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Galveston, TX
Dr. Zwischenberger is Professor of Surgery, University of Texas Medical Branch.
Correspondence to: Joseph B. Zwischenberger, MD, Professor of Surgery, Medicine and Radiology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555; e-mail: jzwische{at}utmb.edu
The treatment of stage 1 lung cancer remains controversial. The landmark study > 10 years ago as reported by Ginsberg and Rubinstein1 for the Lung Cancer Study Group (LCSG) demonstrated the superiority of lobectomy over wedge resection in (T1N0, stage IA) lung cancer. This prospective randomized outcomes study1 demonstrated a 30% increase in the overall death rate and a tripling of the recurrence rate in patients who underwent limited resection in a 5-year follow-up in patients with non-small cell histopathology. Limited resection was defined as segmentectomy or "large adequate wedge resection" with 2 cm of normal lung margin with lymph node sampling, T1N0 status, and clear surgical margins. This LCSG sentinel study1 influenced the next decade of practice. In this issue of CHEST (see page 136), Kraev et al2 report on the 10-year survival of patients with stage 1 lung cancer treated either with wedge resection or lobectomy. The length of follow-up begs reflection. Previous reports commonly followed up patients for 2 to 5 years postoperatively. Kraev et al2 demonstrate that the Kaplan-Meier survival curves do not begin to diverge until 3 years out, when an apparent although statistically insignificant survival advantage is seen with lobectomy. This survival advantage reaches statistical significance when applied to tumors < 3 cm in size (T1 N0, stage 1A). These data are consistent with Ginsberg and Rubinstein1 and with other reports demonstrating survival advantages for patients with stage 1A cancer undergoing lobectomy.
Under the influence of the study by Ginsberg and Rubinstein,1 several other retrospective experiences (13 according to a recent metaanalysis3) have reported on lobe vs wedge for stage 1 lung cancer (not just stage 1A as in the study by Ginsberg and Rubinstein1). Kraev et al2 as well as others have shown a survival difference between stage 1A lobectomy vs wedge. As with Kraev et al,2 most of the outcomes from these more recent studies have been less dramatic than the experience of Ginsberg and Rubinstein.1 Further clouding this issue is a recent report by El-Sherif et al,4 in which improved survival was shown with lobectomy over wedge resection, but disease-free survival was no different in patients with stage 1A lung cancer and worse in patients with stage 1B. The reasons for the less dramatic results deserve explanation. The study by Ginsberg and Rubinstein1 only included patients with stage 1A disease, while most of the more recent series have include stage 1A and 1B patients.
The arguments for a survival advantage for patients undergoing lobectomy have often been debated. Patients who undergo wedge resection do not undergo lobectomy primarily out of fear of irrecoverable pulmonary decline or a high number of comorbidities. This leads to a selection bias toward healthier patients with fewer comorbidities who undergo lobectomy, skewing survival numbers. Also, limited lymph node sampling often accompanies wedge resection, which may lead to understaging of these patients. The retrospective nature of most of the recent studies also encourages bias.
Underpinning the argument of wedge vs lobectomy is the current surgical climate of "smaller is better." Less invasive procedures and smaller resections are the attitude throughout most of the surgical community. However, the tumor biology of lung cancer predisposes to early metastasis, and some5 have even hypothesized that cancer beyond stage 1A represents systemic disease. A rationale for this hypothesis is demonstrated by the lack of a survival advantage and only a slight difference in disease free survival in patients with stage 1B disease undergoing lobectomy instead of wedge resection.
This study by Kraev et al2 represents further affirmation that the treatment of choice for patients with stage 1A lung cancer is lobectomy in all patients who can tolerate the procedure. The results remain less clear about stage 1B disease, as this study as well as others have been unable to demonstrate a definitive survival benefit. It must be emphasized that the only prospective randomized controlled trial for stage 1A lung cancer was the LCSG study,1 and all others have been retrospective. Until a randomized control trial can demonstrate otherwise, lobectomy in stage 1A lung cancer will remain the standard of care for those patients who can tolerate the procedure. Kraev et al,2 while not definitively answering the question of wedge vs lobectomy, do demonstrate a long-term slight survival benefit of lobectomy vs wedge resection in all patients with stage 1 lung cancer based on 10-year follow-up.
Footnotes
The author has no conflicts of interest to disclose.
References
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