Tumor Histology Is Factor in Determining Need for Lobectomy

“Limited resection is not equivalent to lobectomy when used to treat older patients with stage IA lung cancer of invasive cell types, namely invasive adenocarcinoma and squamous cell carcinoma, a population-based study has now determined.

“Instead, these patients may be considered for completion lobectomy or for adjuvant treatments, Rajwanth R. Veluswamy, MD, at Icahn School of Medicine at Mount Sinai, New York, NY, and colleagues report online in the Journal of Clinical Oncology.

” ‘Tumor histology in early-stage lung cancer is an important predictor of survival and has therapeutic implications,’ Veluswamy said in an interview. ‘Patients with relatively indolent tumors such as adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) have excellent survival following resection and are therefore likely to benefit from parenchymal sparing provided by limited surgical approaches.’ “

Zapping Tumor Effective for Stage I Non-Small Cell Lung Cancer (CME/CE)

“Overall survival rates for resectable stage I non-small cell lung cancer (NSCLC) might improve if treated with stereotactic ablative radiotherapy (SABR) rather than lobectomy, the current standard of care, reports a phase III randomized U.S.-Dutch study led by researchers from the University of Texas MD Anderson Cancer Center in Houston.

“Furthermore, SABR is better tolerated.

“The findings, published in The Lancet Oncology, on May 14, 2015, are the first available data from randomized trials comparing SABR and invasive surgery with mediastinal lymph node dissection or sampling. Nonrandomized studies have previously suggested that SABR might be as effective as surgery, but these results are the first randomized data.

” ‘For the first time, we can say that the two therapies are at least equally effective, and that SABR appears to be better tolerated and might lead to better survival outcomes for these patients,’ said principal investigator Joe Y. Chang, MD, PhD, a professor of radiation oncology, in an MD Anderson media release. ‘This study can give physicians confidence to consider a noninvasive option.’ “

Stage I and II NSCLC: Removal of Whole Lung Could Work Better than Removal of Cancerous Lobe Followed by Radiation

“Patients with positive surgical margins after lobectomy and adjuvant radiation for non-small cell lung cancer had an increased risk for death compared with patients who were treated with pneumonectomy without radiation.

“ ‘We have demonstrated that positive margins are not that uncommon and occur in roughly 4% of patients receiving lobectomy for stage I or II non-small cell lung cancer [NSCLC],’ Brian C. Gulack, MD, of Duke University, said during a presentation at the American Association for Thoracic Surgery Annual Meeting. ‘Furthermore, positive margin status is associated with worse overall survival, and among patients with positive margins, adjuvant radiation therapy does not appear to provide a significant long-term survival benefit.’

“Gulack and colleagues analyzed patients with positive margins after lobectomy for stage I and stage II NSCLC from the National Cancer Data Base to determine if adjuvant radiation improved survival. Patients who underwent lobectomy without known induction therapy for NSCLC from 1998 to 2006 were grouped by margin status and assessed based on treatment and outcomes.

“Among 50,010 patients who met study criteria, 3.9% had positive margins after lobectomy. Positive margins were associated with an increased risk for death (adjusted HR = 1.46; 95% CI, 1.39-1.6).”

Video-Assisted Thoracoscopic Surgery Technique for Pneumonectomy Shown to Be Safe

“In the largest series of its kind to date, researchers at Roswell Park Cancer Institute (RPCI) have shown that performing thoracoscopic pneumonectomy, removal of the entire lung through a minimally invasive endoscopic approach, at a high-volume center appears to be safe and may provide pain and survival advantages in the long term.

“ ‘During the past 20 years, portions of the lungs have been removed for lung cancer through lobectomies, and that has been shown to be better done through small incisions or through thoracoscopic lobectomy compared with standard, open lobectomy,’ says Todd Demmy, MD, FACS, Clinical Chair of the Department of Thoracic Surgery and Professor of Oncology at RPCI. ‘We wanted to see if any of the benefits of the lobectomy — which typically involves removal of 20-50% of the organ — carry forward when you take the whole lung out in a pneumonectomy.’

“Dr. Demmy and his colleagues retrospectively reviewed all patients who underwent pneumonectomy at RPCI from 2002 through 2012. Of the 107 consecutive pneumonectomies performed during this time period, 40 cases were done through an open technique, 50 were done through successful video-assisted thoracoscopic surgery (VATS), and 17 were converted from VATS to an open procedure.

“ ‘We performed a relatively large number of pneumonectomies without a significant event in the operating room such as excessive bleeding, which has been one of the major concerns that have prevented other surgeons from trying this technique,’ Dr. Demmy says.”

Researchers Find Removal of Entire Lobe of Lung Offers Increased Survival Benefit Compared to Partial Resection

“Removal of the entire lobe of lung may offer patients with early-stage lung cancer better overall survival when compared with a partial resection, and stereotactic ablative radiotherapy (SABR) may offer the same survival benefit as a lobectomy for some patients, according to a study from The University of Texas MD Anderson Cancer Center.

“The research is the largest population-based study to review modern treatment modalities for early-stage lung cancer and is published in JAMA Surgery.

“According to the American Cancer Society, in 2014, 224,210 people in the U.S. are expected to be diagnosed with lung cancer, and more than 159,260 will die from the disease. Yet with the aging baby-boomer population colliding with spiral CT-screening’s acceptance as a screening tool for lung cancer, the number of cases diagnosed is expected to rise dramatically, says Shervin M. Shirvani, M.D., attending radiation oncologist at Banner MD Anderson Cancer Center in Arizona and an adjunct professor at MD Anderson.”

Poor Quality of Life Does Not Predict Low Survival Rates in High-Risk Lung Cancer Patients Undergoing Surgery

“Quality of life is rarely reported in surgical publications, yet it can be an important metric that can be of use to physicians and patients when making treatment decisions. Prior studies of average-risk patients undergoing lobectomy suggested that low baseline quality-of-life scores predict worse survival in patients undergoing non–small cell lung cancer surgery.

“However, the results of a multicenter, longitudinal study of high-risk lung cancer patients who underwent sublobar resection counters this idea, finding that poor baseline global quality-of-life scores did not predict for worse overall survival or recurrence-free survival or greater risk of adverse events. Bryan F. Meyers, MD, presented the results of this research today on behalf of the Alliance for Clinical Trials in Oncology at the 94th American Association for Thoracic Surgery Annual Meeting in Toronto, Ontario.”

Tissue Analysis May Help Predict Risk of Early-Stage Lung Cancer Returning

The tissue types present in early-stage lung adenocarcinomas, a type of non-small cell lung cancer (NSCLC), may help predict the chances of the cancer returning after surgery. A retrospective study examined outcomes among adenocarcinoma patients whose tumors were 2 cm in diameter or smaller. Patients whose tumors contained 5% or more of a so-called ‘micropapillary’ tissue structure had a higher risk of the cancer returning if they had just the tumor removed. This difference was not found in patients who underwent lobectomy (removal of an entire subsection of lung). The higher risk of recurrence in patients with 5%-plus micropapillary tissue in their tumor may make them better candidates for the more invasive lobectomy procedure.

Radiation and Chemotherapy before Surgery Best Option in Patients with Stage IIIA(N2) NSCLC

Disagreement persists about the best treatment for non-small cell lung cancer (NSCLC) patients with stage IIIA(N2) disease, that is, cancer that has spread to lymph nodes just outside the lung. A recent study compared the outcomes of different treatments. Patients who had received neoadjuvant chemoradiotherapy (chemotherapy and radiation administered before surgery) followed by lobectomy (removal of the lung subsection containing the cancer) had higher 5-year survival rates than patients treated with:

-neoadjuvant chemoradiotherapy and pneumonectomy (removal of the whole lung containing the cancer);

-either lobectomy or pneumonectomy plus adjuvant therapy (chemotherapy and/or radiation administered after surgery);

-concurrent chemoradiotherapy (chemotherapy and radiation delivered at the same time, without surgery).

These findings suggest that neoadjuvant chemoradiotherapy followed by lobectomy is the preferable treatment for stage IIIA(N2) NSCLC.

Analysis Highlights Most Cost-Effective Treatments for Early-Stage Lung Cancer

Researchers have constructed a model to assess the cost-effectiveness of different treatments for stage I non-small cell lung cancer (NSCLC) based on treatment costs, predicted life expectancy, and expected quality of life. Model simulations indicate that lobectomy (removal of an entire subsection of the lungs) is the most cost-effective treatment for patients whose cancer is clearly operable. For patients who are only borderline eligible for surgery due to poor health (‘marginally operable’), who often cannot withstand lobectomy, a type of radiotherapy called stereotactic body radiation therapy (SBRT), also known as stereotactic ablative radiotherapy (SABR), was found to be more cost-effective than wedge resection (removal of a small piece of lung containing the cancer).