Lobar or Sublobar Resection for Peripheral Stage IA Non-Small-Cell Lung Cancer.

Altorki N et al.

The New England Journal of Medicine. 2023 Feb 09; 388(6):489-498

https://doi.org/10.1056/NEJMoa2212083PMID: 36780674

BACKGROUND: The increased detection of small-sized peripheral non-small-cell lung cancer (NSCLC) has renewed interest in sublobar resection in lieu of lobectomy.

METHODS: We conducted a multicenter, noninferiority, phase 3 trial in which patients with NSCLC clinically staged as T1aN0 (tumor size, ≤2 cm) were randomly assigned to undergo sublobar resection or lobar resection after intraoperative confirmation of node-negative disease. The primary end point was disease-free survival, defined as the time between randomization and disease recurrence or death from any cause. Secondary end points were overall survival, locoregional and systemic recurrence, and pulmonary functions.

RESULTS: From June 2007 through March 2017, a total of 697 patients were assigned to undergo sublobar resection (340 patients) or lobar resection (357 patients). After a median follow-up of 7 years, sublobar resection was noninferior to lobar resection for disease-free survival (hazard ratio for disease recurrence or death, 1.01; 90% confidence interval [CI], 0.83 to 1.24). In addition, overall survival after sublobar resection was similar to that after lobar resection (hazard ratio for death, 0.95; 95% CI, 0.72 to 1.26). The 5-year disease-free survival was 63.6% (95% CI, 57.9 to 68.8) after sublobar resection and 64.1% (95% CI, 58.5 to 69.0) after lobar resection. The 5-year overall survival was 80.3% (95% CI, 75.5 to 84.3) after sublobar resection and 78.9% (95% CI, 74.1 to 82.9) after lobar resection. No substantial difference was seen between the two groups in the incidence of locoregional or distant recurrence. At 6 months postoperatively, a between-group difference of 2 percentage points was measured in the median percentage of predicted forced expiratory volume in 1 second, favoring the sublobar-resection group.

CONCLUSIONS: In patients with peripheral NSCLC with a tumor size of 2 cm or less and pathologically confirmed node-negative disease in the hilar and mediastinal lymph nodes, sublobar resection was not inferior to lobectomy with respect to disease-free survival. Overall survival was similar with the two procedures. (Funded by the National Cancer Institute and others; CALGB 140503 ClinicalTrials.gov number, NCT00499330.).

Copyright © 2023 Massachusetts Medical Society.

Altorki N ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Wang X ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Kozono D ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Watt C ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Landrenau R ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Wigle D ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Port J ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Jones DR ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Conti M ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Ashrafi AS ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Liberman M ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Yasufuku K ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Yang S ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Mitchell JD ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Pass H ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Keenan R ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Bauer T ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Miller D ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Kohman LJ ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Stinchcombe TE ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹,
Vokes E ^1,^2,^3,^4,^5,^6,^7,^8,^9,^10,¹¹

Affiliations

¹ From Weill Cornell Medicine, New York-Presbyterian Hospital (N.A., J.P.), Memorial Sloan Kettering Cancer Center (D.R.J.), and New York University Grossman School of Medicine (H.P.), New York, and SUNY Upstate Medical University, Syracuse (L.J.K.) - all in New York
² the Alliance Statistics and Data Management Center and the Department of Biostatistics and Bioinformatics, Duke University (X.W.), and Duke Cancer Institute, Duke University Medical Center (T.E.S.) - both in Durham, NC
³ Alliance Protocol Operations Office (D.K., C.W.) and the University of Chicago Comprehensive Cancer Center (E.V.) - both in Chicago
⁴ University of Pittsburgh Medical Center, Pittsburgh (R.L.)
⁵ Mayo Clinic, Rochester, MN (D.W.)
⁶ Institut Universitaire de Cardiologie et Pneumologie de Québec, Quebec (M.C.), and Centre Hospitalier de l'Université de Montréal, Montreal (M.L.), QC, Surrey Memorial Hospital Thoracic Group Fraser Valley Health Authority, Surrey, BC (A.S.A.), and the University of Toronto, Toronto (K.Y.) - all in Canada
⁷ Johns Hopkins University, Baltimore (S.Y.)
⁸ University of Colorado Hospital School of Medicine, Aurora (J.D.M.)
⁹ Moffitt Cancer Center, Tampa, FL (R.K.)
¹⁰ Hackensack Meridian Health System, Edison, NJ (T.B.)
¹¹ Emory University School of Medicine, Atlanta (D.M.)

Classifications

Changes Clinical Practice
Controversial
Good for Teaching
Interesting Hypothesis
New Finding

Evaluations

Exceptional

21 Mar 2023

Paul Van Schil

+ -1 Evaluators

This article changes clinical practice

For non-small small-sized cell lung cancer (NSCLC) less than 2cm with negative lymph nodes, sublobar resection is not inferior to lobectomy and should be considered.

For non-small small-sized cell lung cancer (NSCLC) up to 2cm, the role of sublobar resection comprising anatomical segmentectomy and wide wedge excision remains controversial. In this multicentre phase III trial, patients with clinical T1aN0 NSCLC until 2cm were randomised between lobectomy and sublobar resection. The comprehensive nodal staging was performed intraoperatively. A total of 697 patients were randomised. After a median follow-up of 7 years, sublobar resection was non-inferior to lobar resection regarding disease-free survival. Also, overall survival was similar in the two procedures.

This landmark trial clearly demonstrates that sublobar resection is a valid oncological resection for NSCLC less than 2cm with negative lymph nodes. However, it should be emphasised that detailed lymph node staging is required intraoperatively to confirm N0 status.

In a rather similar Japanese trial (JCOG0802), anatomical segmentectomy yielded an even better overall survival rate than lobectomy, although the locoregional recurrence rate was higher {1}.

Both of these trials pave the way for more personalised surgical therapy for patients with node-negative NSCLC less than 2cm. For larger tumours or those with positive lymph nodes, lobectomy still remains the standard of care.

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Relevant Specialties

Cancer Biology
Cancer Therapeutics | Cell Growth & Division
Cell Biology
Cell Growth & Division
Critical Care & Emergency Medicine
Respiratory Problems in Critical Care
Molecular Medicine
Cancer Therapeutics | Cell Growth & Division | Respiratory Physiology
Oncology
Cancer Therapeutics | Lung Cancer | Oncologic Drugs
Pharmacology & Drug Discovery
Cancer Therapeutics
Physiology
Respiratory Physiology
Respiratory Biology
Respiratory Physiology
Respiratory Disorders
Lung Cancer | Respiratory Physiology | Respiratory Problems in Critical Care

Clinical Trials

Trial registry title:: Comparison of Different Types of Surgery in Treating Patients With Stage IA Non-Small Cell Lung Cancer
Identifier:: NCT00499330
Sponsor:: Alliance for Clinical Trials in Oncology
Phase:: Phase 3
Gender:: All
Min Age:: 18 Years
Max Age:: N/A
Condition:: Lung Cancer
Interventions:: lobectomy, segmentectomy or wedge resection
Countries:: Australia, Canada, United States
Official Title:: A Phase III Randomized Trial of Lobectomy Versus Sublobar Resection for Small (≤ 2 cm) Peripheral Non-Small Cell Lung Cancer