Sublobar resection is noninferior to lobectomy in patients with carefully staged, peripheral cT1aN0 NSCLC and should be offered to them.

To determine whether sublobar resection (wedge resection or segmentectomy) is noninferior to lobar resection in early-stage stage non–small-cell lung cancer (NSCLC), researchers conducted an international phase 3 trial. Nearly 700 patients with histologically confirmed stage IA node-negative NSCLC were randomized to lobar resection (357 patients) or sublobar resection (340 patients). Node status was confirmed by frozen section examination of level 10 lymph nodes and at least 2 mediastinal stations.

At a median follow-up of 7 years, the primary endpoint — disease-free survival (DFS) — did not differ significantly between groups (hazard ratio, 1.01; 90% CI, 0.83–1.24). The 5-year DFS was 63.6% in the sublobar-resection arm and 64.1% in the lobar-resection arm. There were no significant differences in DFS between the arms in subgroup analyses by tumor size or sites of recurrence. Overall survival (OS) also did not differ significantly between arms (HR, 0.95; 95% CI, 0.72–1.26). The 5-year OS was 80.3% with sublobar resection and 78.9% with lobar resection. There were no significant differences between the arms in lung cancer–related deaths (HR, 0.99) or deaths from other causes (HR, 1.12).

At 6 months, there was a greater reduction from baseline in the median percentage of predicted forced expiratory volume in 1 second (FEV₁)in the lobar-resection arm (−6.0; 95% CI, −8.0 to −5.0) than in the sublobar-resection arm (−4.0; 95% CI, −5.0 to −2.0). The reduction in the median percentage of predicted forced vital capacity (FVC) was also greater in the lobar-resection arm (−5.0; 95% CI, −7.0 to −3.0) than in the sublobar resection arm (−3.0; 95% CI, −4.0 to −1.0).

Comment

A recent trial from Japan showed that segmentectomy was noninferior to lobectomy in patients with T1a/bN0 NSCLC (NEJM JW Oncol Hematol May 9 2022 and Lancet 2022; 399:1607). Together, these trials provide conclusive evidence that sublobar resection is the standard of care for patients with small, peripheral, node-negative NSCLC. As computed tomography screening for lung cancer becomes more widespread, the proportion of patients who meet these criteria will continue to increase. As noted by an editorialist, although many patients are cured of their first NSCLC, the risk for metachronous primary tumors remains quite high. Sublobar resection allows more treatment options for these patients.