Jessica Donington1, Mark Ferguson2, Peter Mazzone3, John Handy4, Matthew Schuchert5, Hiran Fernando6, Billy Loo7, Michael Lanuti8, Alberto de Hoyos9, Frank Detterbeck10, Arjun Pennathur5, John Howington11, Rodney Landreneau5, Gerard Silvestri12. 1. Department of Cardiothoracic Surgery, NYU School of Medicine, New York, NY. Electronic address: Jessica.donington@nyumc.org. 2. Department of Surgery, University of Chicago, Chicago, IL. 3. Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic Foundation, Cleveland, OH. 4. Providence Cancer Center, Portland, OR. 5. Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. 6. Department of Cardiothoracic Surgery, Boston Medical Center, Boston, MA. 7. Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA. 8. Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA. 9. Department of Cardiothoracic Surgery, Northwestern Memorial Hospital, Chicago, IL. 10. Department of Thoracic Surgery, Yale University School of Medicine, New Haven, CT. 11. Department of Surgery, Northshore University Health System, Evanston, IL. 12. Division of Pulmonary Medicine and Critical Care, Medical University of South Carolina, Charleston, SC.
Abstract
BACKGROUND: The standard treatment of stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I NSCLC are not candidates for lobectomy because of severe medical comorbidity. METHODS: A panel of experts was convened through the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. Following a literature review, the panel developed 13 suggestions for evaluation and treatment through iterative discussion and debate until unanimous agreement was achieved. RESULTS: Pretreatment evaluation should focus primarily on measures of cardiopulmonary physiology, as respiratory failure represents the greatest interventional risk. Alternative treatment options to lobectomy for high-risk patients include sublobar resection with or without brachytherapy, stereotactic body radiation therapy, and radiofrequency ablation. Each is associated with decreased procedural morbidity and mortality but increased risk for involved lobe and regional recurrence compared with lobectomy, but direct comparisons between modalities are lacking. CONCLUSIONS: Therapeutic options for the treatment of high-risk patients are evolving quickly. Improved radiographic staging and the diagnosis of smaller and more indolent tumors push the risk-benefit decision toward parenchymal-sparing or nonoperative therapies in high-risk patients. Unbiased assessment of treatment options requires uniform reporting of treatment populations and outcomes in clinical series, which has been lacking to date.
BACKGROUND: The standard treatment of stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic mediastinal lymph node evaluation. Unfortunately, up to 25% of patients with stage I NSCLC are not candidates for lobectomy because of severe medical comorbidity. METHODS: A panel of experts was convened through the Thoracic Oncology Network of the American College of Chest Physicians and the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons. Following a literature review, the panel developed 13 suggestions for evaluation and treatment through iterative discussion and debate until unanimous agreement was achieved. RESULTS: Pretreatment evaluation should focus primarily on measures of cardiopulmonary physiology, as respiratory failure represents the greatest interventional risk. Alternative treatment options to lobectomy for high-risk patients include sublobar resection with or without brachytherapy, stereotactic body radiation therapy, and radiofrequency ablation. Each is associated with decreased procedural morbidity and mortality but increased risk for involved lobe and regional recurrence compared with lobectomy, but direct comparisons between modalities are lacking. CONCLUSIONS: Therapeutic options for the treatment of high-risk patients are evolving quickly. Improved radiographic staging and the diagnosis of smaller and more indolent tumors push the risk-benefit decision toward parenchymal-sparing or nonoperative therapies in high-risk patients. Unbiased assessment of treatment options requires uniform reporting of treatment populations and outcomes in clinical series, which has been lacking to date.
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