Stage I Non-Small Cell Lung Cancer
Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
Stage I non-small cell lung cancer (NSCLC) is defined by the following clinical stage groupings:
Understanding Lung Cancer -- Prevention
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- T1, N0, M0
- T2, N0, M0
Surgery is the treatment of choice for patients with stage I NSCLC. Careful preoperative assessment of the patient's overall medical condition, especially the patient's pulmonary reserve, is critical in considering the benefits of surgery. The immediate postoperative mortality rate is age related, but a 3% to 5% mortality rate with lobectomy can be expected.[1] Patients with impaired pulmonary function are candidates for segmental or wedge resection of the primary tumor.
The Lung Cancer Study Group conducted a randomized study (LCSG-821) to compare lobectomy with limited resection for patients with stage I lung cancer. Results of the study showed a reduction in local recurrence for patients treated with lobectomy compared with those treated with limited excision, but the outcome showed no significant difference in overall survival (OS).[2] Similar results have been reported from a nonrandomized comparison of anatomic segmentectomy and lobectomy.[3] A survival advantage was noted with lobectomy for patients with tumors larger than 3 cm but not for those with tumors smaller than 3 cm; however, the rate of locoregional recurrence was significantly less after lobectomy, regardless of primary tumor size. A study of stage I patients showed that those treated with wedge or segment resections had a local recurrence rate of 50% (i.e., 31 recurrences out of 62 patients) despite having undergone complete resections.[4]
The Cochrane Collaboration group reviewed 11 randomized trials with a total of 1,910 patients who underwent surgical interventions for early stage (I-IIIA) lung cancer.[5] From a pooled analysis of three trials, 4-year survival was superior in patients with resectable stage I to IIIA NSCLC who underwent resection and complete ipsilateral mediastinal lymph node dissection (CMLND) compared with those who underwent resection and lymph node sampling; the hazard ratio (HR) was estimated to be 0.78 (95% confidence interval (CI), 0.65-0.93, P = .005).[5][Level of evidence: 1iiA]
Conclusions about the efficacy of surgery for patients with local and locoregional NSCLC are limited by the small number of participants studied to date and the potential methodological weaknesses of the trials. However, there was a significant reduction in any cancer recurrence (local or distant) in the CMLND group (relative risk [RR] = 0.79; 95% CI, 0.66-0.95; P = .01) that appeared mainly because of a reduction in the number of distant recurrences (RR = 0.78; 95% CI, 0.61-1.00; P = .05). There was no difference in operative mortality. Air leak lasting more than 5 days was significantly more common in patients assigned to CMLND (RR = 2.94; 95% CI, 1.01-8.54; P = .05). Current evidence suggests that lung cancer resection combined with CMLND is associated with a small to modest improvement in survival compared with lung cancer resection combined with systematic sampling of mediastinal nodes in patients with stage I to stage IIIA NSCLC.[5][Level of evidence: 1iiA] CMLND versus lymph node sampling has been evaluated in a large randomized phase III trial (ACOSOG-Z0030). Preliminary analyses of operative morbidity and mortality showed comparable rates from the procedures.[6]
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