Chest
Volume 142, Issue 6, December 2012, Pages 1620-1635
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Evidence-Based Medicine
American College of Chest Physicians and Society of Thoracic Surgeons Consensus Statement for Evaluation and Management for High-Risk Patients With Stage I Non-small Cell Lung Cancer

https://doi.org/10.1378/chest.12-0790Get rights and content

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.

Section snippets

Executive Summary

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 lobectomy candidates because of severe medical comorbidity. Despite high competitive mortality from underlying lung disease, the mortality related to untreated NSCLC cannot be ignored except in patients who are severely debilitated by their comorbidity, with limited life expectancy. A

Materials and Methods

Task forces were independently assembled through the Workforce on Evidence-Based Surgery of the Society of Thoracic Surgeons (STS) and the Thoracic Oncology Network of the American College of Chest Physicians (ACCP) to address high-risk patients with stage I NSCLC, because of commonality of interest, efforts were combined and a multidisciplinary writing committee was assembled. Relevant population, intervention, comparison, and outcome (PICO) questions were formulated and provided to an

Medical Assessment

Morbidity following lobectomy via thoracotomy is not trivial, with a 30% to 40% incidence of postoperative complications and 1% to 5% operative mortality rate.1, 2, 3 Although morbidity is high, many complications do not contribute meaningfully to risk/benefit decisions, such as urinary tract infections, whereas others, including respiratory failure, can significantly impact survival and quality of life. Respiratory failure remains the leading cause of morbidity and mortality after lobectomy.

Discussion

The tendency for early metastasis from NSCLC makes treatment with localized therapies challenging. SBRT, RFA, and sublobar resection have been associated with increased risk for involved lobe and regional recurrence compared with lobectomy. Improvements in radiographic staging and detection of earlier and more indolent cancers tip the risk/benefit balance for high-risk stage I NSCLC toward less radical interventions. Evidence suggests that in well-staged and properly selected patients, sublobar

Summary

There are now several treatment options available for high-risk patients with stage I NSCLC. A multidisciplinary approach is essential for the management of individual high-risk patients with NSCLC, and a similar approach is required on an organizational level to further define the appropriate use of each modality.

Acknowledgments

Author contributions: Dr Donington takes responsibility for the integrity of the work.

Dr Donington: contributed to the conception and design of study, PICO question formation, review of records, analysis and interpretation of evidence, formation of suggestions, suggestions consensus, drafting of manuscript, manuscript editing, and approval of the published version.

Dr Ferguson: contributed to the design of study, review of records, analysis and interpretation of evidence, formation of

References (117)

  • K Nezu et al.

    Recovery and limitation of exercise capacity after lung resection for lung cancer

    Chest

    (1998)
  • MK Ferguson et al.

    Pulmonary complications after lung resection in the absence of chronic obstructive pulmonary disease: the predictive role of diffusing capacity

    J Thorac Cardiovasc Surg

    (2009)
  • GL Colice et al.

    Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition)

    Chest

    (2007)
  • A Brunelli et al.

    Peak oxygen consumption during cardiopulmonary exercise test improves risk stratification in candidates to major lung resection

    Chest

    (2009)
  • P Pate et al.

    Preoperative assessment of the high-risk patient for lung resection

    Ann Thorac Surg

    (1996)
  • DA Holden et al.

    Exercise testing, 6-min walk, and stair climb in the evaluation of patients at high risk for pulmonary resection

    Chest

    (1992)
  • RC Lilenbaum et al.

    Prevalence of poor performance status in lung cancer patients: implications for research

    J Thorac Oncol

    (2008)
  • JR Handy et al.

    What happens to patients undergoing lung cancer surgery? Outcomes and quality of life before and after surgery

    Chest

    (2002)
  • T Schulte et al.

    The extent of lung parenchyma resection significantly impacts long-term quality of life in patients with non-small cell lung cancer

    Chest

    (2009)
  • NC van der Voort van Zyp et al.

    Quality of life after stereotactic radiotherapy for stage I non-small-cell lung cancer

    Int J Radiat Oncol Biol Phys

    (2010)
  • R Lencioni et al.

    Response to radiofrequency ablation of pulmonary tumours: a prospective, intention-to-treat, multicentre clinical trial (the RAPTURE study)

    Lancet Oncol

    (2008)
  • RJ Jensik et al.

    Segmental resection for lung cancer. A fifteen-year experience

    J Thorac Cardiovasc Surg

    (1973)
  • RJ Ginsberg et al.

    Modern thirty-day operative mortality for surgical resections in lung cancer

    J Thorac Cardiovasc Surg

    (1983)
  • RJ Keenan et al.

    Segmental resection spares pulmonary function in patients with stage I lung cancer

    Ann Thorac Surg

    (2004)
  • H Harada et al.

    Functional advantage after radical segmentectomy versus lobectomy for lung cancer

    Ann Thorac Surg

    (2005)
  • M Okada et al.

    Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study

    J Thorac Cardiovasc Surg

    (2006)
  • D Kondo et al.

    Peripheral lung adenocarcinomas: 10 mm or less in diameter

    Ann Thorac Surg

    (2003)
  • T Koike et al.

    Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer

    J Thorac Cardiovasc Surg

    (2003)
  • T Osaki et al.

    Surgical treatment of lung cancer in the octogenarian

    Ann Thorac Surg

    (1994)
  • CM Mery et al.

    Similar long-term survival of elderly patients with non-small cell lung cancer treated with lobectomy or wedge resection within the surveillance, epidemiology, and end results database

    Chest

    (2005)
  • M Okada et al.

    Effect of tumor size on prognosis in patients with non-small cell lung cancer: the role of segmentectomy as a type of lesser resection

    J Thorac Cardiovasc Surg

    (2005)
  • HC Fernando et al.

    Lobar and sublobar resection with and without brachytherapy for small stage IA non-small cell lung cancer

    J Thorac Cardiovasc Surg

    (2005)
  • N Sawabata et al.

    Optimal distance of malignant negative margin in excision of nonsmall cell lung cancer: a multicenter prospective study

    Ann Thorac Surg

    (2004)
  • W Lee et al.

    Limited resection for non-small cell lung cancer: observed local control with implantation of I-125 brachytherapy seeds

    Ann Thorac Surg

    (2003)
  • R Santos et al.

    Comparison between sublobar resection and 125Iodine brachytherapy after sublobar resection in high-risk patients with Stage I non-small-cell lung cancer

    Surgery

    (2003)
  • HC Fernando et al.

    Thirty- and ninety-day outcomes after sublobar resection with and without brachytherapy for non-small cell lung cancer: results from a multicenter phase III study

    J Thorac Cardiovasc Surg

    (2011)
  • HC Fernando et al.

    The impact of adjuvant brachytherapy with sublobar resection on pulmonary function and dyspnea in high-risk patients with operable disease: preliminary results from the American College of Surgeons Oncology Group Z4032 trial

    J Thorac Cardiovasc Surg

    (2011)
  • RC McGarry et al.

    Observation-only management of early stage, medically inoperable lung cancer: poor outcome

    Chest

    (2002)
  • JP Wisnivesky et al.

    Radiation therapy for the treatment of unresected stage I-II non-small cell lung cancer

    Chest

    (2005)
  • X Qiao et al.

    The role of radiotherapy in treatment of stage I non-small cell lung cancer

    Lung Cancer

    (2003)
  • MP Campeau et al.

    Local control and survival following concomitant chemoradiotherapy in inoperable stage I non-small-cell lung cancer

    Int J Radiat Oncol Biol Phys

    (2009)
  • M Chen et al.

    Long-term results of high-dose conformal radiotherapy for patients with medically inoperable T1-3N0 non-small-cell lung cancer: is low incidence of regional failure due to incidental nodal irradiation?

    Int J Radiat Oncol Biol Phys

    (2006)
  • LC Fang et al.

    Comparison of outcomes for patients with medically inoperable Stage I non-small-cell lung cancer treated with two-dimensional vs. three-dimensional radiotherapy

    Int J Radiat Oncol Biol Phys

    (2006)
  • AJ Fakiris et al.

    Stereotactic body radiation therapy for early-stage non-small-cell lung carcinoma: four-year results of a prospective phase II study

    Int J Radiat Oncol Biol Phys

    (2009)
  • M Koto et al.

    A phase II study on stereotactic body radiotherapy for stage I non-small cell lung cancer

    Radiother Oncol

    (2007)
  • QT Le et al.

    Results of a phase I dose-escalation study using single-fraction stereotactic radiotherapy for lung tumors

    J Thorac Oncol

    (2006)
  • RC McGarry et al.

    Stereotactic body radiation therapy of early-stage non-small-cell lung carcinoma: phase I study

    Int J Radiat Oncol Biol Phys

    (2005)
  • H Onishi et al.

    Hypofractionated stereotactic radiotherapy (HypoFXSRT) for stage I non-small cell lung cancer: updated results of 257 patients in a Japanese multi-institutional study

    J Thorac Oncol

    (2007)
  • U Ricardi et al.

    Stereotactic body radiation therapy for early stage non-small cell lung cancer: results of a prospective trial

    Lung Cancer

    (2010)
  • T Xia et al.

    Promising clinical outcome of stereotactic body radiation therapy for patients with inoperable Stage I/II non-small-cell lung cancer

    Int J Radiat Oncol Biol Phys

    (2006)
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