M. Fatima2, H. A. Maqsood1, U. Ahmad3, Z. Zaheer2, S. F. Abid2, A. Bajwa2, A. Sehar2, E. Moazzam2, M. H. Khan2, H. A. Cheema2, M. Azhar2, A. Z. Syeda4, R. S. Martins5, A. Khokhar6, S. A. Naqi2 1Yale New Haven Health, Department Of Surgery, New Haven, CT, USA 2King Edward Medical University Lahore, Surgery, Lahore, PUNJAB, Pakistan 3Punjab Medical College, Surgery, Faisalabad, PUNJAB, Pakistan 4University Of Pennsylvania, Surgery, Philadelphia, PA, USA 5Hackensack Meridian Health, Department Of Thoracic Surgery, North Bergen, NEW JERSEY, USA 6King Edward Medical University, Oncology, Lahore, PUNJAB, Pakistan
Introduction:
Although lobectomy has been the treatment of choice for early-stage non-small cell lung cancer (NSCLC), sub-lobar resection (i.e, segmentectomy or wedge resection) has emerged as an alternative over time due to its ability to preserve additional lung function. This meta-analysis explores the survival outcomes of sub-lobar resection versus lobectomy in patients with stage I NSCLC.
Methods:
We conducted a systematic search of PubMed, EMBASE, Scopus, Google Scholar, Clinicaltrials.gov, and the Cochrane Library from inception up to July 28, 2023. We included randomized controlled trials (RCTS) and retrospective or prospective cohort studies that compared survival outcomes of sub-lobar resection and lobectomy patients with stage I NSCLC (tumor size: ≤ 2 cm). We excluded review articles, case reports, case series, database studies, and studies that did not report the data for patients with tumor sizes less than 2 cm. The 95% confidence intervals (95%CI) and hazard ratios (HRs) for overall survival (OS) and disease-free survival (DFS) were calculated using the random-effects model. A p-value of less than 0.05 was considered significant.
Results:
A total of 27 studies, comprising 10,449 patients (sub-lobar resection = 3,558, lobectomy = 6,246), were included in the meta-analysis. Sub-lobar resection demonstrated comparable OS and DFS to lobectomy (OS; HR:1.10, CI:0.94-1.30, P = 0.23, DFS; HR: 1.10, CI: 0.94-1.29, P = 0.23). However, the subgroup analysis according to the reason for limited resection (intentional, compromised, not specified, intentional and compromised) showed that the sub-lobar resection in the compromised subgroup demonstrated a poorer DFS as compared to lobectomy (HR: 1.52, CI: 1.14-2.02, P = 0.004). Whereas in the subgroup analysis by choice of surgery (segmentectomy, lobectomy, wedge resection, or sub-lobar resection), sub-lobar resection showed no significant improvement in DFS as compared to lobectomy. Additionally, there was no significant difference in OS in the results stratified by choice of surgery or patient selection.
Conclusion:
While sub-lobar resection demonstrated comparable survival outcomes to lobectomy for stage I NSCLC however, it was associated with a poorer DFS in the “compromised subgroup”. Additionally, when evaluating the impact of surgical choice, the results did not indicate any significant improvement in DFS or OS with sub-lobar resection when compared to lobectomy. These findings contribute a distinctive perspective to the ongoing discourse surrounding sub-lobar resection versus lobectomy, underscoring the importance of considering patient selection, underlying reasons for limited resection, and surgical choices when determining the most appropriate approach.
