Everett E. Vokes, MD

In terms of disease-free survival, sublobar resection was not inferior to lobectomy for patients with early-stage non-small cell lung cancer (eNSCLC) whose tumors were 2 centimeters or less in size, according to findings published in The New England Journal of Medicine.

“The increased detection of small-sized peripheral NSCLC has renewed interest in sublobar resection in lieu of lobectomy,” Everett E. Vokes, MD, and colleagues wrote.

Dr. Vokes and colleagues performed a multicenter, noninferiority, phase 3 trial that randomly assigned patients with eNSCLC clinically staged as T1aN0 (tumor size, ≤2 cm) to sublobar resection or lobar resection following intraoperative confirmation of node-negative disease. Disease-free survival served as the primary endpoint, which the investigators defined as the time between randomization and disease recurrence or death from any cause. Secondary endpoints included overall survival, locoregional and systemic recurrence, and pulmonary functions.

From June 2007 through March 2017, the researchers randomly assigned 697 patients (median age, 67.9; 57.4% women; 90.0% White) to sublobar resection (N=340) or lobar resection (N=357). Among patients assigned to sublobar resection, 59.1% underwent wedge resection and 37.9% underwent anatomical segmental resection.

Disease-Free, Overall Survival Similar Between Procedures

At a median follow-up of 7 years, sublobar resection was determined to be noninferior to lobar resection for disease-free survival (HR for disease recurrence or death, 1.01; 90% CI, 0.83-1.24). Overall survival following sublobar resection was comparable to that after lobar resection (HR for death, 0.95; 95% CI, 0.72-1.26). The 5-year disease-free survival was 63.6% (95% CI, 57.9-68.8) following sublobar resection and 64.1% (95% CI, 58.5-69.0) following lobar resection. The 5-year overall survival was 80.3% (95% CI, 75.5-84.3) after sublobar resection and 78.9% (95% CI, 74.1-82.9) after lobar resection. Dr. Vokes and colleagues observed no substantial difference between the two groups regarding locoregional or distant recurrence.

“The absolute difference between the two groups was only 2 percentage points for both [forced expiratory volume in 1 second] and [forced vital capacity],” the researchers wrote. “Although this difference is arguably not clinically meaningful in this patient population with normal baseline pulmonary functions, it may be more clinically relevant in patients with compromised pulmonary functions or in those with lower-lobe disease in whom lobar resection may be associated with greater impairment of pulmonary function.”

They also noted that “a single measurement at 6 months” may not be indicative of potential further decreases or improvement in flow rates at 12 or 18 months after surgery.

A total of 101 deaths related to lung cancer were reported, including 46 in the sublobar resection group and 55 in the lobar resection group, as well as 93 deaths from other causes. Cumulatively, deaths from lung cancer and other causes of death were comparable between groups.

“Sublobar resection for patients with clinical [early-stage] disease by either anatomical segmentectomy or wedge resection is an effective management approach for this subgroup of patients with eNSCLC,” Dr. Vokes and colleagues wrote.