As reported in The New England Journal of Medicine by Nasser Altorki, MD, and colleagues, the phase III CALGB/Alliance 140503 trial showed that in respect to disease-free survival, sublobar resection was noninferior to lobar resection for patients with peripheral stage IA non–small cell lung cancer (NSCLC).
As stated by the investigators, “The increased detection of small-sized peripheral NSCLC has renewed interest in sublobar resection in lieu of lobectomy.”
In the multicenter trial, 697 patients with peripheral NSCLC that was clinically staged as T1aN0 (tumor size ≤ 2 cm) were randomly assigned to undergo sublobar resection (n = 340) or lobar resection (n = 357) after intraoperative pathological confirmation of absence of disease in the hilar and mediastinal lymph nodes. The primary endpoint was disease-free survival, with the noninferiority margin defined as a hazard ratio (HR) of 1.306 for sublobar vs lobar resection.
Nasser Altorki, MD
After a median follow-up of 7 years, sublobar resection was noninferior to lobectomy in terms of disease-free survival (HR = 1.01, 90% confidence interval [CI] = 0.83–1.24; P = .02 for noninferiority). Disease-free survival at 5 years was 63.6% (95% CI = 57.9%–68.8%) in the sublobar resection group vs 64.1% (95% CI = 58.5%–69.0%) in the lobectomy group.
Overall survival was similar in the sublobar resection vs lobectomy groups (HR = 0.95, 95% CI = 0.72–1.26), with 5-year rates of 80.3% (95% CI = 75.5%–84.3%) vs 78.9% (95% CI = 74.1%–82.9%). Lung cancer–related death occurred in 46 (13.5%) vs 55 patients (15.4%), and death from other causes occurred in 48 (14.1%) vs 45 patients (12.6%).
Among 336 patients in the sublobar resection group and 351 patients in the lobectomy group evaluable for recurrence, a post hoc analysis showed similar recurrence-free survival between groups (HR = 1.05, 95% CI = 0.80–1.39); 5-year rates were 70.2% (95% CI = 64.6%–75.1%) after sublobar resection and 71.2% (95% CI= 65.8%–75.9%) after lobectomy. Locoregional recurrence occurred in 13.4% vs 10.0% of patients; regional recurrence only in 1.8% vs 2.6%; and distant recurrence in 15.2% vs 16.8%. A new primary lung cancer was observed in 17.9% vs 14.8% of patients.
At 6 months after surgery, a between-group difference of two percentage points favoring the sublobar resection group was observed in the median percentage of predicted forced expiratory volume in 1 second.
The investigators concluded, “In patients with peripheral NSCLC with a tumor size of 2 cm or less and pathologically confirmed node-negative disease in the hilar and mediastinal lymph nodes, sublobar resection was not inferior to lobectomy with respect to disease-free survival. Overall survival was similar with the two procedures.”
Dr. Altorki, of Weill Cornell Medicine, NewYork-Presbyterian Hospital, is the corresponding author for The New England Journal of Medicine article.
Disclosure: The study was funded by the National Cancer Institute and others. For full disclosures of the study authors, visit nejm.org.The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.