Woodard Gavitt A, Grau-Sepulveda Maria, Onaitis Mark W, Udelsman Brooks V, David Elizabeth A, Jacobs Jeffrey P, Kosinski Andrzej S, Blasberg Justin D, Boffa Daniel J
Division of Thoracic Surgery, Yale School of Medicine, New Haven, Connecticut.
Observational Statistics Group, Duke Clinical Research Institute, Durham, North Carolina.
Ann Thorac Surg. 2025 May;119(5):1071-1081. doi: 10.1016/j.athoracsur.2025.01.004. Epub 2025 Jan 24.
Prospective randomized trials have demonstrated noninferior survival between sublobar resection and lobectomy in healthy patients with non-small cell lung cancer with tumors ≤2 cm. However, some patient attributes are not well represented in randomized trials, and uncertainty remains in the widespread applicability of randomized trial nodal dissection protocols.
Patients with ≤2 cm, node-negative non-small cell lung cancer (cT1 N0) in The Society of Thoracic Surgeons prospective database were linked to Medicare survival data by using a probabilistic matching algorithm. Survival was assessed by propensity score-weighted Kaplan-Meier analysis.
Overall, 20,031 patients were identified, including 11,976 patients who underwent lobectomy, 2586 who underwent segmentectomy, and 5469 who underwent wedge resection. Fewer lymph nodes were sampled in the sublobar resection group (mean, 5.5 vs 12.8), and pathologic upstaging was less common (7.1% vs 14.2%). Overall survival after sublobar and lobar resection was similar within groups understudied in recent trials, including age ≥75 years (P = .07), forced expiratory volume in 1 second of 10% to 59% (P = .14), and Zubrod performance status 2 to 3 (P = .23). When sublobar resection was performed with inadequate nodal evaluation (<2 nodes removed), survival was inferior to survival after lobectomy (P < .001). Among patients with nodal upstaging, lobectomy was not associated with improved survival over sublobar resection (P = .42).
The clinical trial finding that sublobar resections achieve survival similar to that seen with lobectomy in early-stage lung cancer appears to apply to older, less healthy patients in a real-world setting, provided adequate lymph node resection is performed. Performing a lobectomy in the setting of nodal upstaging does not obviously improve survival. Further study is warranted to clarify the role of sublobar resection in the general population.
前瞻性随机试验已证明，在肿瘤≤2 cm的非小细胞肺癌健康患者中，亚肺叶切除与肺叶切除的生存率无差异。然而，一些患者特征在随机试验中未得到充分体现，随机试验淋巴结清扫方案的广泛适用性仍存在不确定性。
利用概率匹配算法，将胸外科医师协会前瞻性数据库中肿瘤≤2 cm、淋巴结阴性的非小细胞肺癌（cT1 N0）患者与医疗保险生存数据相链接。通过倾向评分加权的Kaplan-Meier分析评估生存率。
总体上，共识别出20,031例患者，其中11,976例行肺叶切除术，2586例行肺段切除术，5469例行楔形切除术。亚肺叶切除组采样的淋巴结较少（平均5.5个对12.8个），病理分期上调的情况也较少见（7.1%对14.2%）。在近期试验中研究较少的组内，亚肺叶切除和肺叶切除后的总生存率相似，包括年龄≥75岁（P = 0.07）、1秒用力呼气量为10%至59%（P = 0.14）以及Zubrod体能状态为2至3（P = 0.23）。当亚肺叶切除时淋巴结评估不充分（切除的淋巴结<2个），其生存率低于肺叶切除后的生存率（P < 0.001）。在淋巴结分期上调的患者中，肺叶切除与亚肺叶切除相比，生存率并未提高（P = 0.42）。
临床试验发现亚肺叶切除在早期肺癌中能获得与肺叶切除相似的生存率，这似乎适用于现实环境中年龄较大、健康状况较差的患者，前提是进行充分的淋巴结切除。在淋巴结分期上调的情况下进行肺叶切除并不能明显提高生存率。有必要进一步研究以阐明亚肺叶切除在一般人群中的作用。
