indications for sublobar resection for localized nsclc
TRANSCRIPT
Indications for sublobar resection for localized NSCLC
David H Harpole Jr, MD Professor of Surgery
Associate Professor in Pathology Vice Chief, Division of Surgical Services
Duke University School of Medicine Durham, North Carolina
• 82 year old male with 75 pack year Hx • 2.2 cm right basilar segment lower lobe mass • PET SUVmax 5.0 No Mets • COPD: FEV1 45%, DLCO 60% • Can ambulate up 1 flight of stairs•
Indications for sublobar resection for localized NSCLC
David H Harpole Jr, MD Professor of Surgery
Associate Professor in Pathology Vice Chief, Division of Surgical Services
Duke University School of Medicine Durham, North Carolina
Who Gets Wedge Resection?
• Not Defined in 2016 • Usually Patients at high-risk for lobectomy
– 15-20% Local recurrence with sub-lobar resection
• ACOSOG trial Z04032: Randomized Phase III – VATS Wedge + / - Intraop Brachytherapy
• Tufts / Pitts data suggest lower recurrence rate – Not a candidate for lobectomy – Two of following: FEV1< 40%, DLCO<40%, Age > 75, CHF, Pulmonary hypertension, Home O2
Small T1 Lung Cancers (≤ 1cm)
• Mayo clinic retrospective n=100; 1980-1999 – 3-10 mm diameter, majority adenocarcinoma – Lobectomy + MLND (90%) – 93 T1N0, 5 T1N1, 2 T1N2
• Japanese also observed 10% N1 or N2
– 85% 5-year cancer-specific survival – 64% overall survival – Recommend lobectomy as operation
Miller et al., Ann Thorac Surg, 2001
CALGB 140503 Solitary Pulmonary
Nodule <2.0 cm by CT
Randomize; n=900
Verify NSCLC
All N1 + N2 (-)
Lobectomy N=450 Limited Resection
N=450 Accrual 600/900
Anatomic Segmentectomy • Initially described by Churchill and Belsey (1939) • Interest has been increasing as an option for:
– Very small tumors (<2.0cm) – A superior oncologic therapy for those with margin
pulmonary reserve (better than non-anatomic wedge) – Most commonly performed include:
• Superior segment lower lobe • Basilar segments of lower lobe • Lingual-sparing left upper lobe bi-segment • Lingular bi-segment • Others can also be completed.
Segmentectomy for Small Tumors Fukuoko Japan 2001-2004 (n=34) • Phase II protocol for primary therapy for stage 1A (<2.0 cm)
NSCLC • Outcomes simlar to historical lobectomies in same institution
Shiraishi et al., Surg Endosc 2004
Akashi City, Japan 1985-2002 (n=1272) • Long-term outcomes for pulmonary resections
Tumor Size Lobectomy Segmentectomy p-value < 2.0 cm 92% (159) 97% (129) NS 2.0 to 3.0 cm 87% (268) 85% (161) NS 3.0 cm 81% (497) 63% (53) p=0.01
Okada et al. J Thorac Cardiovasc Surg 2004
To assess outcomes of patients who underwent wedge resection or segmentectomy for stage T1a N0 NSCLC National Cancer Database
Hypothesis: Segmentectomy is associated with improved long-term survival when compared to wedge resection
Objective
In an analysis of a population-based data set, a large proportion of patients was found to have received wedge resection for cT1a N0 NSCLC Segmentectomy for T1a N0 NSCLC had improved long-term survival when compared to wedge resection, even for patients with very small tumors ≤ 1 cm and for patients with no comorbidities No significant differences in 30-day mortality between wedge and segmentectomy
Segmentectomy should be the preferred sublobar resection for cT1a N0 NSCLC
Conclusion