Long-term outcomes of stage I NSCLC (≤3 cm) patients following segmentectomy are equivalent to lobectomy under analogous extent of lymph node removal: a PSM based analysis

Abstract

Background: Segmentectomy has the advantage of less complications, but might have less lymph node sampling and higher risk of recurrence. We aimed to compare treatment outcome between two surgical options, and explore the effect of regional lymph node removal on the prognostic difference. Methods:We retrospectively analyzed data of stage I non-small cell lung cancer (NSCLC) (≤3 cm in size) patients who underwent either segmentectomy, or lobectomy, collected from the Surveillance, Epidemiology and End Results (SEER) database, from 2003 to 2013. The primary endpoints were overall survival (OS) and lung cancer-specific survival (LCSS). We also collected data from Shandong Provincial Hospital as validation.Results: Ultimately 1,156 patients treated by segmentectomy and 17,748 patients treated by lobectomy from SEER database were included in the analysis. Overall, segmentectomy was inferior to lobectomy in terms of OS [hazard ratio (HR): 1.316 (1.186-1.461), P<0.001] and LCSS [HR: 1.310 (1.142-1.504), P<0.001]. When the removal of regional lymph nodes (LN) was taken into consideration, no significant difference was found in OS and LCSS, in any Scope of Regional Lymph Node Surgery layer (0, 1-3, more than 3, and biopsy/sentinel layer, all P>0.05). After propensity score matching (PSM), there was no difference between segmentectomy and lobectomy in OS [HR: 1.081 (0.937-1.248), P=0.286] and LCSS [HR: 1.039 (0.861-1.253), P=0.692]. Only sex, age, histology, summary stage, differentiation, tumor size, and radiation still remained as independent prognostic factors for both OS and LCSS. For validation part, there was no significantly prognostic difference between lobectomy and sublobectomy group in overall (P=0.132) and each regional LN removed layer (0, 1-3, more than 3 layers: all P>0.05).Conclusions: Segmentectomy with proper lymph node resection or sampling could be a good alternative to lobectomy. IntroductionLung cancer is the leading cause of cancer-related death (26.5% of all) and has the second highest annual incidence in both males and females (13.3% for each), in the United States (1). More than half of lung cancer patients (57%) have distant metastasis at diagnosis, and overall 5-year relative survival rate is as low as 18% (1). Lung cancer can be divided into small cell lung cancer (SCLC, less than 20%) and non-small cell lung cancer (NSCLC, more than 80%), with entirely different treatment strategies and prognosis (2). Treatment strategies mainly include surgery, chemotherapy, radiotherapy, targeted therapy, and immunotherapy (2). Therein, approximately 69% of NSCLC patients with stages I and II are treated by surgery, compared to only 9% of patients with stages III and IV (2). Surgery is considered the best treatment option for early stage lung cancer, and anatomical lobectomy with N1 and at least three N2 stations sampling or dissection has become the standard surgery for early NSCLC patients (3). Minimally invasive video-assisted thoracoscopic lobectomy is also preferred for stage I NSCLC patients (4...

Prevalence of Occult Peribronchial N1 Nodal Metastasis in Peripheral Clinical N0 Small (≤2 cm) Non-Small Cell Lung Cancer

“…[25][26][27] Troublingly, several studies have also reported that a considerable proportion of patients with early-stage disease are simply not adequately evaluated for nodal disease (so-called Nx patients), likely underrepresenting the true incidence of N1 disease. 17,25,[28][29][30][31] In their analysis of data from the National Cancer Database, Khullar and Data are presented as n (%), as median (interquartile range), or as indicated.…”

Short‐term local control after VATS segmentectomy and lobectomy for solid NSCLC of less than 2 cm

“…For all the above‐mentioned reasons, the data reported by these authors should be carefully interpreted. Nonetheless, these results are corroborated by an older meta‐analysis 17,18 and by the SEER database 19 where lobectomy was found to be superior to segmentectomy for stage IA lesions, but not for stage IA <2 cm after propensity score matching.…”

Survival Outcomes of Lobectomy in Comparison With Segmentectomy in Clinical Stage I Non-small-cell Lung Cancer: a Meta-analysis

“…Based on the criteria described in the methods, 11 publications were assessed for more detail, but some did not provide enough detail of outcomes of two approaches. Finally, a total of 7 trials (2,4,(15)(16)(17)(18)(19) evaluate the survival outcome of comparing lobectomy with segmentectomy. The search process is described in Fig.…”

“…Surgery should not only perform with complete resection, but also achieve a good quality of life. The surgical therapy for patients may not be universal, as evidence suggests that elderly patients with early-stage NSCLC or patients with intolerance to lobectomy due to poor cardio-pulmonary reserve and multiple comorbidities may favor segmentectomy (19).…”