Segmentectomy vs Lobectomy (JCOG0802 study)...

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Radonc90

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This tweet below is a good thread to follow, segmentectomy vs lobectomy...

It was first published in Sept. 2019 (J Thorac Cardiovasc Surg), and updated at #AATS2021.

There is more labor involved in segmentectomy (more O.R. time), this is similar to previous Japanese studies
of segmentectomy. Hats off to the Japanese surgeons.

Awaiting the CALGB trial...

PS: I think for lesion < 2 cm, SBRT is here to stay, as long as the Pulmonary MDs refer the pts to radonc first.


pubmed.ncbi.nlm.nih.gov

Comparison of pulmonary segmentectomy and lobectomy: Safety results of a randomized trial - PubMed

There was no difference in almost any postoperative measure of intraoperative and postoperative complication in segmentectomy and lobectomy patients, except more air leakage was observed in the segmentectomy arm. Segmentectomy will be a standard treatment if the superior pulmonary function and...
pubmed.ncbi.nlm.nih.gov pubmed.ncbi.nlm.nih.gov


 
So many unknows...
Is it loss of lung parenchyma, is it the bigger procedure inducing more immunosuppression, is it more morbidity due to the bigger procedure >30d post surgery?

I hear and read alot of optimistic views on how these trial results will favor SBRT, but I am more pessimistic myself.
I believe these trial results will actually be a reason to choose surgery over SBRT.

Let me elaborate.

There are three types of patients with peripheral NSCLC with accompanying treatment options.

1. Medically fit patients --> (so far) s.o.c. is lobectomy
2. Medically less fit patients --> sublobar resection (including segmentectomy) vs. SBRT
3. Medically fit or unfit patients with a strong opinion on what kind of treatment they want --> surgery or SBRT according to their preference.


The Japenese data will lead to patients in group 1 now receiving segmentectomy instead of lobectomy, since excessive recurrence rates are rather low and overall survival not impacted by them, apparently. Furthermore, it appears that segmentectomy means less hospitalization time, less morbidity, less lung parenchyma loss, etc...

SBRT is an option for patients in group 2. In these patients, the s.o.c. lobectomy is deemed risky and so the alternatives of sublobar resection or SBRT (with assumed higher recurrence rates) are offered so far as a substitute. Now however that segmentectomy is going to become s.o.c. for patients in group 1, why offer SBRT at all in group 2 if you can perform segmentectomy? This is the new s.o.c. after all!


In other words...

Discussion so far:
"Dear Mr. Smith, you have a small tumor in your lung. Standard treatment would be to remove the affected lung lobe, but your lung function is not good enough for that. Therefore two options exist: to cut out only part of the lung lobe or irradiate the tumor. Both of these treatment options are not as good as removing the entire lung lobe as far as we know."

Discussion from now on:
"Dear Mr. Smith, you have a small tumor in your lung. Standard treatment used to be to remove the affected lung lobe, but your lung function is not good enough for that. However we have good data now which point out that cutting out part of the lung lobe is as good as removing the entire lobe in terms of your life expectancy. The alternative would be to irradiate the tumor."
 
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Palex80 said:
I hear and read alot of optimistic views on how these trial results will favor SBRT, but I am more pessimistic myself.
I believe these trial results will actually be a reason to choose surgery over SBRT.

Discussion so far:
"Dear Mr. Smith, you have a small tumor in your lung. Standard treatment would be to remove the affected lung lobe, but your lung function is not good enough for that. Therefore two options exist: to cut out only part of the lung lobe or irradiate the tumor. Both of these treatment options are not as good as removing the entire lung lobe as far as we know."

Discussion from now on:
"Dear Mr. Smith, you have a small tumor in your lung. Standard treatment used to be to remove the affected lung lobe, but your lung function is not good enough for that. However we have good data now which point out that cutting out part of the lung lobe is as good as removing the entire lobe in terms of your life expectancy. The alternative would be to irradiate the tumor."
Click to expand...
I strongly agree with you, I definitely think that's the direction the discussion will go (especially in America, where surgeons get these patients before we do).

And I'm saying this at a place where our Thoracic Surgery colleagues are incredibly pro-radiation. The patients are going to hear "this one type of surgery is SOC, which you can't have, but we have this different surgery that you can have...or you can have radiation". Your average patient won't understand the nuance between different types of surgery, your average patient is just going to hear "surgery or NOT surgery for the cancer".
 
elementaryschooleconomics said:
I strongly agree with you, I definitely think that's the direction the discussion will go (especially in America, where surgeons get these patients before we do).

And I'm saying this at a place where our Thoracic Surgery colleagues are incredibly pro-radiation. The patients are going to hear "this one type of surgery is SOC, which you can't have, but we have this different surgery that you can have...or you can have radiation". Your average patient won't understand the nuance between different types of surgery, your average patient is just going to hear "surgery or NOT surgery for the cancer".
Click to expand...
I think it depends on place of service... Out in the real world, some of the surgeons are more gun shy with offering a seg to borderline patients, esp with the increased table time. Best scenario is a quick peripheral wedge, or just send it for SBRT... Many times I'm getting a referral straight from Pulmonary with terrible FEV1s and DLCOs without them ever even meeting the surgeon
 
Another interesting fact that I just noticed is the staging groups in that trial.
1620042490110.png


There seem to be about 16-17% of patients with stage IIB disease. I do not know how many of those were pT3 pN0, but my guess is there's at least 10% pN1-tumors in that trial population (+1-3% pN2). I am also not aware of how well the preoperative staging was (PET-CT for all?). But the first person to argue that one can simply give SBRT to all those patients instead of doing a segementectomy may better be ready to answer what will happen to the 10% of those patients that have pN1-disease and will not be treated for that until the first recurrence pops up... And don't say "salvage radiochemotherapy". This is evidently an issue here...
 
medgator said:
I think it depends on place of service... Out in the real world, some of the surgeons are more gun shy with offering a seg to borderline patients, esp with the increased table time. Best scenario is a quick peripheral wedge, or just send it for SBRT... Many times I'm getting a referral straight from Pulmonary with terrible FEV1s and DLCOs without them ever even meeting the surgeon
Click to expand...
That's a good point, there's one thoracic surgeon here in particular that will operate on anything with a pulse (I generally mean that in a complimentary way), and I could see surgeons in different settings being less apt to go down this road.
 
Palex80 said:
There seem to be about 16-17% of patients with stage IIB disease.
Click to expand...
I think you're reading this wrong? More like 2-3% stage IIB?

Kudos to the surgeons here.

I must admit, I have this concern about whether the Japanese surgical data is applicable to my patient population. I didn't see percent smokers listed but nearly everyone had adenocarcinoma and FEV1/FVC interquartile pretty darn good for their patient I think. This may be surgery on much healthier patients than typically seen in US community practice.
 
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Palex80 said:
I thought the same too at first, but the order of stages is mixed up. Have another look at it. 🙂
Click to expand...
I think that is n = 16, not 16%. Only Stage 1a has a percentage in parentheses and the rest are just the absolute numbers of pts (I think)
 
TheWallnerus said:
Re-posted with sadness.
Click to expand...
I have no problem saying a VATS segmentectomy in a well-selected patient in the hands of an experienced surgeon could be considered the standard of care for Stage I lung cancer patients.

SBRT is a the best non-surgical treatment for patients with early-stage lung cancer, hands down, and should be the first alternative in patients deemed unfit for surgical resection. All other modalities (cough cough RFA) have inferior outcomes based on currently-available data.

I’m happy to treat early-stage lung cancer patients with SBRT, but only after a good surgical consultation. Being honest, my SBRT volume is high enough with mets and prostate to where I don’t have to rely on primary lung cancer to drive the service.
 
DireMoose said:
Yes, it is raw numbers of patients. The sum of those #'s in Arm A adds to 554, matching N at the top, but Arm B adds to 553 (+1 Ghost patient!) 👻
Click to expand...
Thank you! Makes sense now!
So, that‘s 2-3% pN1. Which is perfectly ok and a very weak argument against SBRT.
 
I think this is good for patients. A smaller surgery than lobectomy makes more people eligible for surgery, which may reduce SBRT volumes in early stage NSCLC. This may push more medically borderline people who wouldn't be candidates for surgery to become eligible.

I would be comfortable with patients receiving segmentectomy instead of lobectomy (NOT wedge resection) as a result of this trial. It is reassuring that upstaging to N+ seems to be low at 3% for continued consideration of SBRT.
 
evilbooyaa said:
I think this is good for patients. A smaller surgery than lobectomy makes more people eligible for surgery, which may reduce SBRT volumes in early stage NSCLC. This may push more medically borderline people who wouldn't be candidates for surgery to become eligible.

I would be comfortable with patients receiving segmentectomy instead of lobectomy (NOT wedge resection) as a result of this trial. It is reassuring that upstaging to N+ seems to be low at 3% for continued consideration of SBRT.
Click to expand...
I wouldn't interpret it like this at all. This trial really doesn't add anything IMHO. Why? It's mostly super small IA tumors. Why do you think the nodal upstaging rate was so darn low. We don't think that sublobar would be any worse for small tumors. The real question is for the 2+, 3+, etc tumors. Unfortunately this trial doesn't really represent those pts adequately and so can't really answer the million dollar question at all, it just answers the obvious question only. But of course, ***** surgeons will use this as justification to cut on any tumor size because they don't know how to analyze the patient population of a trial and apply it to practice. They just extrapolate out the wazoo, because hey, operating is always the answer.
 
FrostyHammer said:
I wouldn't interpret it like this at all. This trial really doesn't add anything IMHO. Why? It's mostly super small IA tumors. Why do you think the nodal upstaging rate was so darn low. We don't think that sublobar would be any worse for small tumors. The real question is for the 2+, 3+, etc tumors. Unfortunately this trial doesn't really represent those pts adequately and so can't really answer the million dollar question at all, it just answers the obvious question only. But of course, ***** surgeons will use this as justification to cut on any tumor size because they don't know how to analyze the patient population of a trial and apply it to practice. They just extrapolate out the wazoo, because hey, operating is always the answer.
Click to expand...
Does CT surgery really steer the ship where you are and not Pulmonary? My experience has been both sbrt and surgery referrals are coming from Pulmonary after they perform pfts and make their assessment
 
FrostyHammer said:
I wouldn't interpret it like this at all. This trial really doesn't add anything IMHO. Why? It's mostly super small IA tumors. Why do you think the nodal upstaging rate was so darn low. We don't think that sublobar would be any worse for small tumors. The real question is for the 2+, 3+, etc tumors. Unfortunately this trial doesn't really represent those pts adequately and so can't really answer the million dollar question at all, it just answers the obvious question only. But of course, ***** surgeons will use this as justification to cut on any tumor size because they don't know how to analyze the patient population of a trial and apply it to practice. They just extrapolate out the wazoo, because hey, operating is always the answer.
Click to expand...

Prior to this trial I would have advocated for any patient with stage IA NSCLC to get a lobectomy rather than any sort of segmental/wedge resection.

I agree with not extrapolating these results to larger tumors as you note, but these T1b and smaller tumors are frequently those that we are asked to SBRT rather than the patient getting a lobectomy.
 
medgator said:
Does CT surgery really steer the ship where you are and not Pulmonary? My experience has been both sbrt and surgery referrals are coming from Pulmonary after they perform pfts and make their assessment
Click to expand...
Lucky you. Over here everyone STFUs before the surgeon gods. Why do you think I hate them so much 😂
 
To me, there are 2 remarkable things about this trial. Both of which make me question the applicability of the trial to my patient population.

1. Incredibly good outcomes. No perioperative deaths but also very few recurrences or deaths compared to other series of surgery alone for stage I NSCLC. OS remarkable not only for very low risk of death/recurrence by lung cancer (indicating a predominance of favorable biology cancers) but also low risk of death period (5 year OS 91-94%) indicating much healthier patients than we see.

2. If real, 3% difference in overall survival favoring segmentectomy! This is clearly not due to oncologic outcomes but may be indicative of the actual cost of lobectomy over 5 years in a population that is relatively uncompromised compared to large groups of US lung cancer pts.

If lobectomy vs SBRT trials demonstrate improved outcomes for SBRT, this 2nd point could be used to justify subsequent segmentectomy vs SBRT trials.
 
Krukenberg said:
Did that one close due to poor accrual?
Click to expand...
www.utsouthwestern.edu

JoLT-Ca/STABLEMATES Trial

The JoLT-CA/STABLEMATES Trial is a randomized phase III study of sublobar resection (SR) versus stereotactic ablative radiotherapy (SAbR) in high-risk patients with stage I non-small cell lung cancer (NSCLC).
www.utsouthwestern.edu

It looks like 182 patients have been enrolled, according to their newsletter.
 
SubserviantToABR said:
www.utsouthwestern.edu

JoLT-Ca/STABLEMATES Trial

The JoLT-CA/STABLEMATES Trial is a randomized phase III study of sublobar resection (SR) versus stereotactic ablative radiotherapy (SAbR) in high-risk patients with stage I non-small cell lung cancer (NSCLC).
www.utsouthwestern.edu

It looks like 182 patients have been enrolled, according to their newsletter.
Click to expand...
I’ve had a pretty hard time enrolling to this one.
 
medgator said:
Does CT surgery really steer the ship where you are and not Pulmonary? My experience has been both sbrt and surgery referrals are coming from Pulmonary after they perform pfts and make their assessment
Click to expand...

90% driven by CT Surgery for my community

The screening patients get funneled to surgery right away as well
 
My personal impression is that pulmonologists "gain" alot more from surgeons than from us, radiations oncologists.
Referrals from surgeons to pulmonologists for biopsies, functional tests and postoperative complications are quite more common than from us.

Were radiation oncologists to "take away" lobectomies and segmentectomies from the thoracic surgeons, the pulmonologists would be less busy. I would rather send my patients do a "stair climb test" than a complete functional pulmonary workup.
 
Palex80 said:
My personal impression is that pulmonologists "gain" alot more from surgeons than from us, radiations oncologists.
Referrals from surgeons to pulmonologists for biopsies, functional tests and postoperative complications are quite more common than from us.

Were radiation oncologists to "take away" lobectomies and segmentectomies from the thoracic surgeons, the pulmonologists would be less busy. I would rather send my patients do a "stair climb test" than a complete functional pulmonary workup.
Click to expand...
Everyone should get a Cynberknife. That will make us more appealing to the pulm guys. They will get to see our patients to implant fiducials AND manage their subsequent pneumos. Two for one baby!
 
While the Thoracic Surgeons mostly drive the ship in my neck of the woods, we definitely get some direct referrals from community Pulmonologists.

When I see a that a patient is coming direct from Pulm, I don't even need to open the chart to know they're already on baseline 4L...
 
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