Indications for sublobar resection for localized NSCLC

Transcription

1 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

2 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

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4 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

5 Disclosure No relevant conflicts of interest to disclose

6 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 O 2

7 ACOSOG 4032: High-Risk Wedge 252/250 enrolled, No difference in Outcome, ASCO 2013

8 Solitary Pulmonary Nodule Left Upper Lobe Lesion T1N0 NSCLC

9 Small T1 Lung Cancers ( 1cm) Mayo clinic retrospective n=100; 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

10 CALGB Solitary Pulmonary Nodule <2.0 cm by CT Verify NSCLC All N1 + N2 (-) Randomize; n=900 Lobectomy N=450 Accrual 600/900 Limited Resection N=450

11 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.

12 Segmentectomy for Small Tumors Fukuoko Japan (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 (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

13 Wedge Resection vs Segmentectomy for Patients with T1a N0 Non-Small Cell Lung Cancer

14 Objective 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 longterm survival when compared to wedge resection

15 Matched Patient Characteristics

16 Perioperative Outcomes: No Difference

17 Overall Survival Results: Propensity-score-matched Analysis

18 Survival of Patients with Tumors 1 cm: Propensity-score-matched Analysis

19 Overall Survival Results: Subgroup Analysis No comorbidities Bronchioloalveolar Carcinoma

20 Conclusion 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

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