Is limited pulmonary resection equivalent to lobectomy for surgical management of stage I non-small-cell lung cancer?

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: is limited pulmonary resection equivalent to lobectomy in terms of morbidity, long-term survival and locoregional recurrence in patients with stage I non-small-cell lung cancer (NSCLC)? A total of 166 papers were found using the reported search; of which, 16 papers, including one meta-analysis and one randomized control trial (RCT), represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. With regards to 5-year survival rates, the evidence is conflicting: a 2005 meta-analysis and six other retrospective or prospective nonrandomized analyses did not find any statistically significant difference when comparing lobectomy with limited resection. However, three studies found evidence of a decreased overall survival with limited resection, including the only randomized control trial, which showed a 50% increase in the cancer-related death rate (P = 0.09), and a 30% increase in the overall death rate in patients undergoing limited resection (P = 0.08). Age, tumour size and specific type of limited resection were also factors influencing the survival rates. Four studies, including the RCT, found increased locoregional recurrence rates with limited resection. There is also evidence that wedge resections, compared with segmentectomies, lead to lower survival and higher recurrence rates. In conclusion, lobectomy is still recommended for younger patients with adequate cardiopulmonary function. Although limited resection carries a decreased rate of complications and shorter hospital stays, it may also carry a higher rate of loco-regional recurrences. However, limited resection may be comparable for patients >71 years of age, and those with small peripheral tumours.

MDT lung cancer care: Input from the Surgical Oncologist

“…More recent data also suggest that sublobar resections are associated with better preservation of lung function and lower morbidity, especially in elderly patients. 15,16 Local recurrence rates with segmentectomy in the modern era have generally been approximately 5% and thus not dissimilar from the local recurrence rate reported for the lobectomy group in the Lung Cancer Study Group RCT. 17 Given that oncologic superiority was largely supported by the significantly lower local recurrence rates, this observation lends further support to re-examining whether lobectomy is truly superior to sublobar resections.…”

“…Several studies have shown that lower disease-specific and disease-free survival in sublobar resection groups are likely driven by the significantly worse outcomes with wedge resection. 16,[27][28][29] When subcategorized, outcomes have shown that segmentectomy and lobectomy do not have significantly different diseasespecific and disease-free survival but appear to be significantly higher in both when compared with wedge resection. 16,[27][28][29] Part of the oncologic superiority associated with segmentectomy and lobectomy as compared with wedge resection may be due to inadequate lymph node sampling in wedge resection groups.…”

“…16,[27][28][29] When subcategorized, outcomes have shown that segmentectomy and lobectomy do not have significantly different diseasespecific and disease-free survival but appear to be significantly higher in both when compared with wedge resection. 16,[27][28][29] Part of the oncologic superiority associated with segmentectomy and lobectomy as compared with wedge resection may be due to inadequate lymph node sampling in wedge resection groups. Studies demonstrating superior disease-free and OS for lobectomy on unadjusted analyses have also shown that there appears to be no significant difference between lobectomy and sublobar resection if one controls for adequacy of lymph node sampling.…”

The lobar vs. sublobar “limited” resection respiratory function preservation debate: learning to speak the same language

“…That study was, however, criticized due to inconsistencies regarding the collection of data; several non-anatomical resections (wedges) were included in the "limited" resection group, which may have altered the overall outcome of the study. More importantly, the aforementioned study unfortunately shed light on the discrepancies and the multitude of variables among data investigated and reported in different studies (7,(9)(10)(11)(12).…”

“…These two types of resections are distinctly different, both in technical and oncological features (7,10). Additionally, the amount of parenchyma removed per case may vary.…”