Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2022 Jun;14(6):2357-2386.
doi: 10.21037/jtd-21-1824.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 2: systematic review of evidence regarding resection extent in generally healthy patients

Frank C Detterbeck  1 , Vincent J Mase Jr  1 , Andrew X Li  2 , Ulas Kumbasar  3 , Brett C Bade  4 , Henry S Park  5 , Roy H Decker  5 , David C Madoff  6 , Gavitt A Woodard  1 , Whitney S Brandt  7 , Justin D Blasberg  1
Affiliations
Review

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 2: systematic review of evidence regarding resection extent in generally healthy patients

Frank C Detterbeck et al. J Thorac Dis. 2022 Jun.

Abstract

Background: Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, stereotactic body radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods: A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in generally healthy patients is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons with at least some adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results: In healthy patients there is no short-term benefit to sublobar resection vs. lobectomy in randomized and non-randomized comparisons. A detriment in long-term outcomes is demonstrated by adjusted non-randomized comparisons, more marked for wedge than segmentectomy. Quality-of-life data is confounded by the use of video-assisted approaches; evidence suggests the approach has more impact than the resection extent. Differences in pulmonary function tests by resection extent are not clinically meaningful in healthy patients, especially for multi-segmentectomy vs. lobectomy. The margin distance is associated with the risk of recurrence.

Conclusions: A systematic, comprehensive summary of evidence regarding resection extent in healthy patients with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation on which to build a framework for individualized clinical decision-making.

Keywords: Lung cancer; lobectomy; segmentectomy; surgery; wedge.

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-21-1824/coif). The series “A Guide for Managing Patients with Stage I NSCLC: Deciding between Lobectomy, Segmentectomy, Wedge, SBRT and Ablation” was commissioned by the editorial office without any funding or sponsorship. FCD served as the unpaid Guest Editor of the series. HSP serves as an unpaid editorial board member of Journal of Thoracic Disease. HSP reports research funding from RefleXion Medical; consulting fees from AstraZeneca; honoraria and speaking fees from Bristol Myers Squibb; and advisory board fees from Galera Therapeutics; all unrelated to current work. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
(A,B) Symptoms and recovery after lung resection.
Prospective study of patient reported outcomes in patients undergoing lobectomy at MD Anderson (stage I, II NSCLC, 2004–08, n=60, 48% VATS). (A) Time course of the 5 most severe symptoms; 11-point scale from 0 (not present) to 10 (as bad as you can imagine). (B) Time to return to mild pain at 2 contiguous measurements. Reproduced with permission from Fagundes et al. (22). VATS, video-assisted thoracoscopic surgery.
Figure 2
Figure 2
Major randomized controlled trials of lesser resection vs. lobectomy.
Graphic depiction of the 3 major randomized controlled trials. The x axis depicts the type of tumors included relative to proportion of solid/ground glass component, the z axis depicts tumor size, the y axis the resection extent. Three additional RCTs (German, STEPS and JCOG1706) are listed which have limited accrual. References: LCSG (8), CALGB (9), JCOG0802 (10), German (11), STEPS (32), JCOG1706 (33). CALGB, Cancer and Leukemia Group B; CTR, consolidation/tumor ratio; GG, ground glass appearance; IPF pts, Idiopathic pulmonary fibrosis patients; JCOG, Japan Cancer Oncology Group; LCSG, Lung Cancer Study Group; Lobe, lobectomy; Periph, peripheral; QOL, quality of life; Seg, segmentectomy; SL, sublobar; STEPS, Surgical Treatment of Elderly Patients.
Figure 3
Figure 3
Propensity-matched comparison of wedge resection, segmentectomy and lobectomy.
Comparison of resection extent in the National Cancer Database of cIA1,2 NSCLC [2003–6]. This study matched for 14 prognostic factors and performed multiple sensitivity tests; it is assessed to have a low level of residual confounding. Reproduced with permission from Khullar et al. (16). OS, overall survival.
See this image and copyright information in PMC

Comment in

References

    1. Detterbeck FC, Blasberg JD, Woodard GA, et al. A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation—part 1: a guide to decision-making. J Thorac Dis 2022. doi: 10.21037/jtd-21-1823 - DOI - PMC - PubMed
    1. Bade BC, Blasberg JD, Mase VJ, Jr, et al. A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation—part 3: systematic review of evidence regarding surgery in compromised patients or specific tumors. J Thorac Dis 2022. doi: 10.21037/jtd-21-1825 - DOI - PMC - PubMed
    1. Park HS, Detterbeck FC, Madoff DC, et al. A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation—part 4: systematic review of evidence involving SBRT and ablation. J Thorac Dis 2022. doi: 10.21037/jtd-21-1826 - DOI - PMC - PubMed
    1. Elze MC, Gregson J, Baber U, et al. Comparison of Propensity Score Methods and Covariate Adjustment: Evaluation in 4 Cardiovascular Studies. J Am Coll Cardiol 2017;69:345-57. 10.1016/j.jacc.2016.10.060 - DOI - PubMed
    1. Hade EM, Lu B. Bias associated with using the estimated propensity score as a regression covariate. Stat Med 2014;33:74-87. 10.1002/sim.5884 - DOI - PMC - PubMed