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Lobectomy in early NSCLC: Time to wrap up its storyline?

Friday, February 17, 2017

Surgery is the preferred modality for the treatment of early stage non-small cell lung cancer (NSCLC). Following the results of the Lung Cancer Study Group (LCSG) trial in 1995, lobectomies were demonstrated to be the gold standard procedure for patients with stage I disease. However, with recent advancements in imaging that have led to more precise tumor detection, new approaches that preserve lung tissue, including sublobar resections (i.e., wedge resections of segmenectomies involving only a part of the lung), have taken center stage. New data suggest that sublobar may be equally efficacious as lobar resection in clinical stage 1 NSCLC, with similar survival and recurrence rates. This is especially noteworthy for elderly patients or those unable to tolerate an extensive surgical procedure. Several thoracic surgeons, including Nasser Altorki, M.D., weighed in for this review in ASCO/MedPage Today. Read the full article here.

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Nasser Altorki, M.D.Nasser Altorki, M.D. Perhaps the most persuasive argument for lessening the role of lobectomy in early-stage NSCLC came from Nasser Altorki, M.D., of Weill Cornell Medicine, and colleagues. In 2015, they pointed out that "many surgeons now have experience with segmentectomy ... making sublobar resection feasible and applicable for more of these patients. ... The timing is right to challenge the gold standard of lobectomy for early-stage NSCLC in a multicenter trial."

Altorki would certainly know, since he is the principal investigator of a major phase III trial (CALGB-140503) that will compare different types of surgery -- lobectomy, segmentectomy, and wedge resection -- for the treatment of patients with stage IA NSCLC.

In the currently recruiting trial, eligible patients will be stratified according to tumor size (a maximum of 2 cm), histology, and smoking status. The primary outcome will be disease-free survival (DFS) after sublobar resection versus lobectomy up to 7 years. DFS and overall survival (OS) will be followed for up to 7 years. Altorki reported that since 2007, a total of 533 patients have been randomized, and the target accrual is 692.

"The results of CALGB 140503 are vital for evaluating the surgical management of patients with early stage lung cancer (T1aN0), a population that is under-represented in clinical trials," he said.

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Even if lobectomy holds its own as the gold standard treatment, Altorki pointed out that the implementation of low-dose CT-based screening for lung cancer will result in the diagnosis of even more small peripheral lung cancers for which surgical treatment will be indicated.

"Many of these patients have poor lung function related to prior smoking behavior," he said. "Preservation of lung function by limited resection, if equal to lobectomy in cancer control, will result in a better quality of life for these individuals and maximize options for treatment of future second primaries."