New research will usher in the era of precision lung cancer surgery

Lung cancer is one of the leading causes of cancer deaths worldwide. It is a challenging disease to treat, and different treatment options are available, depending on the stage and location of the tumor. One of the most common surgical treatments for lung cancer is lobectomy, which involves the removal of an entire lobe of the lung. However, in recent years, there has been a renewed interest in sublobar resection, which involves the removal of only a portion of the lobe, for small-sized peripheral non–small-cell lung cancer (NSCLC).

Noninferiority of Sublobar Resection:

Two recent multicenter, noninferiority trials, one conducted in the United States (CALGB 140503)¹ and the other in Japan (JCOG0802)², have evaluated the efficacy of sublobar resection compared to lobectomy in patients with peripheral NSCLC. The trials aimed to determine whether sublobar resection is a safe and effective alternative to lobectomy for patients with early-stage NSCLC.

The CALGB 140503 trial included 697 patients with NSCLC clinically staged as T1aN0, randomly assigned to undergo sublobar resection (wedge resection or segmentectomy) or lobectomy after intraoperative confirmation of node-negative disease. The primary endpoint was disease-free survival, defined as the time between randomization and disease recurrence or death from any cause. After a median follow-up of 7 years, the trial found that sublobar resection was noninferior to lobectomy in terms of disease-free survival, overall survival, and recurrence rates. The trial also found that sublobar resection had a slightly lower risk of postoperative pulmonary function decline compared to lobectomy.

Similarly, the JCOG0802 trial included 1106 patients with T1a-bN0 peripheral NSCLC, randomly assigned to undergo segmentectomy or lobectomy. The primary endpoint was 5-year overall survival. After a median follow-up of 7 years, the trial found that sublobar resection was not inferior to lobectomy in terms of overall survival and recurrence rates.

The results of both trials suggest that sublobar resection is a safe and effective alternative to lobectomy for patients with early-stage NSCLC. This is particularly significant for patients with small tumors (≤2 cm) who may benefit from less invasive surgery with potentially fewer side effects.

Implications for Patients:

The findings of these trials will likely impact how surgeons treat patients with early-stage NSCLC, especially those with small tumors. In a recent editorial titled "Initiating the Era of 'Precision' Lung Cancer Surgery," published in the New England Journal of Medicine, Dr. Valerie W. Rusch discusses a potential paradigm shift in early-stage NSCLC surgery³. A new approach to lung cancer surgery uses advanced technology and techniques to precisely target the tumor and minimize damage to healthy lung tissue. This new approach, known as "precision" lung cancer surgery, involves using a combination of advanced imaging techniques, such as PET-CT and MRI scans, to create a detailed map of the tumor and its surrounding tissue. This map is then used to guide the surgeon during the operation, allowing them to precisely target the tumor and minimize damage to healthy lung tissue. Precision lung cancer surgery also incorporates the use of minimally invasive techniques such as video-assisted thoracoscopic surgery (VATS) and robotic-assisted surgery. These techniques involve making small incisions in the chest and using small instruments and cameras to perform the surgery, resulting in less pain, less scarring, and faster recovery times.

Dr. Rusch suggests that precision lung cancer surgery has the potential to revolutionize the way lung cancer is treated, allowing for more precise and effective surgeries, with fewer complications, and faster recovery times. This approach is particularly promising for patients with early-stage NSCLC, as it may allow for more conservative surgeries that preserve more healthy lung tissue.

“This evolution in options in how lung cancer is treated is is akin to how breast cancer evolved from a time when every tumor was treated with a radical mastectomy to a more focused tumor resection approach that allows many patients to have adequate treatment with less invasive surgery," said Dr. Edward Boyle, a founder of Prana Thoracic. “These critical studies are important as the field evolves to develop new techniques and approaches for a growing number of patients identified by lung cancer screening to manage very small tumors found early on CT.  In the past, these patients would have required a full lobectomy with mediastinal lymph node dissection. Now we are learning that with smaller tumors, less lung resection can result in similar results as more lung resection. This continues to expand the opportunity for devices and techniques for more targeted, precision approaches to managing early lung cancer. " 

Key Takeaway:

Overall, these studies support a promising new approach to the treatment of early-stage NSCLC, one that may ultimately lead to better outcomes and improved quality of life for patients. While this era of “precision” lung surgery for NSCLC is still in its early stages, it is an exciting development that has the potential to make a significant impact on the field of lung cancer treatment in the years to come.

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References

1. Altorki NK, Wang X, Kozono D, et al. Lobar or Sublobar Resection for Peripheral Stage IA Non–Small-Cell Lung Cancer. The New England Journal of Medicine. 388(6), 489–498. doi:10.1056/nejmoa2212083
2. Saji H, Okada M, Tsuboi M, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): A multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet. 2022; 399(10335), 1607-1617. doi:10.1016/S0140-6736(21)02333-3
3. Rusch, VW. Initiating the era of “precision” lung cancer surgery. The New England Journal of Medicine, 388(6), 557–558. doi:10.1056/NEJMe2215647