The implementation of sublobar resection in treating early-stage non-small cell lung cancer (NSCLC) showed “comparable oncologic outcomes and complication rates” compared to lobectomy across a variety of clinical trials, according to a systematic review of the surgical technique.
Robert E. Merritt, MD, of The Ohio State University Wexner Medical Center in Columbus, Ohio, and a team of colleagues conducted the review, which was published in Seminars in Thoracic and Cardiovascular Surgery.
The review aimed to summarize sublobar resection as a surgical technique, as well as highlight the “importance of surgical margins, and lymph node sampling, patient selection, perioperative complications, outcomes, and impact of sublobar resection on the quality of life.”
The team reviewed the results of previous randomized clinical trials on sublobar resection to inform the analysis, including ACOSOG Z4032, CALGB/Alliance 140503, and JCOG 0802.
ACOSOG evaluated high-risk patients with stage I NSCLC who either received sublobar resection alone or sublobar resection with brachytherapy. CALGB/Alliance found that disease-free survival post-sublobar resection was “non-inferior to lobectomy” in patients with peripheral tumors less than 2 cm.
Lastly, JCOG compared segmentectomy versus lobectomy and found that segmentectomy correlated with improved overall survival (OS) “despite a higher local recurrence rate.”
The researchers explained that it was important to review and compare the findings of these studies because “there is limited data on short-term and long-term outcomes after sublobar resection for stage I NSCLC in high-risk patients,” despite the procedure typically being administered for “high-risk patients with compromised lung function.”
Furthermore, the use of sublobar resection is becoming increasingly widespread for patients who are considered “normal risk” and have peripheral lung tumors smaller than 2 cm.
Dr. Merritt and colleagues noted that the procedure is typically performed using minimally invasive techniques, which are known to provide reduced postoperative pain, less pulmonary complications, and shorter hospital stays for patients. They also highlighted some of the factors critical for positive patient outcomes in sublobar resection, including achieving “adequate” surgical margins and lymph node evaluation.
The team explained that adequate surgical margins are imperative to “oncologic efficacy” in sublobar resection, underscoring the results of previous studies, which showed that 1.5 to 2.0 cm margins “led to the best outcomes with no improvement for margins larger than 1.5 cm (P=.033).”
In the context of lymph node sampling and evaluation, compared with lobectomy, previous studies have shown that sublobar resection led to “no significant differences in local recurrence, overall survival, or recurrence-free survival.”
Postoperative complications and their impact on patient quality of life was another part of the review heavily analyzed by the research team. According to previous retrospective studies, the rate of postoperative complications for sublobar resection is 11.5% to 32.4%. The ACOSOG trial reflected these results, showing that grade 3 adverse events occurred at a rate of 25.4% to 30.6%, and grade 3 respiratory adverse events occurred at a rate of 19.3% to 25%.
Additionally, sublobar resection does demonstrate some contraindications compared to lobectomy, which include “severely compromised cardiopulmonary function, poor performance status, and tumor features that compromise the oncologic efficacy” of the procedure. The size of a patient’s tumor and its location can also affect whether or not sublobar resection can be performed with the necessary adequate surgical margins.
In conclusion, when specific criteria are met, such as patients having lung tumors measuring 2 cm or less, when physicians are able to obtain adequate margins, and proper lymph node sampling and evaluation is performed, the procedure is a viable option for both high- and normal-risk patients with early-stage NSCLC. This procedure preserves lung parenchyma for patients, even among individuals with compromised lung function.
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