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

Abstract

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.

Lung cancer with air lucency: a systematic review and clinical management guide

“…Reasonable speculation is that data from the recent Japan Clinical Oncology Group study (JCOG0802) (49) (a randomized controlled trial of segmentectomy vs. lobectomy for ≤2 cm tumors that are partially GG up to completely consolidated) may apply to a LCAL with a small solid component; The JCOG0802 study reported similar overall survival (OS) and recurrence-free survival (RFS) for lobectomy and segmentectomy. This is balanced against the general data for solid cI NSCLC that suggests survival is incrementally worse after lobectomy vs. segmentectomy vs. wedge vs. ablation (50,51). The high frequency of additional lung cancers suggests a need to balance management of the LCAL at hand with the ability to address future cancers.…”

“…We propose that segmentectomy may be best (if anatomically suitable) if intervention is undertaken at the first appearance of a solid component (based on infrequent node involvement and a propensity for additional lesions). We propose a pathologic margin of >1 cm be sought (extrapolating from traditional lung cancers) (50). For LCAL with more substantial solid components, we suggest a lobectomy is best (based on the high rate of node involvement and poor survival) (5,8).…”

The more we learn, the more there is to know: the clinical management of stage I non-small cell lung cancer

“…They undertook this opus to create a practical guide for choosing the appropriate treatment strategy for individual patients based not only on the long-term and short-term outcomes, but also on the patient reported outcomes specific to each treatment strategy. This guide (1)(2)(3)(4) promotes a strategy that optimizes patient outcomes as well as patient satisfaction. In this way, we can select treatments that are both guideline concordant and goal concordant for each patient.…”

Resect a little, resect more, irradiate or ablate—what is the best approach?

“…Detterbeck et al have presented a comprehensive 4-part analysis and review of the literature supporting the various operative approaches (lobectomy, segmentectomy, wedge resection) and non-operative approaches for stage I nonsmall cell lung cancer (NSCLC) (1)(2)(3)(4). The literature search was focused over the last 21 years.…”