Real-world perioperative outcomes of segmentectomy versus lobectomy for early-stage lung cancer: a propensity score-matched analysis

Limited resection is comparable to lobectomy for tumor size ≤ 2 cm pulmonary invasive mucinous adenocarcinoma

OBJECTIVES

Invasive mucinous adenocarcinoma (IMA) has a rare incidence with better prognosis than nonmucinous adenocarcinoma. We aimed to investigate the prognosis between limited resection and lobectomy for patients with clinical stage IA IMA ≤ 2 cm.

METHODS

Data were taken from two cohorts: In Shanghai Pulmonary Hospital (SPH) corhort, we identified 403 patients with clinical stage IA IMA who underwent surgery. In the SEER corhort, 480 patients with stage T1 IMA who after surgery were included. Recurrence-free survival (RFS) for SPH corhort, lung cancer-specific survival (LCSS) for the SEER corhort and overall survival (OS) for both corhort were compared between patients undergoing lobectomy and limited resection by Log-rank and Cox proportional hazard regression model.

RESULTS

In SPH corhort, patients who underwent limited resection had equivalent prognosis than those underwent lobectomy (5-year RFS: 79.3% versus. 82.6%, p = 0.116; 5-year OS: 86.2% versus. 88.3%, p = 0.235). However, patients with IMA > 2 to 3 cm had worse prognosis than those with IMA ≤ 2 cm (5-year RFS: 73.7% versus. 86.1%, p = 0.007). In the analysis of IMA > 2 to 3 cm subgroup, multivariate analysis showed that limited resection was an independent risk factor of RFS (hazard ratio, 2.417; 95% confidence interval, 1.157-5.049; p = 0.019), while OS (p = 0.122) was not significantly different between two groups. For IMA ≤ 2 cm, limited resection was not a risk factor of RFS (p = 0. 953) and OS (p = 0.552). In the SEER corhort, IMA ≤ 2 cm subgroup, limited resection was equivalent prognosis in LCSS (p = 0.703) and OS (p = 0.830).

CONCLUSIONS

Limited resection could be a potential surgical option which comparable to lobectomy in patients with clinical stage IA IMA ≤ 2 cm.

Segmentectomy for patients with early-stage pure-solid non-small cell lung cancer

For decades, lobectomy has been the recommended surgical procedure for non-small cell lung cancer (NSCLC), including for small-sized lesions. However, two recent pivotal clinical trials conducted by the Japanese Clinical Oncology Group/West Japan Oncology Group (JCOG0802/WJOG4607L) and the Cancer and Leukemia Group B (CALGB140503), which compared the survival outcomes between lobectomy and sublobar resection (the JCOG0802/WJOG4607L included only segmentectomy, not wedge resection), demonstrated the efficacy of sublobar resection in patients with early-stage peripheral lung cancer measuring ≤ 2 cm. The JCOG0802/WJOG4607L demonstrated the superiority of segmentectomy over lobectomy with respect to overall survival, implying the survival benefit conferred by preservation of the lung parenchyma. Subsequently, the JCOG1211 also demonstrated the efficacy of segmentectomy, even for NSCLC, measuring up to 3 cm with the predominant ground-glass opacity phenotype. Segmentectomy has become the standard of care for early-stage NSCLC and its indications are expected to be further expanded to include solid lung cancers > 2 cm. However, local control is still a major concern for segmentectomy for higher-grade malignant tumors. Thus, the indications of segmentectomy, especially for patients with radiologically pure-solid NSCLC, remain controversial due to the aggressive nature of the malignancy. In this study, we reviewed previous studies and discussed the efficacy of segmentectomy for patients with such tumors.

Lobectomy versus segmentectomy for stage IA3 (T1cN0M0) non-small cell lung cancer: a meta-analysis and systematic review

Background

Segmentectomy has been proven to have better survival and perioperative efficacy than lobectomy for non-small cell lung cancer (NSCLC) up to 2 cm. Whether this result is applicable to stage T1cN0M0 NSCLC (2.1 to 3 cm) remains controversial.

Methods

We conducted a comprehensive search across seven databases to identify relevant studies comparing lobectomy and segmentectomy procedures. Our primary focus was on survival indicators (overall survival [OS] and disease-free survival [DFS]), while for secondary outcomes, operative outcomes, hospitalization outcomes, recurrences, and complications were considered.

Results

After screening, the final analysis included 10 studies (involving 22113 patients in the lobectomy group and 1627 patients in the segmentectomy group). The lobectomy procedure achieved better OS (hazard ratio [HR]: 1.19 [1.07~1.33]) and DFS (HR: 1.37 [1.10~1.71]), which were proven in all subgroups. The OS rate at 2-5 years and DFS rate at 4-5 years were higher in the lobectomy group. The advantages of OS and DFS in the lobectomy group increased over the survival time. More lymph node dissections, intraoperative blood loss and total complications were found in the lobectomy group. Similar hospital stays, 90-day mortality and conversion thoracotomy were found between the two groups.

Conclusion

Lobectomy appeared to be the better choice for patients with stage T1cN0M0 NSCLC with better survival (OS and DFS). However, the complications needed to be taken seriously.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identification CRD42023445013.

Segmentectomy for cancer control in radiologically pure-solid clinical stage IA3 lung cancer

OBJECTIVES

This study aimed to compare cancer control after segmentectomy and lobectomy in patients with radiologically pure-solid clinical stage IA3 non-small-cell lung cancer (NSCLC).

METHODS

Patients with radiologically pure-solid clinical stage IA3 NSCLC who underwent lobectomy or segmentectomy at 3 institutions between 2010 and 2019 were identified. We estimated propensity scores to adjust for confounding variables regarding tumour malignancy, including age, sex, smoking history, tumour size, maximum standardized uptake value on 18F-fluorodeoxyglucose positron emission tomography, lymph node dissection, histological type and lymphatic, vascular and pleural invasion. Cumulative incidence of recurrence (CIR) was evaluated as a primary end point.

RESULTS

Among 412 patients, postoperative recurrence occurred in 7 of 44 patients (15.9%) undergoing segmentectomy, and 71 of 368 patients (19.3%) undergoing lobectomy. CIR was comparable between patients undergoing segmentectomy (5-year rate, 21.9%) and those undergoing lobectomy (5-year rate, 20.8%; P = 0.88). Locoregional recurrence did not differ between patients undergoing segmentectomy (6.8%) and those undergoing lobectomy (9.0%). In multivariable analysis, segmentectomy (versus lobectomy) was not identified as an independent prognostic factor for CIR (hazard ratio, 1.045; 95% confidence interval, 0.475-2.298; P = 0.91). In propensity score matching of 40 pairs, CIR was not significantly different between patients undergoing segmentectomy (5-year rate, 20.7%) and those undergoing lobectomy (5-year rate, 18.4%; P = 0.81).

CONCLUSIONS

Cancer control may be comparable between segmentectomy and lobectomy in patients with radiologically pure-solid clinical stage IA3 NSCLC. Further studies are warranted to clarify the survival benefits of segmentectomy in these patients.

Sublobar Resection for Non-Small Cell Lung Cancer in Octogenarians: A Prospective, Multicenter Study

BACKGROUND

Segmentectomy is a good surgical option for peripheral, early, non-small cell lung cancer (NSCLC) ≤2 cm. However, the role of sublobar resection including wedge resection and segmentectomy remains unclear for octogenarians with >2-cm but ≤4-cm early-stage NSCLC, for which lobectomy is a standard treatment.

METHODS

By use of a prospective registry, 892 patients aged ≥80 years with operable lung cancer were enrolled at 82 institutions. Of these, we analyzed the clinicopathologic findings and surgical outcomes of 419 patients with NSCLC tumors of 2 to 4 cm during a median follow-up of 50.9 months between April 2015 and December 2016.

RESULTS

Five-year overall survival (OS) was slightly but not significantly worse after sublobar resection than after lobectomy in the entire cohort (54.7% [95% CI, 43.2%-93.0%] vs 66.8% [95% CI, 60.8%-72.1%]; P = .09). Multivariable Cox regression analysis of OS revealed that these surgical procedures were not independent prognostic predictors (hazard ratio, 0.8 [0.5-1.1]; P = .16). The 5-year OS was comparable between 192 patients who could tolerate lobectomy but were treated by sublobar resection or lobectomy (67.5% [95% CI, 48.8%-80.6%] vs 71.5% [95% CI, 62.9%-78.4%]; P = .79). Recurrence after sublobar resection and lobectomy was locoregional in 11 (11%) of 97 and in 23 (7%) of 322 patients, respectively.

CONCLUSIONS

OS might be equivalent between sublobar resection with a secure surgical margin and lobectomy for selected patients aged ≥80 years with peripheral early-stage NSCLC tumors of 2 to 4 cm who can tolerate lobectomy.