Abstract
Previous comparisons of surgery and stereotactic body radiotherapy (SBRT) for early-stage (ES) non-small cell lung cancer (NSCLC) did not account for the extent of regional lymph node examination (LNE) during surgery. To compare long-term overall survival (OS) of patients with ES NSCLC after surgery vs SBRT when the extent of regional LNE in patients undergoing surgery is thoroughly considered. Cohort study with survival comparisons using the multivariable Cox proportional hazards model and after propensity score matching. Data from the National Cancer Database were analyzed from October 28, 2018, through April 18, 2019. Patients with ES NSCLC diagnosed between January 1, 2004, and December 31, 2015, who underwent any curative-intent surgery or SBRT were included. Long-term OS. Of 104 709 total patients, 91 330 underwent surgery (42 508 [46.5%] male; median [interquartile range] age, 68 [61-75] years) and 13 379 received SBRT (6065 [45.3%] male; median [interquartile range] age, 75 [68-81] years). Surgery, especially lobectomy (hazard ratio [HR], 0.53; 95% CI, 0.50-0.56), and regional LNE, especially when more than 10 lymph nodes were examined (HR, 0.73; 95% CI, 0.69-0.77), were associated with better long-term OS (P < .001). Pneumonectomy was not associated with reduced mortality risk when 0 nodes were examined (HR for stage T1, 1.43; 95% CI, 0.67-3.06; P = .35; HR for stage T2-T3, 0.62; 95% CI, 0.34-1.13; P = .12) or when more than 15 nodes were examined for stage T1 disease in patients younger than 80 years (HR, 0.77; 95% CI, 0.54-1.09; P = .14) or when patients aged 80 years or older received regional LNE of any extent (>15 nodes examined: HR for stage T1, 0.65; 95% CI, 0.16-2.64; P = .54; HR for stage T2-T3, 0.90; 95% CI, 0.50-1.60; P = .71). Less extensive surgery was not associated with improved OS when 0 nodes were examined in patients aged 80 years or older with stage T2 to T3 tumors (HR for lobectomy, 0.90; 95% CI, 0.65-1.25; P = .53) and in selected operable patients older than 75 years with stage T1 tumors (HR for lobectomy, 1.07; 95% CI, 0.57-2.00; P = .84). This study found that, overall, surgery coupled with regional LNE of appropriate extent was associated with the best long-term OS in patients with ES NSCLC.
Highlights
Especially lobectomy, and regional lymph node examination (LNE), especially when more than 10 lymph nodes were examined (HR, 0.73; 95% CI, 0.69-0.77), were associated with better long-term overall survival (OS) (P < .001)
Pneumonectomy was not associated with reduced mortality risk when 0 nodes were examined (HR for stage T1, 1.43; 95% CI, 0.67-3.06; P = .35; hazard ratio (HR) for stage T2-T3, 0.62; 95% CI, 0.34-1.13; P = .12) or when more than 15 nodes were examined for stage T1 disease in patients younger than 80 years (HR, 0.77; 95% CI, 0.54-1.09; P = .14) or when patients aged 80 years or older received regional LNE of any extent (>15 nodes examined: HR for stage T1, 0.65; 95% CI, 0.16-2.64; P = .54; HR for stage T2-T3, 0.90; 95% CI, 0.50-1.60; P = .71)
Less extensive surgery was not associated with improved OS when 0 nodes were examined in patients aged 80 years or older with stage T2 to T3 tumors (HR for lobectomy, 0.90; 95% CI, 0.65-1.25; P = .53) and in selected operable patients older than 75 years with stage T1 tumors (HR for lobectomy, 1.07; 95% CI, 0.57-2.00; P = .84)
Summary
Lung cancer is the leading cause of cancer-related death in the United States and worldwide, with non–small cell lung cancer (NSCLC) accounting for more than 80% of all cases diagnosed.[1,2,3] The standard curative treatment for early-stage (ES) NSCLC (stage I or II) is lobectomy combined with systematic or lobe-specific lymph node dissection and/or sampling, other options of anatomic pulmonary resection and noninvasive treatments are available.[3,4,5,6,7] Owing to the prognostic and therapeutic implications of regional nodal metastasis, accurate lymph node staging based on the standard of care is of critical importance during surgery for ES NSCLC.[7,8,9] the number of regional lymph nodes examined during lung cancer surgery is highly variable in daily clinical practice. Many patients who underwent lobar or greater resection had no lymph node examination (LNE), fewer than 6 lymph nodes examined, or inadequate retrieval of intrapulmonary lymph nodes from resection specimens.[9,10,11,12,13,14] All led to understaging and worse-than-expected stagestratified survival, while the most optimal number of regional lymph nodes to be examined may be well beyond what was recommended.[11,14]
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