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Surgery With Lymph Node Examination ‘Best’ Approach For Early NSCLC Survival

Patients with early-stage non-small-cell lung cancer have better survival with surgery and regional lymph node assessment versus stereotactic body radiotherapy
21 Nov 2019
Non-Small Cell Lung Cancer;  Radiation Oncology;  Surgical Oncology;  Therapy
By Lynda Williams, Senior medwireNews Reporter

Author: By Lynda Williams, Senior medwireNews Reporter

medwireNews: Analysis of data from the US National Cancer Database confirms that lobectomy with adequate regional lymph node assessment offers the best overall survival (OS) for patients with early-stage non-small-cell lung cancer (NSCLC). 

“Our findings are consistent with previous studies and the current guidelines, which support lobectomy with adequate regional lymph node assessment to be the standard of care in operable patients with [early-stage] NSCLC, say Alexander Chi, from Marshfield Clinic in Wisconsin, USA, and co-authors in JAMA Network Open. 

The team collated information for 104,709 patients were who were diagnosed with T1–3 N0M0 primary NSCLC between 2004 and 2015, 91,330 of whom were treated with surgery with curative intent, most commonly lobectomy (79.3%) or wedge resection (14.7%). These patients underwent examination of 1–10 (55.8%), 11–15 (15.6%) and more than 15 (14.2%) regional lymph nodes, respectively. 

The remaining 13,379 patients received stereotactic body radiotherapy (SBRT), of whom 4.2% had a limited regional lymph node examination and 3.9% regional lymph node aspiration or biopsy. 

Five-year OS ranged from 48.1% to 64.6% with surgery versus 30.4% with SBRT, giving a significant hazard ratio (HR) in favour of surgery, regardless of whether lobectomy (HR=0.40), segmentectomy (HR=0.48), wedge resection (HR=0.55) or pneumonectomy (HR=0.71). 

And 5-year OS was further improved when surgery included regional lymph node surgery (63.6 vs 48.8% for no lymph node surgery, HR=0.66). The 5-year OS rate was 50.2% for patients with no nodes examined, increasing to 62.9% with 1–10, 65.3% for 11–15 and 64.6% for more than 15 lymph nodes, respectively. 

By contrast, neither limited examination, nor aspiration/biopsy of regional lymph nodes, significantly improved OS for the SBRT cohort, the researchers note. 

Multivariable analysis indicated that younger age, fewer comorbidities, and tumour characteristics such as having a single nodule or adenocarcinoma histology were significantly associated with improved OS. 

After adjusting for confounding factors, however, OS was significantly better with receipt of lobectomy (HR=0.53), segmentectomy (HR=0.60), wedge resection (HR=0.67) or pneumonectomy (HR=0.75) compared with SBRT. 

And examination of more than 10 or more than 15 lymph nodes also independently reduced the risk of death compared with no lymph node check (both HR=0.73), the investigators say. 

Nevertheless, Alexander Chi et al found that the survival benefit associated with surgery did vary with patient age, the extent of surgery and lymph node examination, and tumour stage. For example, there was a reduced risk of mortality with pneumonectomy plus lymph node examination for patients aged less than 80 years compared with SBRT but for such patients with T1 disease, this only occurred if 15 or fewer nodes were assessed.  

Furthermore, pneumonectomy did not offer a survival benefit for patients older than 80 years regardless of lymph node examination, say the researchers, who suggest that elderly patients may be at particular risk for increased morbidity and mortality from extensive primary or lymph node surgery as they are “less likely to tolerate surgery owing to increased likelihood of frailty and comorbidities”. 

They conclude: “As a result, SBRT may be a reasonable alternative treatment in these situations.”  



Chi A, Fang W, Sun Y, Wen S. Comparison of long-term survival of patients with early-stage non-small-cell lung cancer after surgery vs stereotactic body radiotherapy. JAMA Netw Open 2019; 2: e1915724. doi:10.1001/jamanetworkopen.2019.15724

Last update: 21 Nov 2019

medwireNews (www.medwireNews.com) is an independent medical news service provided by Springer Healthcare. © 2019 Springer Healthcare part of the Springer Nature group

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