Donington, Jessica S.

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Survival After Sublobar Resection Versus Lobectomy for Clinical Stage IA Lung Cancer Analysis From the National Cancer Database

1513Journal of Thoracic Oncology ® • Volume 10, Number 11, November 2015
The debate over the elective use of sublobar resection for early-stage non–small-cell lung cancer (NSCLC) is one of the oldest in thoracic surgical oncology. The only random-
ized trial on this subject reported to date is from the Lung Cancer Study group1 and has 
guided surgical care for the past 20 years, but completed enrollment in 1988. It used staging 
methods that are outdated by modern standards, and its results may now belong to a previ-
ous era. Two prospective randomized trials investigating the intentional use of sublobar 
resections for stage IA NSCLC are underway in North America (Cancer and Leukemia 
Group B 140503) and Japan (JCOG0802/WJOG4607), but it will be many years before 
signiﬁcant conclusions can be made. Outcomes from retrospective analysis of sublobar 
resections can be difﬁcult to interpret because these resections are used in divergent clini-
cal settings. Sublobar resections are used intentionally as a parenchymal sparing procedure 
in patients with small, peripheral, or indolent tumors who would tolerate lobectomy, but 
they are also used as a compromise procedure in frail and debilitated patients who do not 
have adequate cardiopulmonary reserve to tolerate lobectomy. One of the most important 
questions that needs to be asked when embarking on a comparison of outcomes between 
lobectomy and sublobar resection for early-stage NSCLC is “what is the speciﬁc indication 
for sublobar resection in this population?” Evaluating surgical outcomes in a heterogeneous 
population that contains both medically ﬁt and unﬁt patients is of limited utility because of 
the compelling evidence that short-term and long-term survivals are signiﬁcantly decreased 
in those with medical comorbidity.
Population-based analyses like this work from Khullar et al.2 are incredibly informa-
tive in situations where randomized data are lacking. Results can validate ﬁndings from 
small single institution retrospective reviews, generate hypothesis, and reﬁne populations 
for further analysis. When performing outcomes research it is important to determine 
if the data set being analyzed has sufﬁcient information to address the question raised. 
The National Cancer Data Base (NCDB) is an incredibly large and powerful tool, but as 
with many other large data sets, the information collected may not be granular enough to 
address all clinical questions. A data point that is clearly not collected in the NCDB relates 
to the indication for sublobar resection in NSCLC. Speciﬁcally, was a sublobar resec-
tion implemented as a compromise procedure in a debilitated patient or as a parenchymal 
sparing option in an otherwise healthy patient? Although both of those are considered 
“curative intent surgery,” anticipated short-term and long-term outcomes are quite differ-
ent. In the work from Khullar et al.,2 a propensity matched analysis was used to try and 
circumvent the issue of surgical intent, but the NCDB data may not be explicit enough to 
adequately match patients on the most important variable. The primary source of comor-
bidity for thoracic surgery patients is pulmonary. The Charlson/Deyo comorbidity index 
DOI: 10.1097/JTO.0000000000000674
Copyright © 2015 by the International Association for the Study of Lung Cancer
ISSN: 1556-0864/15/1011-1513
Survival After Sublobar Resection Versus Lobectomy for 
Clinical Stage IA Lung Cancer
Analysis From the National Cancer Database
Jessica S. Donington, MD
Department of Cardiothoracic Surgery, NYU School of Medicine, New York, NY.
Disclosure: The author declares no conflict of interest.
Address for correspondence: Jessica S. Donington, MD, MSCR, Department of Cardiothoracic Surgery, NYU School of Medicine, 530 First Ave, Suite 9V, 
New York, NY 10016. E-mail: jessica.donington@nyumc.org
EDITORIAL
1514 Copyright © 2015 by the International Association for the Study of Lung Cancer
Editorial Journal of Thoracic Oncology ® • Volume 10, Number 11, November 2015
was used for matching, which simply lists lung disease as a 
yes/no question without any grading of the severity of pul-
monary compromise. The Charlson/Deyo comorbidity index 
is an excellent adjunct to preoperative risk assessment with 
pulmonary function tests, but it is not a replacement for the 
important risk stratiﬁcation information provided by pulmo-
nary function tests. No thoracic surgeon is going to make 
a decision on the extent of pulmonary resection based on 
Charlson/Deyo score alone.
The NCDB is not unique in these limitations. Over the 
past 5 years there has been a large series of manuscripts inves-
tigating the role of sublobar resection for NSCLC from the 
Surveillance Epidemiology and End Result registry, which 
also lacks information on surgical intent and comorbidity. 
Each of the seven trials outlined in Table 1 compares survival 
between lobectomy and sublobar resections for early-stage 
NSCLC,3–9 but subtle differences in the populations analyzed 
related to factors such as age, tumor size, histology, and year 
of diagnosis result in different conclusions regarding equiva-
lence of outcome.
Our understanding of NSCLC biology has grown dra-
matically in the two decades since the Lung Cancer Study 
Group’s landmark publication.1 Stage I NSCLC is no longer 
viewed as a homogeneous disease with a uniform prognosis 
and surgical management also needs to evolve and become 
more varied. There is a growing mountain of single institution 
and retrospective data that indicate sublobar resections pre-
serve pulmonary parenchyma and confer similar survival to 
lobectomy in well selected individuals with small, peripheral, 
and indolent tumors. Population-based analysis like the one 
reported here2 serves as an important reminder that similar 
outcomes should not be anticipated in all patients. We need 
to continue to be selective in the use of intentional sublobar 
resection and not allow sublobar techniques compromise 
surgical margins or thoroughness intraoperative lymph node 
evaluation. Good oncologic surgical techniques beneﬁt both 
the medically ﬁt and unﬁt patients who undergo sublobar pro-
cedures. We should continue to integrate sublobar resections 
into treatment algorithms for stage IA NSCLC while await-
ing randomized data, which will better deﬁne indications for 
intentional use.
REFERENCES
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TABLE 1. Analysis of Data SEER Registry Between 2010 and 2015 Comparing Survival Between Lobectomy and Sublobar 
Resection for Early-Stage NSCLC
Author Population Lobectomy Comparator Years Overall Survival Results
Wisnivesky et al.3 Stage I NSCLC, <2 cm, Medicare 
patients >65 yr
Sublobar resectiona 1998–2002 Sublobar resection equivalent to lobectomy in 
unadjusted and propensity matched analysis
Whitson et al.4 Stage IA NSCLC Segmentectomy 1998–2007 Segmentectomy inferior to lobectomy regardless of 
tumor size
Kates et al.5 Stage I NSCLC <1 cm Sublobar resectiona 1988–2005 Sublobar resection equivalent to lobectomy in 
unadjusted and propensity matched analysis
Yendamuri et al.6 Stage I NSCLC <2 cm Segmentectomy and wedge 1988–1998 Segmentectomy and wedge inferior to lobectomy
1999–2004 Segmentectomy equivalent to lobectomy, wedge 
resection inferior to lobectomy
2005–2008 Segmentectomy and wedge equivalent to lobectomy
Shirvani et al.7 Stage I NSCLC, <5 cm, Medicare 
patients >65 yr
Sublobar resectiona 2001–2007 Sublobar resection inferior to lobectomy in unadjusted 
analysis
Whitson et al.8 BAC (now AIS, MIA or lepidic 
predominant ADC)
Segmentectomy and wedge 1998–2007 Segmentectomy both equivalent to lobectomy and 
superior to wedge resection
Shirvani et al.9 Node negative, early-stage 
NSCLC, <5 cm, Medicare  
age >65 yr
Sublobar resectiona 2003–2009 Sublobar resection inferior to lobectomy in unadjusted 
and propensity-matched analysis
aSegmentectomy and wedge resection analyzed together.
SEER, Surveillance, Epidemiology, and End Result; NSCLC, non–small-cell lung cancer; wedge, wedge reection; BAC, bronchoalveolar carcinoma; AIS, adenocarcinoma insitu; 
MAI, minimally invasive adenocarcinoma, ADC, adenocarcinoma.


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Survival After Sublobar Resection Versus Lobectomy for Clinical Stage IA Lung Cancer Analysis From the National Cancer Database

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