medwireNews: Sub-lobar resection is noninferior to lobectomy with respect to disease-free survival (DFS) and overall survival (OS) in patients with clinical stage T1a N0 non-small-cell lung cancer (NSCLC) and tumors no larger than 2 cm, report the CALGB 140503 investigators.
This study together with the recent JCOG 0802 trial showing the noninferiority of segmentectomy to lobectomy in a comparable patient population establishes sub-lobar resection “as the standard of care for this subset of patients,” said presenter Nasser Altorki (Weill Cornell Medicine – New York-Presbyterian Hospital, USA) at the IASLC World Conference on Lung Cancer 2022.
He explained to the audience in Vienna, Austria, that “lobar resection has been the standard of care for the treatment of stage I lung cancer since 1995,” but “with the newer imaging modalities, better staging, smaller tumors, and definitely lung cancer screening, there has been a resurging interest in sub-lobar resection.”
The phase 3 CALGB 140503 study recruited 697 patients with peripheral, small-sized, cT1a N0 NSCLC without metastases to the major hilar or mediastinal lymph nodes, and randomly assigned them to undergo sub-lobar resection (segmentectomy or wedge resection at the surgeon’s discretion) or lobectomy. In the sub-lobar group, 58.8% had a wedge resection.
Over a median follow-up of 7 years, sub-lobar resection was noninferior to lobar resection with regard to the primary endpoint of DFS. The 5-year DFS rates were a comparable 63.6% and 64.1%, respectively.
Sub-lobar resection was also noninferior to the lobar approach for the secondary endpoint of OS, with respective 5-year rates of 80.3% and 78.9%.
And there were no significant differences between the sub-lobar and lobar resection groups with respect to either lung cancer-related events (recurrences or deaths) or competing deaths.
Altorki and colleagues also evaluated pulmonary function, finding that the percent predicted forced expiratory volume in 1 second (FEV1) worsened in both the sub-lobar and lobar resection study arms at 6 months postsurgery, but to a significantly lesser degree in the sub-lobar group, at a median change from baseline of 4% versus 6%.
The same was true for percent predicted forced vital capacity (FVC), but in this case the between-group difference from baseline did not reach statistical significance, at median decreases of 3% and 5%, respectively.
“Although the absolute difference in the magnitude of reduction in FEV1 and FVC favored the sub-lobar resection arm at 6 months, it may not be clinically meaningful,” cautioned Altorki.
The discussant – Hisashi Saji, from St Marianna University School of Medicine in Kawasaki, Japan, who is also the lead investigator of the JCOG 0802 trial – agreed that “sub-lobar resection must be considered as a standard of care for small-sized peripheral [NSCLC] without lymph node metastasis.”
He speculated that “[s]ublobar resection reserves the possibility of more extensive treatment for upcoming life-threatening diseases such as second primary cancer, respiratory disease, or cerebrovascular disease, etc after curing lung cancer.”
Saji concluded that they hope to conduct a meta-analysis to further dissect the results by subgroups, including type of sub-lobar resection, nodal factors, and histology among others.
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IASLC World Conference on Lung Cancer 2022; Vienna, Austria: 6–9 August