Erin Gillaspie, MD, MPH, FACS, a faculty member of Vanderbilt University Medical Center’s (VUMC's) department of thoracic surgery, discussed trials that helped lung cancer surgeries evolve.
Erin Gillaspie, MD, MPH, FACS, of Vanderbilt University Medical Center (VUMC), discussed trials that helped to evolve lung cancer surgery as thoracic surgeons now consider lobectomies over segment or wedge resection.
Gillaspie is a faculty member of VUMC’s department of thoracic surgery and an assistant professor of thoracic surgery. She also presented at The American Journal of Managed Care®’s Institute for Value-Based Medicine® held in Nashville, Tennessee on August 17, 2023.
How is surgery in lung cancer evolving by considering lobectomy versus segment or wedge resection?
We had this major landmark trial that came out in thoracic surgery that has been 15 years in the making. It's called the CALGB 140503 trial, and I have to give a major shoutout to Dr. Altorki, who was really the heart and soul of this trial and helped it to come to fruition.
The inspiration behind this was we're finding cancers that are smaller and smaller, our CT scans are getting better and better, we're finding subsolid lesions. The idea of taking out an entire lobe for something that sometimes comes back as just a couple of millimeters of invasive cancer really didn't feel like we're doing the right thing for patients. The historic precedent was always that we needed to do a lobectomy, and there were actually even trials establishing that as the definitive treatment from the Lung Cancer Study Group back in 1995.
Dr. Altorki put this really thoughtful trial together. He took tumors that were 2 centimeters or less with pathologically staged mediastinals. We had to actually sample 2 and 2 lymph node stations, and 1 and 1 lymph node station and send that all to pathology while the patient was on the operating table, and they would measure our tumor, they would check to make sure our lymph nodes were negative, and then we'd call them, and the patients were randomized to a lobar or sublobar resection.
For the patients who were having a sublobar resection, that means anything less than a lobe, so that could be a wedge resection, or a segmentectomy, and that was left up to the treating surgeon. What they looked for is a couple of different things. One, they wanted to look at surgical outcomes. Are we doing both types of surgery very safely? Are we having equal length of stays, equal morbidity, equal mortality? Two, how did this impact pulmonary function? That’s one of the big quality of life pieces for patients, how well are they breathing after these surgeries?
Then, they looked at their long-term outcomes, so disease-free survival, overall survival, then recurrence, and pattern of recurrence. What they found was that surgery can be performed very, very safely in both groups, which is fantastic.
There were some differences in pulmonary function, however, they weren't really as statistically significantly different as expected. Actually, a little less of a decline than expected for the lobectomy patients, which is actually a good thing because that tells us we can also safely do a lobectomy for the patients who need it.
The other piece to this, so disease-free survival was noninferior, so that's one of our oncologic outcomes, which is really critical. So, our disease-free survival is noninferior, and our overall survival is also noninferior for our sublobar resection group; we can do the surgery safely, and we can have a good oncologic outcome.
The disappointing part of this study for all of us is the recurrence rates, and that's something that just disappoints us about lung cancer in general. As I sort of alluded to before, our recurrence rates, even for very small tumors, are about 35%. Gosh, that's a lot.
So, a couple take-home messages from this. One, I think we need to continue to have a better understanding of tumor biology and what's driving these recurrences. Are there certain pathologic features? Are there certain pet features? Are there behavioral features that we can use to help guide additional therapy? Especially, which of these therapies do we need to be moving even into the earlier setting? Which patients do we need to think about for even these small tumors, potentially some adjuvant treatments, like targeted therapies or immunotherapy?
One of the interesting take-home points of this, and one of the things that a lot of people worried about, was, is there going to be a different pattern of recurrence when we're thinking about lobectomy versus sublobar resection? There wasn't a major difference between those 2 things.
One of my favorite things about a lot of trials like these is they do answer a lot of questions, but they help to develop a lot of new questions, too, which is really fantastic because that helps set us up for the next phase of trials to help continue to make all of our therapies as efficacious as possible for our patients.