Dataset Information

Segmentectomy and Wedge Resection for Elderly Patients with Stage I Non-Small Cell Lung Cancer: A Systematic Review and Meta-Analysis.

ABSTRACT:

Background

Considerable controversies exist regarding the efficacies of segmentectomy and wedge resection for elderly patients with early-stage non-small cell lung cancer (NSCLC). This systematic review and meta-analysis aimed to solve these issues.

Methods

We searched the online databases PubMed, Web of Science, EMBASE, and Cochrane Library to identify eligible studies. Elderly patients were defined as ≥65 years. Early-stage NSCLC was defined as stage I based on TNM systems. The primary endpoints were survival outcomes (overall survival (OS), cancer-specific survival (CSS), and disease-free survival (DFS)) and recurrence patterns. The second endpoints were perioperative morbidities. The hazard rate (HR) and odds ratio (OR) were effect sizes.

Results

Sixteen cohort studies (3140 participants) and four database studies were finally included. Segmentectomy and lobectomy showed no significant difference in OS (cohort studies HR 1.00, p = 0.98; database studies HR 1.07, p = 0.14), CSS (HR 0.91, p = 0.85), or DFS (HR 1.04, p = 0.78) in elderly patients with stage I NSCLC. In contrast, wedge resection showed inferior OS (HR 1.28, p < 0.001), CSS (HR 1.17, p = 0.001) and DFS (HR 1.44, p = 0.042) compared to lobectomy. Segmentectomy also showed comparable local recurrence risk with lobectomy (OR 0.98, p = 0.98), while wedge resection showed increased risk (OR 5.46, p < 0.001). Furthermore, sublobar resections showed a decreased risk of 30/90-day mortality, pneumonia, and leak complications compared to lobectomy.

Conclusion

Segmentectomy is promising when applied to elderly patients with stage I NSCLC, while wedge resection should be limited. Randomized controlled trials are warranted to validate these findings.

SUBMITTER: Wang P

PROVIDER: S-EPMC8782039 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:The incidence of early-stage non-small cell lung cancer (NSCLC) among the elderly is expected to rise dramatically owing to demographic trends and increased computed tomographic screening. However, to our knowledge, no modern trials have compared the most common treatments for NSCLC.To determine clinical characteristics and survival outcomes associated with the 3 most commonly used definitive therapies for early-stage NSCLC in the elderly.The Surveillance, Epidemiology, and End Results database linked to Medicare was used to determine the baseline characteristics and outcomes of 9093 patients with early-stage, node-negative NSCLC who underwent definitive treatment consisting of lobectomy, sublobar resection, or stereotactic ablative radiotherapy (SABR) from January 1, 2003, through December 31, 2009.Overall and lung cancer-specific survival were compared using Medicare claims through December 31, 2012. We used proportional hazards regression and propensity score matching to adjust outcomes for key patient, tumor, and practice environment factors.The median age was 75 years, and treatment distribution was 79.3% for lobectomy, 16.5% for sublobar resection, and 4.2% for SABR. Unadjusted 90-day mortality was highest for lobectomy (4.0%) followed by sublobar resection (3.7%; P = .79) and SABR (1.3%; P = .008). At 3 years, unadjusted mortality was lowest for lobectomy (25.0%), followed by sublobar resection (35.3%; P < .001) and SABR (45.1%; P < .001). Proportional hazards regression demonstrated that sublobar resection was associated with worse overall survival (adjusted hazard ratio [AHR], 1.32 [95% CI, 1.20-1.44]; P < .001) and lung cancer-specific survival (AHR, 1.50 [95% CI, 1.29-1.75]; P < .001) compared with lobectomy. Propensity score-matching analysis reiterated these findings for overall survival (AHR, 1.36 [95% CI, 1.17-1.58]; P < .001) and lung cancer-specific survival (AHR, 1.46 [95% CI, 1.13-1.90]; P = .004). In proportional hazards regression, SABR was associated with better overall survival than lobectomy in the first 6 months after diagnosis (AHR, 0.45 [95% CI, 0.27-0.75]; P < .001) but worse survival thereafter (AHR, 1.66 [95% CI, 1.39-1.99]; P < .001). Propensity score-matching analysis of well-matched SABR and lobectomy cohorts demonstrated similar overall survival in both groups (AHR, 1.01 [95% CI, 0.74-1.38]; P = .94).Lobectomy was associated with better outcomes than sublobar resection in elderly patients with early-stage NSCLC. Propensity score matching suggests that SABR may be a good option among patients with very advanced age and multiple comorbidities.

Project description:BackgroundLobectomy has long been regarded as the standard treatment for operable non-small cell lung cancer (NSCLC). Recent studies suggested that segmentectomy could achieve a good prognosis for early-stage NSCLC and might be an alternative to lobectomy in this cohort. Until now, on the issue of comparison between lobectomy and segmentectomy, there remains no published randomized controlled trial (RCT), and all existing evidence is low. Recently, a categorization of lower-level evidence has been proposed, namely, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. The aim of this meta-analysis is to compare the oncologic outcome between lobectomy and segmentectomy in NSCLC with the clinical T1N0M0 stage according to the GRADE system.MethodsPubMed, the PMC database, EMBASE, Web of Science, and the Cochrane library were searched prior to May 2019 to identify studies that compared the prognosis between lobectomy and segmentectomy for clinical T1N0M0 NSCLC. The evidence level of the included studies was assessed according to the GRADE system, including level IIA, probably not confounded nonrandomized comparison; level IIB, possibly confounded nonrandomized comparison; and level IIC, probably confounded nonrandomized comparison. The predefined outcomes included overall survival (OS) and disease-free survival (DFS). Univariable and multivariable hazard ratios (HRs) with 95% confidence intervals (95% CI) were pooled using a random-effects model.ResultsTwelve nonrandomized studies involving 8,072 participants were included. Of these studies, two were classified as IIA level (16.7%), six as IIB level (50.0%), and four as IIC level (33.3%). When crude HRs were included, compared with lobectomy, segmentectomy was associated with shorter OS but comparable DFS in the entire cohort (OS, pooled HR =1.45, 95% CI, 1.23 to 1.67; DFS, pooled HR =1.03, 95% CI, 0.65 to 1.82) and in patients with nodules ?2 cm (OS, pooled HR =1.55, 95% CI, 1.33 to 1.80; DFS, pooled HR =0.98, 95% CI, 0.55 to 1.77). When adjusted HRs were included, the impact of segmentectomy on OS and DFS was comparable to that of lobectomy in the entire cohort (OS, pooled HR =1.39, 95% CI, 0.92 to 2.10; DFS, pooled HR =0.83, 95% CI, 0.66 to 1.03) and in patients with nodules ?2 cm (OS, pooled HR =1.61, 95% CI, 0.87 to 3.00; DFS, pooled HR =0.90, 95% CI, 0.63 to 1.27).ConclusionsBased on our results, although shorter OS is observed in patients received segmentectomy, it is necessary to wait for more results from RCT to draw a valid conclusion.