Interact CardioVasc Thorac Surg 2009;8:364-372. doi:10.1510/icvts.2008.178947
© 2009 European Association of Cardio-Thoracic Surgery
Best evidence topic - Thoracic general |
Does lobectomy achieve better survival and recurrence rates than limited pulmonary resection for T1N0M0 non-small cell lung cancer patients?
Themistokles Chamogeorgakis*,
Costas Ieromonachos,
Emmanouil Georgiannakis and
Dimitrios Mallios
Department of Cardiothoracic Surgery, Attikon Hospital, University of Athens, Rimini 1, Haidari, Greece
Received 29 February 2008;
received in revised form 10 June 2008;
accepted 19 June 2008
*Corresponding author. Tel.: +30 2105832150; fax: +30 2105326416.
E-mail address: thchamogeorgakis{at}yahoo.com (T. Chamogeorgakis).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: ‘Does lobectomy achieve better survival and recurrence rates than limited pulmonary resection for T1N0M0 non-small cell lung cancer patients?’ Altogether 225 papers were found using the reported search, of which nineteen 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. A meta-analysis published in 2005 showed a 0.7% (P=0.3659) survival difference at one year, 1.9% (P=0.5088) at three years and 3.6% (P=0.3603) at five years. The largest study prior to the meta-analysis was a randomized controlled study of 247 patients with T1N0 tumors that showed eight locoregional recurrences in the lobectomy group compared to 21 in the sublobar group, which was statistically significant. Since the meta-analysis we identified three studies, two of which showed no difference in survival and recurrence between wedge resection and lobectomy for T1N0 tumors and one that showed improved survival after lobectomy compared to wedge resection for T1N0 tumors. We conclude that wedge resection is not comparable to lobectomy for stage IA NSCLC. The increased long-term mortality associated with wedge resection is mainly due to non-cancer deaths, reflecting a higher risk patient group with many comorbid conditions. Segmental resection is comparable to lobectomy for small peripheral tumors. Sublobar resection is associated with shorter hospital stay. For bronchioalveolar carcinoma sublobar resection is recommended provided intra-operative pathologic consultation confirms pure bronchioalveolar histology without evidence of invasion, and surgical margins are free of disease.
Key Words: Non-small cell lung cancer; Limited resection; Sublobar resection; Segmentectomy; Wedge resection; Lobectomy; Recurrence
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
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2. Three-part question
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In [patients with stage I non-small cell lung cancer] is [lobectomy or sublobar resection] the best treatment in terms of [disease free survival].
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3. Clinical scenario
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A 52-year-old patient, smoker, comes to your office with a biopsy-proven 2.5 cm squamous cell lung carcinoma located at the posterior segment of the right upper lobe. His metastatic work up is negative. He asks you if a sublobar resection and lobectomy have equal long-term results. His pulmonologist told him that the surgical options are lobectomy, segmentectomy and wedge pulmonary resection.
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4. Search strategy
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Medline 1950 to May 2008 using OVID interface (Limited resection.mp OR sublobar.mp OR wedge resection.mp OR limited pulmonary resection.mp OR limited lung resection.mp OR conservative resection.mp OR conservative pulmonary resection.mp OR wedge excision.mp OR segmentectomy.mp) AND (Carcinoma, Non-Small-Cell Lung/or non-small cell lung cancer.mp).
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5. Search outcome
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Two hundred and twenty-five papers were found using the reported search. From these, 19 papers were identified that provided the best evidence to answer the question. These are presented in Table 1.
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6. Results
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Nakamura et al. performed a meta-analysis in this area in 2005 [2]. They identified 14 studies (12 retrospective, 1 randomized controlled trial, and 1 matched paired analysis) of lobectomy vs. sublobar resection totaling 2790 patients. The difference in survival rate was 0.7% (P=0.3659) at one year, 1.9% (P=0.5088) at three years, and 3.6% (P=0.3603) at five years. They conclude that there is no difference in survival. There was significant heterogeneity in their results at three years (Q=27, P=0.0026) and five years (Q=33.6, P=0.0004) which does weaken their findings. In particular, because the studies were conducted over a large time span (1980–2004), the reason for limited resection differed from study to study (the most frequent reason was poor cardiopulmonary function). In addition, the percentage of non-squamous carcinoma ranged from 39.7% [3] to 90.5% [4] and the percentage of male patients ranged from 50.6% [4] to 100% [3].
Ginsberg performed a randomized controlled study of lobectomy vs. limited resection of 247 patients with clinical T1N0M0 NSCLC [5]. Limited resection was associated with a 30% increase in overall death rate (P=0.088) and a 50% increase in cancer related death rate (P=0.094). There were 21 patients with loco-regional recurrence in the limited resection group and eight patients with loco-regional recurrence in the lobectomy group (P=0.008). The follow-up period of 4.5 years was probably sufficient for recurrence detection and not for survival assessment; this may be the reason why locoregional recurrence reached statistical significance and survival did not. There was no difference in operative morbidity and mortality, except that six patients in the lobectomy group required prolonged ventilation. The change from baseline pulmonary function was not statistically significant at 12 and 18 months postoperatively.
Several other observational studies were published after the meta-analysis comparing limited resection and lobectomy for stage IA NSCLC. El-Sherif et al. [6] in their retrospective analysis showed that the 7-year disease-free survival was equal between lobectomy and sublobar resection for stage Ia NSCLC (P=0.308). In the same study, if all stage I NSCLC tumors were included in the analysis, recurrence rate was comparable between the two groups; the lobectomy group had, however, a survival advantage over the sublobar (54% vs. 40%, P=0.0038). Okada et al. [7] performed a prospective non-randomized study of lobectomy vs. sublobar resection of 567 patients with tumors <2 cm. The recurrence rate, 60-month disease-free survival and overall survival were comparable between the two groups. Finally, Fibla et al. [8] in a relatively small retrospective study of 78 patients published in the Spanish literature showed similar results with regards to recurrence and overall survival for the two surgical treatment options (lobectomy vs. sublobar resection) in stage I NSCLC.
For the specific histology of bronchioalveolar carcinoma sublobar resection is recommended, provided that the CT-scan shows a pure ground-glass appearance, intra-operative pathologic consultation confirms pure bronchioalveolar histology without evidence of invasion, and surgical margins are free of disease [9].
Other retrospective reports have shown superior survival and decreased recurrence rate with lobectomy. Kraev et al. [10] demonstrated a 20% 10-year survival advantage for patients with tumors <3 cm who underwent lobectomy compared to wedge resection (P=0.008). The increased long-term mortality associated with sublobar resections is mainly due to non-cancer deaths, reflecting a higher risk patient group with many comorbid conditions [11]. With regards to short-term outcomes it appears that sublobar resection is associated with shorter hospital stay compared to lobectomy [11].
Late pulmonary function data are conflicting: Ginsberg did not show any superiority with sublobar resection [5]; Keenan, however, showed preservation of pulmonary function with smaller pulmonary operations [12].
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7. Clinical bottom line
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We identified 19 papers and in particular a meta-analysis of 2005 summarizing 14 of these studies. The meta-analysis showed a 0.7% (P=0.3659) survival difference at one year, 1.9% (P=0.5088) at three years and 3.6% (P=0.3603) at five years. The largest study prior to the meta-analysis was a randomized controlled study of 247 patients with T1N0 tumors that showed eight loco-regional recurrences in the lobectomy group compared to 21 in the sublobar group which was statistically significant. Since the meta-analysis we identified three studies, two of which showed no difference in survival and recurrence between wedge resection and lobectomy for T1N0 tumors and one that showed improved survival after lobectomy compared to wedge resection for T1N0 tumors. In addition, we identified one more study in the Spanish literature that was not included in the meta-analysis that showed no difference in survival between lobectomy and wedge resection for stage I NSCLC. We conclude that wedge resection is not comparable to lobectomy for stage IA NSCLC. Segmental resection is comparable to lobectomy for small peripheral tumors.
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References
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Abstract
1. Introduction