Small-sized Non-small Cell Lung Cancer Research Articles

ASO Visual Abstract: Early Postoperative Patient-Reported Outcomes After Thoracoscopic Segmentectomy Versus Lobectomy for Small-Sized Peripheral Non-small Cell Lung Cancer

ASO Visual Abstract: Early Postoperative Patient-Reported Outcomes After Thoracoscopic Segmentectomy Versus Lobectomy for Small-Sized Peripheral Non-small Cell Lung Cancer

Segmentectomy for Inner Location Small-Sized Non-Small Cell Lung Cancer: Is It Feasible?

BackgroundThe efficacy of segmentectomy for inner small-sized non-small-cell lung cancer (NSCLC) remains unknown. We aimed to elucidate whether segmentectomy for inner small-sized NSCLC, defined using a novel 3-dimensional measuring method, yields feasible oncologic outcomes compared with segmentectomy for outer lesions. MethodsWe retrospectively analyzed patients with small-sized (<2 cm) cN0 NSCLC who underwent segmentectomy between January 2007 and December 2020. The tumor centrality ratio, which was measured by using 3-dimensional reconstruction software, was evaluated. The location of tumor origin was confirmed pathologically. Cases with a ratio <2:3 and >2:3 were allocated to the inner group and outer group, respectively. Oncologic outcomes were compared between the 2 groups. ResultsOur cohort was divided into the inner group (n = 75) and outer group (n = 127). The proximal distance from a tumor was >20 mm in all cases. The tumor centrality ratio was associated with the pathologic origin of a tumor. The rate of unforeseen positive lymph node metastasis was significantly higher in the inner group (P = .04). There were no significant differences in the 5-year recurrence-free survival (91% vs 87%, P = .67). Univariate analysis identified age, consolidation/tumor ratio, the presence of ground-glass opacity, and lymphovascular invasion, but not tumor centrality, as significant prognostic factors for recurrence-free survival. In the multivariate analysis, the presence of ground-glass opacity and lymphovascular invasion remained significant. ConclusionsRegarding oncologic outcomes, segmentectomy with a safety proximal distance could be feasible, even for inner small-sized NSCLC. Tumor invasiveness, not tumor centrality, may influence tumor recurrence.

Predicting recurrence of non-small cell lung cancer based on mean computed tomography value

BackgroundThe aim of this study was to assess the ability of using mean computed tomography (mCT) values to predict non-small cell lung cancer (NSCLC) tumor recurrence.MethodsA retrospective study was conducted on 494 patients with stage IA NSCLC. Receiver operating characteristics analysis was used to assess the ability to use mCT value, C/T ratio, tumor size, and SUV to predict tumor recurrence. Multiple logistic regression analyses were performed to determine the independent variables for the prediction of tumor recurrence.ResultsThe m-CT values were − 213.7 ± 10.2 Hounsfield Units (HU) for the recurrence group and − 594.1 ± 11.6 HU for the non-recurrence group (p < 0.0001). Recurrence occurred in 45 patients (9.1%). The tumor recurrence group was strongly associated with a high CT attenuation value, high C/T ratio, large solid tumor size, and SUV. The diagnostic value of mCT value was more accurate than the C/T ratio, excluding the pure ground-glass opacity and pure solid (0 < C/T ratio < 100) groups. The SUV and mCT are independent predictive factors of tumor recurrence.ConclusionsThe evaluation of mCT values was useful for predicting recurrence after the limited resection of small-sized NSCLC, and may potentially contribute to the selection of suitable treatment strategies.

Segmentectomy Versus Lobectomy in Small-Sized Peripheral Non-Small Cell Lung Cancer (JCOG0802/WJOG4607L): A Multicentre, Randomised, Controlled, Phase 3 Trial

Background: Lobectomy is the standard of care for early-stage non-small cell lung cancer (NSCLC). The survival and clinical benefits of segmentectomy have not been investigated in a randomized trial setting. We conducted a randomized controlled noninferiority trial comparing segmentectomy and lobectomy for small-sized peripheral NSCLC. Methods: Patients with clinical stage IA NSCLC (tumor diameter ≤2 cm; consolidation/tumor ratio > 0·5) were randomly assigned to undergo either lobectomy or segmentectomy. The primary endpoint was overall survival (OS). The secondary endpoints included postoperative respiratory function, relapse-free survival (RFS), proportion of local relapse, and adverse events. Findings: Between August 10, 2009 and October 21, 2014, 1106 patients (lobectomy, n = 554; segmentectomy, n = 552) were enrolled. Patient baseline clinicopathological factors were well balanced. At a median follow-up of 7·3 years, the 5-year OS was 94·3% for segmentectomy and 91·1% for lobectomy. Superiority as well as noninferiority in OS were confirmed using a stratified Cox regression model (hazard ratio [HR], 0·663; 95% confidence interval [CI], 0·474–0·927; one-sided P < 0·0001 for noninferiority; P = 0·0082 for superiority). Improved OS was observed consistently across all predefined subgroups in the segmentectomy arm. The significant differences at 1 year in the reduction of median forced expiratory volume in 1 second at 1 year between the two arms was 3·5% ( P < 0·0001), which did not reach the predefined threshold of 10%. The 5-year RFS was 88·0% for segmentectomy and 87·9% for lobectomy (HR, 0·998; 95% CI, 0·753–1·323). The proportions of local relapse were 10·5% and 5·4% for segmentectomy and lobectomy, respectively ( P = 0·0018). Fifty-two (63%) of 83 patients and 27 (47%) of 58 patients died of other diseases after lobectomy and segmentectomy, respectively. Interpretation: This was the first phase 3 trial to demonstrate the benefits of segmentectomy in OS. Segmentectomy should be the standard surgical procedure for patients with small-sized peripheral NSCLC. Trial Registration: University Hospital Medical Information Network–Clinical Trial Registry Number: UMI02317. Funding: Ministry of Health, Labor and Welfare of Japan and the Japan Agency for Medical Research and Development Declaration of Interest: All authors declare no competing interests for this study. Ethical Approval: The study protocol was approved by the JCOG and WJOG Protocol Review Committees and the institutional review boards of all participating hospitals.

Feasibility of limited resection for peripheral small-sized non-small cell lung cancer: a retrospective single-center-based study.

This study aimed to establish new criteria for limited resection of non-small cell lung cancer (NSCLC) based on computed tomography findings and maximum standardized uptake value (SUVmax). Between December 2007 and December 2015, 611 patients underwent lung cancer surgery; of these, 70 with cT1aN0M0 who underwent limited resection were enrolled. Criteria for undergoing intentional limited resection (ILR) were (1) tumor ground-glass opacity (GGO) ratio of ≥ 0.75 and (2) tumor SUVmax ≤ 1.5. Patients who met criteria (1) and (2) underwent partial resection, and those who only met criteria (2) underwent segmentectomy as ILR. The control group was subjected to limited surgery without meeting the criteria. Overall, 45 and 25 patients who met the criteria were included in the ILR and control groups, respectively. In the ILR group, 13 patients underwent partial resection, and 32 underwent segmentectomy; in the control group, 18 patients underwent partial resection and 7 underwent segmentectomy. According to our criteria, no relapsed cases occurred in the ILR group, although six patients showed recurrence of lung cancer in the control group. The 5-year overall survival (OS) rates in the ILR and control groups were 100% and 67.7%, respectively, and the relapse-free survival (RFS) rates were 100% and 61.6%, respectively. The log-rank test showed that this difference was statistically significant (OS: P < 0.0001, RFS: P < 0.0001). SUVmax may serve as a predictive marker of recurrence to determine the treatment strategy for patients with NSCLC. Patients with low GGO ratio and low SUVmax may be cured by limited resection.

The prognosis of small-sized non-small cell lung cancer with visceral pleural invasion after sublobar resection.

BackgroundSublobar resection is sometimes performed as a surgical treatment for small peripheral tumors. However, there is a question about whether sublobar resection is adequate treatment when visceral pleural invasion is diagnosed postoperatively. The purpose of this study was to evaluate the prognosis of patients with small-sized stage IB non-small cell lung cancer (NSCLC) after sublobar resection.MethodsFrom January 2010 to December 2018, 227 consecutive patients with eighth edition TNM stage IB NSCLC (per the joint staging system of the International Association for the Study of Lung Cancer and the American Joint Committee on Cancer) underwent curative surgery at a single center. Those patients were reviewed retrospectively. The clinicopathological characteristics and prognosis were compared between the sublobar resection group and the lobectomy group. The sublobar resection group included only small-sized (invasive component size ≤2 cm) NSCLC.ResultsIn all study patients, clinicopathological characteristics between the sublobar resection and lobectomy groups were not different except in maximum standardized uptake value (SUVmax) and invasive component size. The 5-year recurrence-free survival (RFS) rate was 80.7% after sublobar resection and 73.4% after lobectomy (P=0.349). The 5-year overall survival (OS) rate was 87.3% after sublobar resection and 84.8% after lobectomy (P=0.503). In patients with small-sized NSCLC, the clinicopathological characteristics were not different between the sublobar resection group and the lobectomy group. The 5-year RFS rate was 80.7% after sublobar resection and 72.3% after lobectomy (P=0.417). The 5-year OS rate was 87.3% after sublobar resection and 91.2% after lobectomy (P=0.956). Sublobar resection was not a risk factor for recurrence in the multivariate analysis.ConclusionsThe prognosis of sublobar resection in patients with small-sized stage IB NSCLC was comparable with lobectomy. Thus, additional completion lobectomy may not be essential in this setting, despite postoperative upstaging from T1 to T2a.

Metastatic Patterns of Mediastinal Lymph Nodes in Small-Size Non-small Cell Lung Cancer (T1b).

Background: Lymph node metastasis (LNM) status is critical to the treatment. Fewer studies has focused on LNM in patients with small-size non-small cell lung cancer (NSCLC). This study aims to investigate clinicopathological characteristics associated with skip N2 (SN2) and non-skip N2 (NSN2) metastasis, and their metastatic patterns in NSCLC with tumor size of 1–2 cm.Methods: We reviewed the records of NSCLC patients with tumor size of 1–2 cm who underwent lobectomy with systematic lymph node dissection (LND) between January 2013 and June 2019. Clinical, radiographical, and pathological characteristics were compared among N1, SN2, and NSN2 groups. Metastatic patterns of mediastinal lymph node were analyzed based on final pathology.Results: A total of 63 NSCLC patients with tumor size of 1–2 cm were staged as pN2, including 25 (39.7%) SN2 and 38 (60.3%) NSN2. The incidence rates of SN2 and NSN2 were 2.8% (25/884) and 4.3% (38/884), respectively. For all clinicopathological characteristics, no significant difference was observed among the groups of N1, SN2, and NSN2. For the tumor located in each lobe, specific nodal drainage stations were identified: 2R/4R for right upper lobe; 2R/4R and subcarinal node (#7) for right middle lobe and right lower lobe; 4L and subaortic node (#5) for left upper lobe; #7 for left lower lobe. However, there were still a few patients (10.9%, 5/46) had the involvement of lower zone for tumors of upper lobe and the involvement of upper zone for lower lobe.Conclusions: SN2 occurs frequently in patients with small-size NSCLC. Whether lobe-specific selective LND is suitable for all small-size patients deserves more studies to confirm. Surgeons should be more careful when performing selective LND for tumors located in the lower and upper lobes.

An Externally-Validated Dynamic Nomogram Based on Clinicopathological Characteristics for Evaluating the Risk of Lymph Node Metastasis in Small-Size Non-small Cell Lung Cancer.

Background: Lymph node metastasis (LNM) status is of key importance for the decision-making on treatment and survival prediction. There is no reliable method to precisely evaluate the risk of LNM in NSCLC patients. This study aims to develop and validate a dynamic nomogram to evaluate the risk of LNM in small-size NSCLC.Methods: The NSCLC ≤ 2 cm patients who underwent initial pulmonary surgery were retrospectively reviewed and randomly divided into a training cohort and a validation cohort as a ratio of 7:3. The training cohort was used for the least absolute shrinkage and selection operator (LASSO) regression to select optimal variables. Based on variables selected, the logistic regression models were developed, and were compared by areas under the receiver operating characteristic curve (AUCs) and decision curve analysis (DCA). The optimal model was used to plot a dynamic nomogram for calculating the risk of LNM and was internally and externally well-validated by calibration curves.Results: LNM was observed in 12.0% (83/774) of the training cohort and 10.1% (33/328) of the validation cohort (P = 0.743). The optimal model was used to plot a nomogram with six variables incorporated, including tumor size, carcinoembryonic antigen, imaging density, pathological type (adenocarcinoma or non-adenocarcinoma), lymphovascular invasion, and pleural invasion. The nomogram model showed excellent discrimination (AUC = 0.895 vs. 0.931) and great calibration in both the training and validation cohorts. At the threshold probability of 0–0.8, our nomogram adds more net benefits than the treat-none and treat-all lines in the decision curve.Conclusions: This study firstly developed a cost-efficient dynamic nomogram to precisely and expediently evaluate the risk of LNM in small-size NSCLC and would be helpful for clinicians in decision-making.

Characteristics and risk factors of recurrence in clinical stage I non-small cell lung cancer patients undergoing anatomic segmentectomy.

Although lobectomy is the standard surgical procedure for small-sized non-small cell lung cancer (NSCLC), segmentectomy has been performed for various reasons. The aim of this study was to investigate the characteristics of and risk factors for recurrence in early-stage NSCLC patients undergoing segmentectomy. We retrospectively reviewed 179 patients with clinical stage I NSCLC who underwent segmentectomy. Preoperative factors were analyzed using the log-rank test for univariate analyses. Multivariate analyses were performed using a Cox proportional hazards regression model to identify independent risk factors for recurrence. For the significant factors, optimal cutoff points were determined by receiver operating characteristic (ROC) analysis. During the follow-up period of 51months, 18 patients developed recurrence; 5 had locoregional (including 2 with margin recurrences only), 9 had distant, and 4 had both locoregional and distant recurrence. Multivariate and ROC analysis identified radiologic solid tumor size with a cutoff point of 1.5cm as an independent risk factor for recurrence. Three patients in the solid size < 1.5cm group (n = 119) developed recurrence, 2 of whom had surgical margin recurrence, compared to 15 patients in the solid size ≥ 1.5cm group (n = 60). The indication for segmentectomy should be decided upon with caution, and the segments to be resected should be carefully considered to secure an appropriate surgical margin in this low-risk subgroup of patients because they may have a relatively higher risk of surgical margin recurrence, despite being at decreased risk.

Comparison of outcomes following segmentectomy or lobectomy for patients with clinical N0 invasive lung adenocarcinoma of 2cm or less in diameter.

Previous studies have reported similar survival between segmentectomy and lobectomy for patients with small-sized non-small cell lung cancer. However, part of those patients were with adenocarcinoma in situ or minimally invasive adenocarcinoma, which were considered to have a favorable prognosis. We compared survival outcomes of patients with clinical N0 invasive lung adenocarcinomas of no more than 2cm who underwent segmentectomy or lobectomy. Between June 1, 2008, and May 31, 2018, 1018 patients with clinical N0 invasive lung adenocarcinomas of no more than 2cm in diameter on thin-section chest CT scans were retrospectively included in this study. Of them, 214 underwent segmentectomy and 804 underwent lobectomy. Propensity-score matching of preoperative factors, such as gender, age, smoking status, forced expiratory volume in 1 s predicted%, tumor's CT appearance, tumor size on CT scan and tumor location was used to compare survival outcomes of those patients receiving different surgical treatments. Cox proportional hazard regression model was used to identify independent prognostic factors. This study was approved by the Committee for Ethical Review of Research (Fudan University Shanghai Cancer Center IRB# 090977-1). Informed consent was waived because of the retrospective nature of this study. Average follow-up time was 42.5months. Before matching, the lobectomy group had a shorter recurrence-free survival (P = 0.02), but similar overall survival (P = 0.60). After matching, no significant difference of overall survival or recurrence-free survival was found between the two groups (P = 0.70 and P = 0.40, respectively). Our results suggest that segmentectomy achieved similar recurrence-free and overall survival compared with lobectomy for patients with clinical N0 invasive lung adenocarcinomas of no more than 2cm. Therefore, segmentectomy could be an alternative approach. These results need to be further validated by randomized trials.

MS07.04 Stage I (Resectable) NSCLC: Surgery

MS07.04 Stage I (Resectable) NSCLC: Surgery

P3.16-20 Feasibility of Limited Resection for Peripheral Small-Sized Non-Small Cell Lung Cancer According to FDG Accumulation and Imaging Findings

With the progress of diagnostic imaging modalities, such as CT and FDG-PET, the number of resectable lung cancer, particularly small peripheral lung cancer, is increasing. We focused on the SUVmax of FDG-PET as a prognostic factor for lung cancer and established criteria for limited resection on the basis of CT findings and SUVmax. Since 2007, we continuously monitored the recurrence and prognosis of non-small cell lung cancers (NSCLCs) resected using our criteria. Here, we report the results of this study. Between December 2007 and December 2015, 611 consecutive patients underwent surgery for NSCLC at our institution. Of these, 73patients with cT1aN0M0 who underwent limited resection (partial resection or segmentectomy) were enrolled. The criteria for undergoing limited resection were as follows: ①tumor GGO ratio of ≥0.75and ② tumor SUVmax of ≤1.5. GGO ratio was calculated using the following equation: GGO ratio=[(maximum diameter of the tumor) – (maximum diameter of tumor consolidation)] / (maximum diameter of the tumor). The group that met our criteria and underwent limited resection was designated as intended limited resection group (ILR group), and the group subjected to limited surgery without meeting the criteria treated as control group. The study included 35 men and 38 women with a median age of 65 (range, 36–84) years. In total, 51 patients who met our criteria were included in the ILR group, and 21 patients who did not meet the criteria were included in the control group. The control group was selected for limited resection in terms of complications, pulmonary hypofunction, and heart failure. Regarding surgical approach, in the ILR group, 19 patients underwent partial resection and 32 underwent segmentectomy; in the control group, 13 patients underwent partial resection and 8 underwent segmentectomy. According to our criteria, no relapsed cases were reported in the ILR group. Moreover, the 5-year overall survival rates of the ILR and control groups were 100% and 60.5%, respectively, and the disease-free survival rates were 100% and 56.0%, respectively, indicating a significant difference (P < 0.0001). In the control group, 6 patients showed the recurrence of lung cancer. In this study, we analyzed the feasibility of our criteria for performing limited resection on the basis of CT findings and SUVmax. In the ILR group, no relapsed cases were reported, suggesting that our criteria may be useful in determining patient’s eligibility for undergoing reduction surgery.

Appropriate lymphadenectomy significantly reduced recurrence after segmentectomy for patients with non-small cell lung cancer.

Segmentectomy has been widely used for small-sized non-small cell lung cancer (NSCLC). The objective of this study is to determine the impact of number of harvested lymph nodes (LNs) on survival for patients undergoing segmentectomy. The clinicopathologic data of patients undergoing segmentectomy for NSCLC from July 2011 to December 2014 were retrospectively analyzed. Survival analysis was performed by Kaplan-Meier method and Cox regression analysis. A total of 259 patients with NSCLC were eligible for analysis. Patients with harvested LN ≥6 had higher frequency of nodal metastasis in pathologic examination (9.4% vs. 1.5%, P=0.005). The 3-year recurrence-free survival (RFS) of patients with harvested LN ≥6 (90.2%) was significantly higher than that of patients with harvested LN <6 (73.7%, log-rank P=0.038). Multivariable Cox analysis identified harvested LN ≥6 as an independent predictor for improved RFS [hazard ratio (HR) =0.35; 95% confidence interval (CI): 0.14-0.90; P=0.029]. There was no significant difference in RFS between patients with harvested LN station ≥3 and <3 (log-rank P=0.34). The number of harvest LN ≥6 was independently associated with improved RFS for NSCLC patients undergoing segmentectomy, supporting the National Comprehensive Cancer Network (NCCN) guidelines of appropriate LN sampling.

Pulmonary adenocarcinoma possibly developed from the cut-end of small-sized adenocarcinoma in the lung periphery as recurrence 13\xa0years after its wedge resection

BackgroundIt is a big topic for general thoracic surgery whether still curability can be obtained by limited resection for peripheral small-sized nodules of non-small cell lung cancer (NSCLC) in the current era of frequent computed tomography (CT) use. Accumulation of information on problematic cases would be meaningful for surgeons to select better surgical procedures.Case presentationA 69-year-old man was pointed out an enlarged 2.1-cm solid nodule on the edge of staple line of the residual right upper lobe by chest CT. He had past history of the lung cancer surgery, wedge resection of the same right upper lobe 13 years ago. The pathological findings were 1.1-cm, p-TlbN0M0, p-stage IA2-adenocarcinoma. Thereafter, he received no adjuvant therapy. This time, the trans-bronchial lung biopsy revealed adenocarcinoma. After the completion lobectomy of the residual right upper lobe, the tumor was diagnosed as adenocarcinoma consistent with recurrence of small-sized adenocarcinoma in the lung periphery developed from the cut-end because of similarities between present and previous tumors on histopathology and p53-positivity.ConclusionsWhen limited resection has been performed for small-sized NSCLC presenting solid nodule on thin-slice CT images, long-term postoperative follow-up time will be necessary for monitoring, considering the possibility of cut-end recurrence.

Lobectomy versus Sublobar Resection in Non-Lepidic Small-Sized Non-Small Cell Lung Cancer.

BackgroundRecently, many surgeons have chosen sublobar resection for the curative treatment of lung tumors with ground-glass opacity, which is a hallmark of lepidic lung cancer. The purpose of this study was to evaluate the oncological results of sublobar resection for non-lepidic lung cancer in comparison with lobectomy.MethodsWe conducted a retrospective chart review of 328 patients with clinical N0 non-small cell lung cancer sized ≤2 cm who underwent curative surgical resection from January 2009 to December 2014. The patients were classified on the basis of their lesions into non-lepidic and lepidic groups. The survival rates following lobectomy and sublobar resection were compared within each of these 2 groups.ResultsThe non-lepidic group contained a total of 191 patients. The 5-year recurrence-free survival rate was not significantly different between patients who received sublobar resection or lobectomy in the non-lepidic group (80.1% vs. 79.2%, p=0.822) or in the lepidic group (100% vs. 97.4%, p=0.283). Multivariate analysis indicated that only lymphatic invasion was a significant risk factor for recurrence in the non-lepidic group. Sublobar resection was not a risk factor for recurrence in the non-lepidic group.ConclusionThe oncological outcomes of sublobar resection and lobectomy in small-sized non-small cell lung cancer did not significantly differ according to histological type.

Association Between PD-L1 Expression and Metabolic Activity on 18F-FDG PET/CT in Patients with Small-sized Lung Cancer.

We evaluated the metabolic characteristics of small-sized lung cancer using 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) with regard to programmed cell death ligand 1 (PD-L1) expression. PD-L1 expression was evaluated by immunohistochemistry with the antibody clone SP142 in 263 patients with surgically resected primary small-sized lung cancer. Specimens with <5% tumor membrane staining were considered negative. We examined the association between the frequency of PD-L1 expression and the maximum standardized uptake value (SUVmax) in preoperative 18F-FDG PET/CT. Among patients with non-small cell lung cancer (NSCLC), the SUVmax was significantly higher in those with PD-L1 expression than in those without (p<0.0001). However, there was no correlation between SUVmax and PD-L1 expression in patients with neuroendocrine tumors (p=0.9638). Multivariate analysis revealed that smoking and a high SUVmax were independent predictors of PD-L1 expression. PD-L1 expression was related to high glucose metabolism in small-sized NSCLC.

PC 01.01 SABR as First Line Treatment Option

SBRT for small-sized non-small cell lung cancer: Surgery has historically been the primary treatment option for patients with Stage I non–small-cell lung cancer (NSCLC). Although Stage I NSCLC is technically curable, the presence of significant co morbidity increases the risk of postoperative complications and reduces the potential role of surgery even early stage NSCLC. Because nonsurgical treatment options such as conventional radiotherapy have historically achieved suboptimal outcomes, some have argued that the risks associated with surgery in patients with severe COPD were justified. The reason for poor tumor control with conventional radiation therapy has been shown to be due to insufficient total radiation doses, which is usually 60 Gy or lower. Dose escalation with CRT have shown that a total dose of just above 80 Gy seems to be tolerable while doses exceeding 90 Gy, necessary for optimal tumor control, were associated with high risk of unacceptable lung toxicity. Since the 2000s, stereotactic body radiation therapy has rapidly spread as medical physics improved. Stereotactic body radiation therapy has been revealed to be equivalent to surgery in tumor ablation. With stereotactic body radiotherapy (SBRT) the radiation dose to normal tissue is minimized and the dose per fraction can be increased resulting in biologic doses up to twice as high as in CRT. This has resulted in improvement of local tumor control rates up to 88% to 100%, comparable to the rates after surgery. SBRT is a safe and effective treatment option for these patients, with outcomes that do not appear to be inferior to surgery. SBRT is not associated with the considerable initial risks of operative mortality and prolonged hospitalization. Patients who do undergo surgery may benefit from avoiding open lobectomy, instead using less invasive approaches such as video-assisted thoracoscopic surgery or open segmentectomy. All patients with Stage I NSCLC and severe COPD should be evaluated in a multidisciplinary setting and afforded an informed decision of the risks and benefits of both surgery and SBRT. In role of SBRT can also be extended even in patients with oligometastases and oligo-recurrence, the oligometastases and oligo-recurrence who sometimes cured with only local therapy. Radiotherapy (RT) can cause immunogenic tumor cell death resulting in cross-priming of tumor-specific T-cells, acting as an in situ tumor vaccine; however, SBRT alone has limit in inducing effective anti-tumor immunity resulting in systemic tumor rejection. Immunotherapy can complement SBRT to help overcome tumor-induced immune suppression, as demonstrated in many pre-clinical tumor models. There are many trials underway for combinations of different immunotherapies and SBRT. SBRT, early stage NSCLC, inoperable

P3.04-011 A Prospective Study to Optimize the Extent of Pulmonary Resection According to Decision-Making Algorithm in cStage IA NSCLC

Recent advances in imaging technology and the widespread use of low-dose computed tomography screening have greatly increased the chance of detecting small-sized non-small cell lung cancer (NSCLC) with indolent features (radiologically ground-glass opacity and histopathologically lepidic pattern adenocarcinoma). This change in the disease pattern of NSCLC has led to a resurgence of interest in sublobar resection. The purpose of this study is to determine the outcome of patients with clinical stage IA NSCLC treated by 3 types of surgical resection (wide wedge resection, segmentectomy, or lobectomy) according to the institutional decision-making algorithm.

Invited Commentary

Invited Commentary

Impact of multiple malignancies on surgical outcomes in patients with 1cm or smaller non-small cell lung cancer.

Because most patients with small-sized non-small cell lung cancer (NSCLC) are asymptomatic, their lesions are detected by cancer screenings or routine checkups for other diseases. Incidences of multiple malignancies have been reported to be 27% in patients with stage I-III NSCLC. Some patients have treatment histories for other malignancies, and their small-sized NSCLC was incidentally detected during follow-up. There is no established report regarding the influence of multiple malignancies on small-sized NSCLC prognosis. Therefore, we investigated the correlation between multiple malignancies and surgical outcomes in patients with small-sized NSCLC. In total, 44 patients underwent definitive pulmonary resection for NSCLC of 1cm or smaller between January 2003 and December 2012. Tumor size was measured by macroscopic findings of the resected specimens, and we then retrospectively investigated their clinical courses. One patient had hemoptysis symptoms, whereas 43 patients were asymptomatic; among them, NSCLC was detected by examinations for other diseases in 31 patients and by cancer screening in 12 patients. In total, 20 patients (45%) had multiple malignancies. The median follow-up period was 68months. One patient had a recurrence from current NSCLC. No patients died of current NSCLC. The overall 5-year survival rate was 90% for all patients. Patients with multiple malignancies had significantly poorer prognoses compared with those without multiple malignancies (P=0.016). However, patients with treatment intervals of more than 5years had prognoses equivalent to those of patients without multiple malignancies (P=0.829). Only the presence of multiple malignancies was a significantly poor prognostic factor in univariate and multivariate analyses. NSCLC of 1cm or smaller showed good prognoses. The presence of multiple malignancies was a significantly poor prognostic factor, and short treatment intervals also correlated with poor prognosis.