Surgery for Advanced-Stage Non-Small Cell Lung Cancer: Lobectomy or Sub-Lobar Resection?

Zhexue Hao; Hengrui Liang; Yichi Zhang; Wei Wei; Yuting Lan; Shuxian Qiu; Guo Lin; Runchen Wang; Yulin Liu; Yingying Chen; Jun Huang; Wei Wang; Fei Cui; Taichiro Goto; Jin Yong Jeong; Giulia Veronesi; Alberto Lopez-Pastorini; Hitoshi Igai; Wenhua Liang; Jianxing He; Jun Liu

Disclosures

Transl Lung Cancer Res. 2021;10(3):1408-1423. 

In This Article

Abstract and Introduction

Abstract

Background: Metastatic non-small cell lung cancer (NSCLC) has many comorbidities, such as chronic obstructive pulmonary disease, coronary heart disease, and older age-related comorbidities. A survival benefit was observed in such patients who underwent surgery for selected oligometastatic disease. However, to the best of our knowledge, there is no evidence to support whether lobectomy (compared with sub-lobar resection) would further prolong these patients' lives.

Methods: Patients with metastatic NSCLC who underwent primary tumor resection were identified from the Surveillance, Epidemiology, and End Results (SEER) database and then divided into lobectomy and sub-lobar resection groups. Propensity score matching (PSM, 1:1) was performed to match the baseline characteristics of the two groups. Cancer-specific survival (CSS) was estimated.

Results: In total, 24,268 patients with metastatic NSCLC were identified; 4,114 (16.95%) underwent primary tumor surgery, and of these, 2,045 (49.71%) underwent lobectomy and 1,766 (42.93%) underwent sub-lobar resection. After PSM, 644 patients in each group were included. Lobectomy was independently correlated with longer median CSS time [hazards ratio (HR): 0.70, 95% confidence interval (CI): 0.61–0.80, P<0.001]. The 1, 2, and 3-year survival rates after PSM also favored the lobectomy group. However, no significant survival difference was found for wedge resection and segmentectomy (HR: 0.96, 95% CI: 0.70–1.31, P=0.490). The 1-, 2-, and 3-year survival rates after PSM also exhibited no difference within the sub-lobar group. We explored whether lymph node dissection would provide additional survival benefits for stage IV NSCLC patients. According to the multivariate Cox analysis of the matched population, lymph node dissection was independently associated with better CSS (HR: 0.76, 95% CI: 0.66–0.88, P<0.001) and overall survival (OS) (HR: 0.74, 95% CI: 0.65–0.86, P<0.001). We confirmed this result in the different types of surgery and found that the lymph node dissection group consistently had better survival outcomes both in the lobectomy group and sub-lobar resection population. According to the subgroup analysis, with the exception of stage T4 and brain metastatic patients, all of the patient subtypes exhibited greater benefit from lobectomy than sub-lobar resection.

Conclusions: Lobectomy has a greater survival benefit in metastatic NSCLC patients compared with sub-lobar resection when radical treatment of primary site was indicated.

Introduction

Lung cancer is one of the leading causes of cancer death worldwide.[1] Approximately 85% of patients with lung cancer have non-small cell lung cancer (NSCLC).[2] The 5-year survival rate of these patients has been reported to be 12–15%, and approximately 60% are diagnosed with stage IV disease on first diagnosis.[3] Patients with NSCLC usually have comorbidities as well, such as chronic obstructive pulmonary disease, coronary heart disease, and/or age-related comorbidities.[4] Compared with early-stage NSCLC, indication to surgery for advanced-stage NSCLC requires accurate selection of candidates.

The recommended treatment for stage IV NSCLC is usually systemic therapy (i.e., chemotherapy, molecular targeted therapy, or immune therapy).[5] Traditionally, the stage IV treatment strategy for NSCLC does not include curative-intent local therapy (surgery or radiation), and the therapeutic goals are focused on disease control, palliation, and optimization of the quality of life. However, several recent clinical studies have shown that local consolidative therapy may be beneficial for certain stage IV NSCLC patients can and improve overall survival (OS).[6,7] Gomez et al. conducted a phase II clinical trial that considered the effects of local consolidative therapy in oligometastatic disease.[8] The updated long-term outcomes indicated that patients receiving local consolidative therapy had better progression-free survival (PFS) (14.2 vs. 4.4 months, P=0.022) and OS (41.2 vs. 17 months; P=0.017).

Lobectomy and systematic lymph node dissection are the gold standard treatment modalities for early-stage NSCLC. Recently published studies have indicated that primary tumor resection (would also be) is beneficial for stage IV NSCLC patients after systemic treatment in presence of a single or few synchronous metastatic sites and improves their OS.[9–11] However, to the best of our knowledge, no study has explored which surgery type (lobectomy or sub-lobar resection) provides the greater survival benefit in these patients.

To address this unresolved issue, we performed a population-based study to determine whether lobectomy or sub-lobar resection would have the greater benefit in stage IV NSCLC patients. We present the following article in accordance with the STROBE reporting checklist (available at http://dx.doi.org/10.21037/tlcr-21-39).

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