages in a screened patient cohort.

Graphical abstract

Section snippets

National Lung Screening Trial

The NLST is a randomized controlled trial that compared mortality from lung cancer in patients undergoing screening with LDCT scan or plain chest radiography. The trial enrolled 53,454 persons from 33 participating centers across the United States between August 2002 and April 2004. Inclusion criteria focused on persons who are high risk for lung cancer (55-74 years old, >30 pack/years smoking history, and current or former smoker who quit within the previous 15 years). Symptomatic persons and

Results

Over the NLST study period, 1057 potentially curative surgeries were performed in 1029 patients with confirmed, screen-detected lung cancer. Of those, 987 patients who underwent lobectomy (n = 821) or SLR (wedge, n = 114; segmentectomy, n = 52) were included in this study. SLR was performed in 109 of 616 patients (18%) in the spiral CT arm and in 57 of 371 patients (15%) in the x-ray arm (P = .343). Demographics, clinicopathological characteristics, and perioperative outcomes are reported in

Discussion

Despite 2 large landmark trials reporting an overall reduction in lung cancer mortality, LDCT screening for lung cancer remains grossly underused in the eligible patient population.⁹^,¹⁰ At a median follow-up of 6.5 years, the NLST reported a 20% decrease in lung cancer mortality and a 6.7% reduction in overall mortality in high-risk patients who underwent just 3 annual LDCT scans.¹ Despite the relatively short screening period, the reduced lung cancer mortality with LDCT screening persisted

Conclusions

We demonstrated that SLR appears to be a reasonable and adequate oncological procedure that is comparable to lobectomy for screen-detected lung cancers. The use of carefully collated data from the randomized NLST and the large number of patients undergoing SLR are significant strengths of this study. It is possible that some degree of selection bias contributed to the improved outcomes in patients undergoing SLR. Tumor size was smaller in the entire SLR group compared with patients undergoing

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Cited by (24)

Long-term Survival After Lung Cancer Resection in the National Lung Screening Trial
2024, Annals of Thoracic Surgery
This study sought to evaluate the long-term survival and causes of death after surgery among patients with pathologic stage IA non-small cell lung cancer (NSCLC) in the National Lung Screening Trial (NLST).
Patients who underwent surgery and who had a diagnosis of pathologic stage IA NSCLC in the NLST were identified for analysis. The 5- and 10-year overall survival and lung cancer–specific survival, stratified by operation type, were evaluated. Among patients who underwent lobectomy, the causes of death and the cumulative incidence of lung cancer death were assessed.
A total of 380 patients (n = 329, 86.6% lobectomy; n = 20, 5.3% segmentectomy; n = 31, 8.1% wedge resection) met inclusion criteria. Median follow-up time from the date of surgery was 7.8 years (interquartile range, 4.8-10.7 years). The 10-year overall survival rate was 58.3% (95% CI, 52.4%-63.8%) for lobectomy, 59.9% (95% CI, 33.2%-78.8%) for segmentectomy, and 45.2% (95% CI, 20.8%-66.9%) for wedge resection. The 10-year lung cancer–specific survival rate was 74.3% (95% CI, 68.6%-79.1%) for lobectomy, 81.3% (95% CI, 51.3%-93.8%) for segmentectomy, and 84.8% (95% CI, 64.0%-94.1%) for wedge resection. Lung cancer was the leading cause of death, accounting for 55.8% of deaths after lobectomy. The 10-year cumulative incidence of lung cancer death after lobectomy was 22.5% (95% CI, 18.3%-27.1%).
The 10-year overall survival rate after lobectomy among patients with pathologic stage IA NSCLC in the NLST was 58%. Lung cancer was the leading cause of death, accounting for more than 55% of deaths.
Extent of surgical resection for radiologically subsolid T1N0 invasive lung adenocarcinoma: When is a wedge resection acceptable?
2024, Journal of Thoracic and Cardiovascular Surgery
To evaluate whether wedge resection (WR) was appropriate for the patients with peripheral T1 N0 solitary subsolid invasive lung adenocarcinoma.
Patients with peripheral T1N0 solitary subsolid invasive lung adenocarcinoma who received sublobar resection were retrospectively reviewed. Clinicopathologic characteristics, 5-year recurrence-free survival, and 5-year lung cancer-specific overall survival were analyzed. Cox regression model was used to elucidate risk factors for recurrence.
Two hundred fifty-eight patients receiving WR and 1245 patients receiving segmentectomy were included. The mean follow-up time was 36.87 ± 16.21 months. Five-year recurrence-free survival following WR was 96.89% for patients with ground-glass nodule (GGN) ≤2 cm and 0.25< consolidation-to-tumor ratio (CTR) ≤0.5, not statistically different from 100% for those with GGN≤2 cm and CTR ≤0.25 (P = .231). The 5-year recurrence-free survival was 90.12% for patients with GGN between 2 and 3 cm and CTR ≤0.5, significantly lower than that of patients with GGN ≤2 cm and CTR ≤0.25 (P = .046). For patients with GGN≤2 cm and 0.25<CTR≤0.5, 5-year recurrence-free survival and lung cancer-specific overall survival were 97.87% and 100% following WR versus 97.73% and 92.86% following segmentectomy (recurrence-free survival: P = .987; lung cancer-specific overall survival: P = .199), respectively. For patients with GGN between 2 and 3 cm and CTR ≤0.5, 5-year recurrence-free survival following WR was significantly lower than that following SEG (90.61% vs 100%; P = .043). Multi-variable Cox regression analysis showed that spread through airspace, visceral pleural invasion, and nerve invasion remained independent risk factors for recurrence of patients with GGN between 2 and 3 cm and CTR ≤0.5 following WR.
WR might be appropriate for patients with invasive lung adenocarcinoma appearing as peripheral GGN ≤2 cm and CTR ≤0.5, but inappropriate for those with invasive lung adenocarcinoma appearing as peripheral GGN between 2 and 3 cm and CTR ≤0.5.
Is wedge a dirty word? Demographic and facility-level variables associated with high-quality wedge resection
2023, JTCVS Open
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.
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.
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.
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 vs Lobectomy for Clinical Stage IA Non-Small Cell Lung Cancer With Occult Lymph Node Disease
2023, Annals of Thoracic Surgery
Sublobar resection is increasingly performed for stage Ia non-small cell lung cancer, but pathologic lymph node upstaging remains a common clinical scenario. This study compares the long-term prognosis of patients with clinical stage Ia disease and occult lymph node disease undergoing wedge resection vs lobectomy.
The National Cancer Database was queried for patients treated with wedge resection or lobectomy for clinical stage Ia (cT1N0) non-small cell lung cancer and who were pathologically upstaged with either pN1/pN2 disease. Overall survival (OS) was compared by extent of resection using inverse probability treatment weighting–adjusted Cox regression analyses.
Of 5437 clinical stage Ia patients included, 3408 (62.7%) were found to have occult pN1 and 2029 (37.3%) to have occult pN2. Of 5437 patients, 93.5% (5082) were treated with lobectomy and 6.5% (355) underwent wedge resection. Lobectomy was associated with improved OS compared with wedge resection for patients with occult pN1 disease (median OS, 70.0 months [95% CI, 66.6-77.4] vs 36.4 months [95% CI, 24.2-45.6]; P < .001) but not for pN2 disease (median OS, 48.2.1 months [95% CI, 43.8-52.9] vs 43.7 months [95% CI, 31.2-62.4]; P = 0.24). On inverse probability treatment weighting–adjusted multivariable analysis, adjusting for demographics, comorbidities, margin status, and pathologic T and N stage, lobectomy remained associated with improved survival (adjusted hazard ratio, 0.73; 95% CI, 0.60-0.89; P = .0016).
Lobectomy is associated with improved survival in clinical stage Ia non-small cell lung cancer patients with occult lymph node disease. These data may aid the decision for completion lobectomy for patients with unanticipated N1 lymph node upstaging.
Treatment of Stage I Lung Cancer Detected by Computed Tomography Screening
2022, JTO Clinical and Research Reports
Citation Excerpt :
In a different cohort from the same database, 5-year overall survival was equivalent for lobectomy and sublobar resection, but the number of lymph nodes sampled was lower and recurrence rates were 39% higher in the sublobar group.9 Retrospective analyses of data from I-ELCAP10 and NLST11 both found equivalent survival of screen-detected stage I lung cancer with lobectomy or sublobectomy. These findings may support a role for sublobar resection in selected patients, as was done in a subgroup of our patients who had smaller nodules.
Reducing lung cancer deaths through early detection by computed tomography (CT) screening requires delivery of effective treatment. We performed this retrospective study to determine the types of treatment used for screen-detected stage I lung cancer at our academic center and to compare the demographic and clinical characteristics of patients by type of treatment.
All persons screened in the lung cancer screening program at our institution through June 16, 2021, were included. Those with screening CT findings needing follow-up were managed through a thoracic surgery clinic. Demographic and clinical characteristics of patients diagnosed with having stage I lung cancer through June 16, 2021, were compared by type of treatment, with follow-up through December 31, 2021.
Stage I NSCLC was diagnosed in 54 of 2203 persons screened (2.5%), on the basis of biopsy in 37 and on imaging findings in 17 patients in whom a tissue diagnosis could not be obtained. Treatment was by lobectomy in 18, sublobar resection in 14, and stereotactic body radiation therapy (SBRT) in 22. Patients treated with SBRT had lower forced expiratory volume in 1 second (p < 0.001) and diffusing capacity of the lung for carbon monoxide (p < 0.001) and more comorbidities (p = 0.003) than those treated with surgery. New or recurrent cancer developed in nine patients (three lobectomy, three sublobar resection, three SBRT).
Many patients with screen-detected stage I lung cancer are medically unfit for lobectomy, and a variety of treatments are being used. Assessment of treatment-based outcomes will be critical for ensuring an optimal balance of the risks and benefits of CT screening in a medically diverse population.
Commentary: Lobectomy should be the exception rather than the rule to resect screen-detected stage I non–small cell lung cancer
2022, Journal of Thoracic and Cardiovascular Surgery

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: Institutional Review Board review was deemed unnecessary and patients' consent was waived because of the retrospective nature of this analysis and the study data were derived from a publically accessible, de-identified, database.

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Thoracic: Lung CancerSublobar resection is comparable to lobectomy for screen-detected lung cancer

Abstract

Objective

Methods

Results

Conclusions

Graphical abstract

Section snippets

National Lung Screening Trial

Results

Discussion

Conclusions

Ann Thorac Surg

Lancet Respir Med

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Clin Lung Cancer

Ann Thorac Surg

J Thorac Oncol

Lung Cancer

J Thorac Cardiovasc Surg

Thoracic: Lung Cancer
Sublobar resection is comparable to lobectomy for screen-detected lung cancer