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

Abstract

Background: Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), 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 older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with 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 older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group.

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

Keywords: Lung cancer; chronic obstructive pulmonary disease (COPD); ground glass nodule; older age; surgery.

Figure 1

5-year outcomes of patients with localized lung cancer.
Survival and cause of death in patients with localized lung cancer by age and presence of comorbidities; SEER data 2000–2010. Reproduced with permission from Howlader et al. (7).

Figure 2

OS and LCSS for sublobar resection or lobectomy in propensity-matched cohorts.
Survival of patients with cI-IIA NSCLC in the SEER-Medicare database 2003–09, age ≥65, extensively propensity-matched (19 factors, 4 sensitivity analyses). Reproduced with permission from Shirvani et al. (12). OS, overall survival; LCSS, lung cancer specific survival.

Figure 3

Morbidity and mortality of lobectomy in patients with limited pulmonary reserve.
Rates of postoperative mortality and cardiopulmonary complications in propensity-matched VATS and open lobectomy groups, stratified by ppoFEV1% and ppoDLCO%. *, P<0.05. Reproduced with permission from Burt et al. (71). VATS, video-assisted thoracic surgery; ppoFEV1%, predicted postoperative percent of predicted forced expiratory volume in 1 second; ppoDLCO%, percent of predicted diffusing capacity of the lung for carbon monoxide.

Figure 4

Major prospective studies of ground glass tumors.
Major prospective studies by resection extent, size and ground glass proportion. References: JCOG0201 (112,113), JCOG0802 (114), JCOG1211 (115), Yoshida Trial (116,117), JCOG0804 (118). CTR, consolidation/tumor ratio (size of consolidation on lung windows/total tumor size including ground glass component); DFS, disease-free survival; GG, ground glass; GGO, ground glass opacity; RCT, randomized controlled trial; Seg, segmentectomy.