COLORADO SPRINGS – Patients with stage 1a non–small cell lung cancer deemed medically inoperable or high risk can undergo surgical resection safely and with excellent results, judging by results of a single-center retrospective study.

Indeed, their perioperative morbidity and mortality and 5-year recurrence-free survival rates were similar to those of low-risk patients undergoing tumor resection, Dr. Andrea S. Wolf said at the annual meeting of the Western Thoracic Surgical Association.

"These outcomes in high-risk patients provide the standard to which nonoperative therapies should be compared," said Dr. Wolf of Brigham and Women’s Hospital, Boston.

Of the 170,000 new cases of non–small cell lung cancer (NSCLC) diagnosed annually in the United States, 80% are deemed inoperable because of extensive malignancy or severe comorbidities, including chronic obstructive pulmonary disease, which affects roughly half of patients with NSCLC. Stereotactic body radiation therapy (SBRT), which uses advanced imaging techniques to deliver a targeted radiation dose to a tumor, is making substantial inroads in these inoperable patients. But Dr. Wolf’s study suggests that surgery is feasible for many patients considered high risk for pulmonary resection.

She reviewed the records of 66 patients with stage 1a disease considered high risk and 158 low-risk controls, all of whom underwent surgical resection at Brigham and Women’s Hospital during 1997-2006. None had pure bronchoalveolar carcinoma. Patients were deemed high risk if they were aged 80 years or older, or if their forced expiratory volume in 1 second (FEV₁) was 50% or less of the predicted amount. Forty percent of the high-risk patients met the age criterion, 60% met the diminished pulmonary function standard, and 5% fulfilled both. Pathologic findings were similar in the high- and low-risk groups, with a median tumor size of 1.5 cm.

With a median 6 years of follow-up, the local recurrence rate was 18% in the high-risk population and 16% in the low-risk cohort. The distant recurrence rate was 15% in both groups.

The 5-year overall survival rate was 54% in the high-risk group and significantly better at 68% in the low-risk group (P = .04). However, there was no significant difference in 5-year recurrence-free survival: 73% and 77% in the high- and low-risk groups, respectively.

Perioperative mortality occurred in 2% of low-risk patients and none of the high-risk patients. The perioperative major morbidity rate was 14% in the high-risk group and 8% in the low-risk group. Similarly, there were no significant between-group differences in the rates of any individual major complications, which included MI, pulmonary embolus, and reoperation for bleeding.

"Your rationale is right on target," discussant Dr. Joseph B. Shrager told Dr. Wolf. "It’s highly important in this era of SBRT to document the excellent results we can get with surgery in very-high-risk patients. And zero deaths, which is what you showed here and was equivalent to the experience with low-risk patients, is certainly admirable."

That being said, he added that he was disappointed with the Boston surgeons’ low use of anatomic resection in the high-risk group. Only 18% underwent lobectomy and another 6% received segmentectomy, while 76% had a wedge resection.

"There were less than one-tenth as many segmentectomies as wedges in the high-risk patients. So, really, what you’ve shown is that a lesser operation – or you might even say our least-good operation – can safely be done in high-risk patients. The question now is, is that lesser operation better than SBRT? Because if it’s not, then SBRT will probably win that argument. I have to say, I think we have a better chance of winning out over SBRT with surgery if we’re comparing it to segmentectomy than if we’re comparing it to wedge," said Dr. Shrager, professor and chief of the division of thoracic surgery at Stanford (Calif.) University.

Dr. Wolf replied that, like Dr. Shrager, she and her coinvestigators were "surprised" at the high rate of wedge resection because thoracic surgeons at Brigham and Women’s Hospital tend to promote anatomic resection whenever possible. She suspects some of the wedges were performed in an effort to spare parenchyma when a tumor bordered segmental boundaries.

Dr. Shrager also took the Boston surgeons to task for the fact that only 38% of high-risk patients in the series underwent lymph node sampling.

"Short of a proven survival advantage for surgery over SBRT, which we don’t have yet, all we can say is at least we’re providing better lymph node staging. So why not more lymph node sampling?" Dr. Shrager asked.

Dr. Wolf said this, too, came as a surprise to her and her colleagues. The most likely explanation is that in many instances patients and surgeons sought smaller, quicker operations in an effort to spare the patient. But given the compelling evidence showing that lymph node sampling is critical for accurate staging and for determining the need for adjunctive therapy, that’s not an adequate excuse.

"Going forward, we’re very interested in making sure nodes are sampled, even with wedge resections," she said.

Dr. Wolf declared no conflicts.☐

Resection Works Well for High-Risk NSCLC Patients