Drake Lauren, Timmerman Robert, Fernando Hiran C
Department of Surgery, Allegheny Health Network, Pittsburgh, PA, USA.
Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX, USA.
Transl Lung Cancer Res. 2025 Aug 31;14(8):3153-3160. doi: 10.21037/tlcr-2025-387. Epub 2025 Aug 23.
Pulmonary resection with mediastinal lymph node dissection is the standard of care for standard-risk operable patients with early-stage non-small cell lung cancer (NSCLC), while stereotactic body radiation therapy (SBRT) is the mainstay treatment for inoperable patients. Within the last decade, SBRT has become increasingly used to treat high-risk operable patients who may otherwise be offered a compromise operation such as wedge resection, as well as standard-risk operable patients who would be able to tolerate lobectomy. The aim of this review is to discuss the current available data comparing SBRT and surgery with an emphasis on the ongoing randomized JoLT-Ca Sublobar Resection (SR) Versus Stereotactic Ablative Radiotherapy (SABR) for Lung Cancer (Stablemates) and veterans affairs lung cancer surgery or stereotactic radiotherapy (VALOR) studies.
A search for studies comparing SBRT to surgery in early-stage NSCLC was conducted on PubMed. An emphasis was made on selecting publications between 2020 to 2024 to include the most recent studies on the topic. Meta-analyses, systematic reviews, propensity matched studies, retrospective reviews and national database analyses were included. ClinicalTrials.gov was searched for information pertaining to current randomized trials.
The majority of current data supports surgery over SBRT based on overall survival (OS), however, a direct comparison between the two has been challenging. Definitions for locoregional control, requirements of biopsy proven malignancy, the extent of surgical resection and mediastinal lymphadenectomy, and primary end points vary by study. Previous randomized controlled trials have failed to accrue, though two ongoing randomized studies, Stablemates (NCT02468024) and VALOR (NCT02984761), are nearing accrual which will better inform clinicians which treatment may be preferable to which patients.
The current evidence favors surgery over SBRT for early-stage NSCLC in terms of OS, especially for standard-risk operable patients. For high-risk operable patients, surgery should still be considered standard of care, however the evidence is less clear, since many studies show similar recurrence rates. Based on the current evidence, we recommend surgical resection with mediastinal lymph node dissection for all patients with early-stage NSCLC who are operable. For patients medically unfit to undergo surgery, SBRT should be considered the standard of care.
对于早期非小细胞肺癌（NSCLC）的标准风险可手术患者，肺切除联合纵隔淋巴结清扫是标准治疗方案，而立体定向体部放疗（SBRT）是不可手术患者的主要治疗方法。在过去十年中，SBRT越来越多地用于治疗可能接受妥协性手术（如楔形切除术）的高风险可手术患者，以及能够耐受肺叶切除术的标准风险可手术患者。本综述的目的是讨论目前比较SBRT和手术的可用数据，重点是正在进行的随机化JoLT - Ca肺叶下切除术（SR）与立体定向消融放疗（SABR）治疗肺癌（Stablemates）以及退伍军人事务部肺癌手术或立体定向放疗（VALOR）研究。
在PubMed上搜索比较早期NSCLC中SBRT与手术的研究。重点选择2020年至2024年之间的出版物，以纳入该主题的最新研究。纳入荟萃分析、系统评价、倾向匹配研究、回顾性研究和国家数据库分析。在ClinicalTrials.gov上搜索与当前随机试验相关的信息。
基于总生存期（OS），目前大多数数据支持手术优于SBRT，然而，两者之间的直接比较具有挑战性。局部区域控制的定义、活检证实恶性肿瘤的要求、手术切除范围和纵隔淋巴结清扫以及主要终点因研究而异。以前的随机对照试验未能招募到足够的患者，不过两项正在进行的随机研究，即Stablemates（NCT02468024）和VALOR（NCT02984761），即将完成招募，这将为临床医生提供更好的信息，告知哪种治疗方法可能更适合哪些患者。
就OS而言，目前的证据支持早期NSCLC患者手术优于SBRT，特别是对于标准风险可手术患者。对于高风险可手术患者，手术仍应被视为标准治疗方法，然而证据不太明确，因为许多研究显示复发率相似。基于目前的证据，我们建议对所有可手术的早期NSCLC患者进行手术切除并纵隔淋巴结清扫。对于因医学原因不宜接受手术的患者，应考虑SBRT作为标准治疗方法。
