Lobectomy improves disease-free survival over sublobar resection for high-risk stage IA non-small cell lung cancer

To investigate disease-free survival (DFS) of sublobar resection versus lobectomy for stage IA non-small cell lung cancer (NSCLC) with preoperative high-risk features.

Data were abstracted from a prospective database to identify patients with clinical T1a-T1bN0M0 NSCLC (≤2 cm) who underwent lobectomy or sublobar resection (wedge resection or segmentectomy). 1:1 propensity matching was used to balance the dataset for forced expiratory volume in 1 second ≥60% and high-risk features: cT1b versus cT1a, standard uptake value of the primary tumor on positron emission tomography, solid versus subsolid tumor texture on computed tomography, and micropapillary/solid histology. The primary outcome was DFS.

In total, 825 patients met inclusion criteria: 52% (n = 426) patients underwent lobectomy and 48% (n = 399) of patients underwent sublobar resection (45% segmentectomy, 55% wedge resection). Lobectomy was associated with more preoperative high-risk features: cT1b (P < .001), greater standard uptake value (P < .001), solid tumor texture on computed tomography (P < .001), and micropapillary/solid histology (P < .001). In total, 660 patients were included in the matched analysis with all high-risk features balanced. Nodal upstaging (N1) was greater in patients who underwent lobectomy (9.1% vs 3.4%, P = .004). Five-year DFS (85% vs 74%, P = .12) was equivalent in the matched cohort. Lobectomy was protective for recurrence in the presence of 2 or greater high-risk features: sublobar resection patients with 2 high-risk features (hazard ratio, 1.77; 95% confidence interval, 1.13-2.76, P = .012) or 3-4 high-risk features (hazard ratio, 1.97; 95% confidence interval, 1.25-3.10, P = .004) had worse DFS.

Lobectomy should be considered over sublobar resection for stage IA NSCLC ≤2 cm in the presence of multiple high-risk features.