Staging of Early-Stage Lung Cancer without Routine PET in Candidates for Segmentectomy

Abstract

Introduction We aimed to investigate the accuracy of clinical staging without the routine use of positron emission tomography/computed tomography (PET/CT) in patients with cIA1 and cIA2 non-small-cell lung cancer (NSCLC) scheduled for segmentectomy.

Methods A total of 305 consecutive segmentectomies were retrospectively analyzed. Overall survival was calculated using the Kaplan–Meier method. Logistic regression was performed to investigate factors independently associated with pathologic upstaging.

Results The Union for International Cancer Control (UICC) upstaging was found in 86 patients (28%). Upstaged patients had longer operative times (146 ± 46 vs. 131 ± 44 minutes, p = 0.009), a higher number of lymph node resection (17 ± 10 vs. 13 ± 8, p = 0.001), and a higher rate of L1 involvement (34 vs. 16%, p < 0.001) than nonupstaged patients. N1 was found in 10 patients (3%) and N2 in 13 patients (4%). Nodal positive patients had longer operation times (154 ± 50 vs. 133 ± 44 minutes, p = 0.031) and higher rates of R1 (9 vs. 1%, p = 0.006) and L1 (39 vs. 20%, p < 0.026) than patients without nodal involvement. The 3- and 5-year overall survival rates for nonupstaged and upstaged patients were 85 and 67% and 67 and 54%, respectively (p = 0.040). In logistic regression, L1 involvement (odds ratio [OR]: 2.394, p = 0.005) and the number of dissected lymph nodes (OR: 1.037, p = 0.016) were independently associated with upstaging. Patients who received PET as part of clinical staging did not have a significantly lower nodal upstaging.

Conclusion Selective use of PET/CT based on the results of CT may be a viable option for patients with proven or suspected NSCLC up to 2 cm in size.

Keywords

lung cancer - lung cancer treatment (surgery medical) - positron emission tomography - thoracoscopy/VATS

• References

• 1 D'Cunha J, Herndon II JE, Herzan DL. et al; Cancer and Leukemia Group B. Poor correspondence between clinical and pathologic staging in stage 1 non-small cell lung cancer: results from CALGB 9761, a prospective trial. Lung Cancer 2005; 48 (02) 241-246
• 2 Altorki N, Wang X, Kozono D. et al. Lobar or sublobar resection for peripheral stage IA non-small-cell lung cancer. N Engl J Med 2023; 388 (06) 489-498
• 3 Saji H, Okada M, Tsuboi M. et al; West Japan Oncology Group and Japan Clinical Oncology Group. 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. Lancet 2022; 399 (10335): 1607-1617
• 4 Stamatis G, Leschber G, Schwarz B. et al. Survival outcomes in a prospective randomized multicenter phase III trial comparing patients undergoing anatomical segmentectomy versus standard lobectomy for non-small cell lung cancer up to 2 cm. Lung Cancer 2022; 172: 108-116
• 5 National Institute for Health and Care Excellence (NICE). 2019 Exceptional Surveillance of Lung Cancer: Diagnosis and Management (NICE guideline NG122). London: National Institute for Health and Care Excellence (NICE); 2019
• 6 de Groot PM, Chung JH, Ackman JB. et al; Expert Panel on Thoracic Imaging. ACR Appropriateness Criteria^® noninvasive clinical staging of primary lung cancer. J Am Coll Radiol 2019; 16 (5S): S184-S195
• 7 Remon J, Soria JC, Peters S. ESMO Guidelines Committee. Electronic address: [e-mail]. Early and locally advanced non-small-cell lung cancer: an update of the ESMO Clinical Practice Guidelines focusing on diagnosis, staging, systemic and local therapy. Ann Oncol 2021; 32 (12) 1637-1642
• 8 Schütte W, Gütz S, Nehls W. et al. Prävention, Diagnostik, Therapie und Nachsorge des Lungenkarzinoms. Pneumologie 2023; 77 (10) 671-813
• 9 Silvestri GA, Gonzalez AV, Jantz MA. et al. Methods for staging non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143: e211S-e250S
• 10 Heineman DJ, Ten Berge MG, Daniels JM. et al. The quality of staging non-small cell lung cancer in the Netherlands: data from the Dutch lung surgery audit. Ann Thorac Surg 2016; 102 (05) 1622-1629
• 11 Navani N, Fisher DJ, Tierney JF, Stephens RJ, Burdett S. NSCLC Meta-analysis Collaborative Group. The accuracy of clinical staging of stage I-IIIa non-small cell lung cancer: an analysis based on individual participant data. Chest 2019; 155 (03) 502-509
• 12 Kozower BD, Meyers BF, Reed CE, Jones DR, Decker PA, Putnam Jr JB. Does positron emission tomography prevent nontherapeutic pulmonary resections for clinical stage IA lung cancer?. Ann Thorac Surg 2008; 85 (04) 1166-1169 , discussion 1169–1170
• 13 Herder GJ, Kramer H, Hoekstra OS. et al; POORT Study Group. Traditional versus up-front [¹⁸F] fluorodeoxyglucose-positron emission tomography staging of non-small-cell lung cancer: a Dutch cooperative randomized study. J Clin Oncol 2006; 24 (12) 1800-1806
• 14 Gómez-Caro A, Boada M, Cabañas M. et al. False-negative rate after positron emission tomography/computer tomography scan for mediastinal staging in cI stage non-small-cell lung cancer. Eur J Cardiothorac Surg 2012; 42 (01) 93-100 , discussion 100
• 15 Chen D, Mao Y, Wen J. et al. Numbers and stations: impact of examined lymph node on precise staging and survival of radiologically pure-solid NSCLC: a multi-institutional study. JTO Clin Res Rep 2020; 1 (03) 100035
• 16 Liang W, He J, Shen Y. et al. Impact of examined lymph node count on precise staging and long-term survival of resected non-small-cell lung cancer: a population study of the US SEER database and a Chinese multi-institutional registry. J Clin Oncol 2017; 35 (11) 1162-1170
• 17 Saji H, Tsuboi M, Yoshida K. et al. Prognostic impact of number of resected and involved lymph nodes at complete resection on survival in non-small cell lung cancer. J Thorac Oncol 2011; 6 (11) 1865-1871
• 18 Zhu Z, Song Z, Jiao W. et al; Written on behalf of AME Lung Cancer Collaborative Group. A large real-world cohort study of examined lymph node standards for adequate nodal staging in early non-small cell lung cancer. Transl Lung Cancer Res 2021; 10 (02) 815-825
• 19 Huang H, Wang T, Hu B, Pan C. Visceral pleural invasion remains a size-independent prognostic factor in stage I non-small cell lung cancer. Ann Thorac Surg 2015; 99 (04) 1130-1139
• 20 Shimizu K, Yoshida J, Nagai K. et al. Visceral pleural invasion is an invasive and aggressive indicator of non-small cell lung cancer. J Thorac Cardiovasc Surg 2005; 130 (01) 160-165
• 21 Hsu JS, Han IT, Tsai TH. et al. Pleural tags on CT scans to predict visceral pleural invasion of non-small cell lung cancer that does not abut the pleura. Radiology 2016; 279 (02) 590-596
• 22 Zhao LL, Xie HK, Zhang LP. et al. Visceral pleural invasion in lung adenocarcinoma ≤3 cm with ground-glass opacity: a clinical, pathological and radiological study. J Thorac Dis 2016; 8 (07) 1788-1797
• 23 Mathey-Andrews C, Abruzzo AR, Venkateswaran S. et al. Segmentectomy vs lobectomy for early non-small cell lung cancer with visceral pleural invasion. Ann Thorac Surg 2024; 117 (05) 1007-1014
• 24 Kagimoto A, Tsutani Y, Shimada Y. et al. Oncological outcome of segmentectomy for early-stage non-small-cell lung cancer with invasive characteristics: a multicentre study. Eur J Cardiothorac Surg 2022; 62 (02) ezac055
• 25 Lula Lukadi J, Mariolo AV, Ozgur EG. et al. Upstaged from cT1a-c to pT2a lung cancer, related to visceral pleural invasion patients, after segmentectomy: is it an indication to complete resection to lobectomy?. Interdiscip Cardiovasc Thorac Surg 2023; 37 (04) ivad102