Patients with stage I non–small cell lung cancer who underwent anatomic segmentectomy had similar outcomes to those who underwent lobectomy in a large propensity-matched trial comparing the two approaches, which was reported online June 30 in the Journal of Clinical Oncology.
Long-term survival and recurrence rates, as well as perioperative morbidity and mortality, were not significantly different between the two groups of patients, even though lobectomy is considered the gold standard of treatment for early-stage non–small cell lung cancer (NSCLC), said Dr. Rodney J. Landreneau of the department of cardiothoracic surgery, University of Pittsburgh Medical Center, and his associates.
If the results of this retrospective single-center study are validated in future prospective, multicenter, randomized controlled trials, "anatomic segmentectomy should be considered as a valid alternative to lobectomy in properly selected patients," the investigators noted.
Interest in using the less radical segmentectomy approach is being driven by earlier detection of smaller lesions using computed tomography imaging, a new understanding of lesion pathology, and the fact that the randomized controlled trial that established lobectomy as the gold standard occurred more than 20 years ago, said Dr. Hisao Asamura, in his editorial commentary on the study.
The investigators identified 392 patients in their center’s lung cancer database who had anatomic segmentectomy and 800 who had lobectomy, then performed propensity matching to account for the confounding effects of patient age, sex, smoking status, and forced expiratory volume in 1 second (FEV1) level; tumor size; and patient history of hypertension, chronic obstructive pulmonary disease, diabetes, gastroesophageal reflux, coronary artery disease, and other types of cancer. They then assessed outcomes in 624 propensity-matched patients: 312 who had segmentectomies (cases) and 312 who had lobectomies (controls).
Approximately 93% of the study cohort were current or former smokers. The mean patient age was 68.5 years at baseline. The mean tumor size was 2.2 cm. The participants were followed for a median of 5.4 years.
Overall survival was 54% for cases and 60% for controls, a nonsignificant difference. Both locoregional recurrence rates (5.5% and 5.1%, respectively) and distant recurrence rates (14.8% and 11.6%) also showed no significant difference by treatment type. Perioperative morbidity (1.2% and 2.5%) and mortality (2.6% and 4.8%) slightly favored anatomic segmentectomy, but not significantly so, Dr. Landreneau and his associates reported (J. Clin. Oncol. 2014 June 30 [doi:10.1200/JCO.2013.50.8762]).
Further analyses demonstrated that anatomic segmentectomy was not a predictor of recurrence or of survival.
Surgeons excised a greater number of lymph nodes with lobectomy (median, 12 nodes) than with anatomic segmentectomy (median, 6 nodes). However, the number of lymph node stations assessed was the same in both groups (a median of three in each), and the proportion of cancers that required upstaging at surgery was not significantly different between cases (29.5%) and controls (36.5%).
Multicenter prospective randomized trials comparing the two approaches are needed to confirm these findings. Two such trials are currently underway, the researchers said.
This study was supported in part by the National Heart, Lung, and Blood Institute; the Thoracic Surgery Foundation for Research and Education; and the National Cancer Institute. Dr. Landreneau reported no potential financial conflicts of interest; two of his associates reported ties to Varian and Accuray.