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

OBJECTIVE: Computed tomographic screening is detecting ever smaller peripheral non-small cell lung cancers. These smaller cancers are amenable to sublobar resection, but sublobar resection is not currently the treatment of choice. This study compared sublobar resection with lobar resection for stage IA non-small cell lung cancers to assess whether sublobar resection is appropriate treatment for certain lesions. The use of adjuvant brachytherapy was also evaluated. METHODS: A retrospective multicenter study of 291 patients with T1 N0 disease was done. Outcomes after sublobar resection (n = 124) were compared with those after lobar resection (n = 167). Brachytherapy was used in conjunction with 60 (48%) sublobar resection operations. Analysis based on tumor diameter was performed. RESULTS: There were 137 cancers smaller than 2 cm and 154 cancers ranging from 2 to 3 cm. Patients undergoing sublobar resection were older (68.4 vs 66.1 years, P = .018) with poorer pulmonary function (forced expiratory volume in 1 second of 53.1% vs 78.2%, P = .001). Mean follow-up was 34.5 months. Brachytherapy decreased local recurrence rate significantly among patients undergoing sublobar resection, from 11 (17.2%) to 2 (3.3%). For tumors smaller than 2 cm, there was no difference in survival between sublobar resection and lobar resection groups. For the larger tumors (2-3 cm), median survival was significantly better in the lobar resection group, at 70 versus 44.7 months ( P = .003). CONCLUSION: Intraoperative brachytherapy may reduce the local recurrence that is usually reported with sublobar resection. Our experience supports the further investigation of the use of sublobar resection with brachytherapy for peripheral stage IA non-small cell lung cancers smaller than 2 cm.

Resection of multifocal non-small cell lung cancer when the bronchioloalveolar subtype is involved.

OBJECTIVE: Bronchioloalveolar lung cancer is commonly multifocal and can also present with other non-small cell types. The staging and treatment of multifocal non-small cell cancer are controversial. We evaluated the current staging of multifocal bronchioloalveolar carcinoma and the therapeutic effectiveness of resection when this tumor type is involved. METHODS: We reviewed our experience between 1992 and 2000 with complete pulmonary resections for bronchioloalveolar carcinoma. Kaplan-Meier survival curves were calculated from the dates of pulmonary resection. RESULTS: Among 73 patients with bronchioloalveolar carcinoma, 14 patients, 7 male and 7 female with a mean age of 65 years (51-87 years), had multifocal lesions without lymph node metastases. Follow-up was 100% for a median of 5 years (range 2.6-8.5 years). Tumor distribution was unilateral in 9 patients and bilateral in 5 patients. The multifocal nature of the disease was discovered intraoperatively in 4 patients. Nine patients had 2 lesions, 4 patients had 3 lesions, and 1 patient had innumerable discrete foci in a single lobe. Operative mortality was 0. Postoperatively, 10 patients were staged pIIIB or pIV on the basis of multiple foci of similar morphology; 4 patients had some differences in histology (implying multiple stage 1 primaries). The median survival time to death from cancer was 14 months (141 days-5.6 years). The overall 5-year survival after resection of multifocal bronchioloalveolar carcinoma was 64%. Unilateral or bilateral distribution had no impact on survival. CONCLUSIONS: The current staging system is not prognostic for multifocal bronchioloalveolar carcinoma without lymph node metastases. Complete resection of multifocal non-small cell lung cancer when bronchioloalveolar carcinoma is a component may achieve survivals similar to that of stage I and II unifocal non-small cell lung cancer. When bronchioloalveolar carcinoma is believed to be one of the cell types in multifocal disease without lymph node metastases, consideration should be given to surgical resection.