Doing More With Less in Lung Cancer Surgery

Patients with stage 1A non-small cell lung cancer (NSCLC) who undergo surgery to remove a small portion of their lung have outcomes comparable to patients who have surgery removing an entire lobe, according to recent study results.

Although the findings published in the New England Journal of Medicine showed that patients with stage 1A NSCLC can benefit from having less lung tissue removed, one of the study’s researchers explained that patient selection is critical before making this decision.

“In a group of patients where the cancer is less than 1 inch ... and is near the edge of the lung, you can go in and biopsy the lymph nodes to make sure that the lymph nodes are clean,” Dr. Nasser Khaled Altorki, chief of thoracic surgery at Weill Cornell Medicine and NewYork-Presbyterian Hospital, said in an interview with CURE. “If the lymph nodes are clean of cancer, then it’s OK to take a section of the lobe, not the whole (lobe). ... So you biopsy the lymph nodes first and make sure that these are small tumors and near the edge of the lung.”

Researchers sought to determine whether outcomes would differ if patients with stage 1A NSCLC underwent a wedge resection (a procedure to remove a tumor with a margin of tissue around it) versus having a lobectomy (removing a whole section of the lung).

“Make believe that you’re in an apartment, which is the lobe, and the apartment has rooms,” Altorki explained. “Each room is a segment, or you can take a part of the room, which is a wedge. So either one of those is acceptable and results in similar survival or freedom from cancer recur- rence as taking the whole lobe.”

In this phase 3 trial, researchers analyzed data from 697 patients with stage 1A NSCLC, meaning that their tumor was no bigger than 2 centimeters. Patients were randomly assigned to undergo sublobar resection (340 patients) or lobar resection (357 patients) after it was confirmed that their disease had not spread to nearby lymph nodes.

Researchers focused on several outcomes, including disease-free survival (time between being randomly assigned and either disease recurrence or all-cause death), overall survival (the length of time a patient with cancer remains alive), lung function and disease recurrence. Patients were followed for a median of seven years.

After five years, patients who underwent surgery to remove part of their lung had similar rates of disease-free survival (63.6% versus 64.1%, respectively) and overall survival (80.3% versus 78.9%) compared with those who underwent surgery to remove a whole section of the lung.

Researchers also did not notice any significant differences between the two groups regarding the incidence of locoregional recurrence (recurrence of cancer in the same area as the original tumor or in nearby lymph nodes) or distant recurrence (cancer that has returned in another part of the body far away from its original site).

At six months, patients who under- went surgery to remove part of their lung had improved predicted forced expiratory volume in one second (the volume of air that a patient exhales during a forced breath during a certain period of time) compared with those who had an entire lung removed, although the difference between both groups was just 2 percentage points.

Altorki explained that the area of surgical treatment for stage 1A NSCLC has improved drastically over the past 15 to 20 years. Approximately 80% of
the procedures to remove a lobe of the lung or less than a lobe now are done minimally invasively, which he called “an amazing change in how we practice.”

He also said that the mortality risk from surgery or during hospitalization is an estimated 1% when the entire lobe is removed and approximately 0.5% for the removal of less than a lobe.

“It’s slightly lower, it’s not significantly lower, but it’s important,” Altorki said. “If you can halve the death rate, that would be great.”

Because the findings from this study confirmed success in removing less than a lobe of the lung in appropriately selected patients with stage 1A NSCLC, Altorki said that the implementation of this surgical tactic may be an easy transition in the operating room.

Altorki said, “I think people were already thinking (that removing less of the lobe would result in similar outcomes) before the trial, and the trial sort of gave them the ‘Yes, you’re right, you could do that. It’s OK.’ And it is good for patients. If there’s any winner in this, it is the patient who won, because you don’t want any more of your body (removed than you) need to.”

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