Segmentectomy improves survival in small-sized peripheral non-small-cell lung cancer: Lancet

Japan: A new study published in The Lancet shows that segmentectomy should be the usual surgical technique for individuals with early-stage non-small-cell lung cancer (NSCLC).

For early-stage non-small-cell lung cancer, lobectomy is the mainstay of therapy. Segmentectomy's survival and therapeutic advantages have not been studied in a randomized clinical trial setting. Considering this, Hisashi Saji and the team conducted the study with the objective to see if segmentectomy was in any way superior to lobectomy in patients with small-sized peripheral non-small-cell lung cancer.

In Japan, a non-inferiority, randomized, controlled study was done at 70 institutions. Patients with NSCLC at clinical stage IA were randomly randomized to either lobectomy or segmentectomy. The minimization approach was used for randomization, with balancing for the institution, histological type, age, sex, and thin-section CT results. The distribution of treatments was not hidden from the investigators or the patients. The main outcome was overall survival for all patients who were randomly allocated. Postoperative respiratory function (6 and 12 months), the proportion of local relapse, amount of blood loss, relapse-free survival, adverse events, duration of hospital stay, duration of chest tube placement, the proportion of segmentectomy completion, duration of surgery, and the number of automatic surgical staples used were the secondary endpoints.

The key findings of this study were as follows:

1. 1106 individuals were recruited to get lobectomy or segmentectomy between August 10, 2009, and October 21, 2014.

2. The groups were well balanced in terms of patient baseline clinicopathological variables.

3. 22 patients in the segmentectomy group were converted to lobectomies, and one patient had broad wedge resection.

4. At a median follow-up of 73 years, segmentectomy had a 94.3% 5-year overall survival rate and lobectomy had a 91.1% 5-year overall survival rate; superiority and non-inferiority in overall survival were verified using a stratified Cox regression model.

5. In the segmentectomy group, improved overall survival was demonstrated uniformly across all identified categories.

6. The significant difference in the decrease of median forced expiratory volume in 1 sec between the two groups at 1-year follow-up was 35%, which did not meet the specified clinical significance criterion of 10%.

7. The 5-year relapse-free survival rate for segmentectomy was 88%, whereas lobectomy was 89%.

8. The proportion of patients with local recurrence was 10.5% for segmentectomy and 5.4% for lobectomy.

9. After lobectomy and segmentectomy, 52 of 83 patients and 27 of 58 patients died of other illnesses, respectively.

10. There was no 30-day or 90-day mortality. Both groups experienced a comparable number of postoperative complications of grade 2 or above.

In conclusion, this was the first phase 3 experiment to indicate that segmentectomy outperformed lobectomy in terms of overall survival in patients with small-peripheral NSCLC. According to the findings, segmentectomy should be the usual surgical treatment for this patient population.

Reference:

Saji, H., Okada, M., Tsuboi, M., Nakajima, R., Suzuki, K., Aokage, K., Aoki, T., Okami, J., Yoshino, I., Ito, H., Okumura, N., Yamaguchi, M., Ikeda, N., Wakabayashi,. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. In The Lancet (Vol. 399, Issue 10335, pp. 1607–1617). Elsevier BV. https://doi.org/10.1016/s0140-6736(21)02333-3