Sublobar Resection without Staging and Lymphadenectomy for Nodules <2 cm Is No Adequate Therapy for Patients with Non-Small Cell Lung Cancer

Background: Anatomical resection remains the gold standard for early-stage non–small cell lung cancer (NSCLC). Lobectomy with radical lymphadenectomy is accepted to be the treatment of choice, providing the best overall survival. Due to the widespread use of high-resolution computed tomography, there is an increase in detecting small-sized nodules. Hence, the margin of pulmonary resection required to achieve complete resection of the malignancy has been an eagerly debated issue in the last years. Thus, there is a special interest in the selective use of sublobar, parenchyma-sparing resection techniques in the management of small < 2 cm nodules. The comparison of long-term survival rates between lobectomy and sublobar resections are discussed controversially. Not least because many studies dealing with sublobar resection do not perform guideline-based staging and little to no lymphadenectomy intraoperatively. In addition, some studies do not present data on long-term survival rates. Here, we evaluated postoperative nodal upstaging and the occurrence of lymphangiosis and hemangiosis carcinomatosa in patients with nodules < 2 cm.

Method: A total of 747 patients underwent surgery for NSCLC at our institution between 2012 and 2020. We retrospectively reviewed data of NSCLC patients with <2 cm nodules (n = 236). Nodal upstaging and L1 were analyzed. pN0 patients were compared with patients with nodal upstaging. 1-, 3-, and 5-year survival rates were measured.

Results: The mean tumor size was 1.4 cm ± 0.39 in our cohort. 14% of our patients showed a cT1a tumor and 86% of patients showed a cT1b tumor. 24.0 ± 12.3 lymph nodes were dissected and analyzed per patient, and 0.7 ± 2.0 of those were affected. 16.1% of patients showed an L1 affection and 7.6% a V1 affection. 11 (4.7%) patients were diagnosed with a lymph node involvement preoperatively. 39 (16.5%) patients were upstaged due to lymph node involvement postoperatively (p < 0.001). Upstaged patients showed significantly worse 3- (upstaged: 60.6% vs. pN0: 83.2%; p = 0.01) and 5-year (upstages: 38% vs. pN0 71.5%; p = 0.02) survival rates.

Conclusion: The present study demonstrates that 16.5% of patients with <2 cm nodules were nodal upstaged postoperatively. Hence 1.3% of patients were diagnosed in stage IIIa preoperatively and 11.9% postoperatively. These results underline that lymphadenectomy during surgery is crucial for NSCLC patients irrespective of the tumor size and the surgical approach.

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
03 February 2022