Evaluation and Management for High-Risk Patients With Stage I Non-small Cell Lung Cancer
Publication Date: December 1, 2012
Last Updated: March 14, 2022
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 multidisciplinary consensus panel was 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 to address treatment of high-risk patients with stage I NSCLC. The management suggestions were unanimously agreed upon by the consensus panel and represent expert opinions based on available literature.
Respiratory failure and pulmonary complications represent the most significant risks following lung resection, and preprocedural risk assessment is based primarily on pulmonary function. Currently available treatment techniques for high-risk patients with stage I NSCLC include sublobar resection with or without brachytherapy, stereotactic body radiotherapy (SBRT), and radiofrequency ablation (RFA). Each of these modalities has historically been associated with decreased procedural morbidity and mortality but increased involved lobe and regional recurrence when compared with lobectomy. Improvements in radiographic staging and the detection of smaller and more indolent tumors push risk/benefit decisions toward parenchymal sparing or nonoperative therapies in this population. Unbiased assessment of treatment options for high-risk patients requires uniform reporting of comorbidities and outcomes in clinical series, which has been lacking to date.
2. Diffusing capacity of lung for carbon monoxide (Dlco) accurately predicts morbidity and mortality following major lung resection. Assessment of Dlco, including calculation of estimated postoperative value, prior to resection is strongly suggested as a means for assessing risk.
3. Peak oxygen consumption with exercise accurately predicts morbidity and mortality following major lung resection. The predictive ability is strongest in patients with impaired FEV1 or Dlco. Assessment of peak oxygen consumption with exercise prior to major lung resection in patients with impaired FEV1 or Dlco is suggested as a means for assessing risk.
6. In patients with stage I NSCLC >75 years of age, segmentectomy or extended wedge resection is suggested as an effective and potentially beneficial alternative to lobectomy.
7. Anatomic segmentectomy is preferred when possible to wedge resection in patients who undergo sublobar resection for stage I NSCLC.
8. Adjuvant intraoperative brachytherapy should be considered in conjunction with sublobar resection to reduce involved lobe recurrence.
10. A modified SBRT treatment schedule is suggested for tumors within 2 cm of the proximal bronchial tree to decrease treatment-related toxicity.
12. When RFA is used for tumors >3 cm, combination with radiation therapy is suggested, but there is no consensus on sequence of therapy.
13. RFA is not suggested for lesions adjacent to major bronchovascular structures or the esophagus.
Respiratory failure and pulmonary complications represent the most significant risks following lung resection, and preprocedural risk assessment is based primarily on pulmonary function. Currently available treatment techniques for high-risk patients with stage I NSCLC include sublobar resection with or without brachytherapy, stereotactic body radiotherapy (SBRT), and radiofrequency ablation (RFA). Each of these modalities has historically been associated with decreased procedural morbidity and mortality but increased involved lobe and regional recurrence when compared with lobectomy. Improvements in radiographic staging and the detection of smaller and more indolent tumors push risk/benefit decisions toward parenchymal sparing or nonoperative therapies in this population. Unbiased assessment of treatment options for high-risk patients requires uniform reporting of comorbidities and outcomes in clinical series, which has been lacking to date.
Medical Assessment
1. FEV1 accurately predicts morbidity and mortality following major lung resection. Assessment of FEV1, including calculation of estimated postoperative value, prior to resection is suggested as a means for assessing risk.2. Diffusing capacity of lung for carbon monoxide (Dlco) accurately predicts morbidity and mortality following major lung resection. Assessment of Dlco, including calculation of estimated postoperative value, prior to resection is strongly suggested as a means for assessing risk.
3. Peak oxygen consumption with exercise accurately predicts morbidity and mortality following major lung resection. The predictive ability is strongest in patients with impaired FEV1 or Dlco. Assessment of peak oxygen consumption with exercise prior to major lung resection in patients with impaired FEV1 or Dlco is suggested as a means for assessing risk.
Relevant Outcome Measures
4. Health-related functional status and quality-of-life assessment are important and underreported for the treatment of high-risk patients with stage I NSCLC and suggested for inclusion in clinical decisions.Sublobar Resection
5. Segmentectomy or extended wedge resection with margins >1 cm or equal to the tumor diameter with hilar and mediastinal nodal evaluation is suggested as a safe and effective alternative to lobectomy in high-risk patients with stage I NSCLC.6. In patients with stage I NSCLC >75 years of age, segmentectomy or extended wedge resection is suggested as an effective and potentially beneficial alternative to lobectomy.
7. Anatomic segmentectomy is preferred when possible to wedge resection in patients who undergo sublobar resection for stage I NSCLC.
8. Adjuvant intraoperative brachytherapy should be considered in conjunction with sublobar resection to reduce involved lobe recurrence.
Radiation Therapy
9. Conventionally fractionated radiation therapy with definitive intent and sufficient dose intensity is a reasonable treatment option for high-risk stage I NSCLC, but, for tumors <5 cm, where normal tissue dose constraints can be respected, SBRT is preferred over conventionally fractionated radiation therapy for definitive treatment of high-risk stage I NSCLC.10. A modified SBRT treatment schedule is suggested for tumors within 2 cm of the proximal bronchial tree to decrease treatment-related toxicity.
Percutaneous Ablative Therapy
11. RFA is a reasonable treatment option in high-risk patients with stage I NSCLC with peripheral lesions <3 cm, but reduced primary tumor control limits enthusiasm for its use to those patients who are not candidates for SBRT or sublobar resection.12. When RFA is used for tumors >3 cm, combination with radiation therapy is suggested, but there is no consensus on sequence of therapy.
13. RFA is not suggested for lesions adjacent to major bronchovascular structures or the esophagus.
Overview
Title
Evaluation and Management for High-Risk Patients With Stage I Non-small Cell Lung Cancer
Authoring Organizations
American College of Chest Physicians
Society of Thoracic Surgeons