Lancet: The era of comprehensive sublobar resection for small lung cancer is coming!

In April 2022, the Lancet, one of the top international medical journals ( Lancet , IF=79.

In April 2022, the Lancet, one of the top international medical journals ( Lancet , IF=79.

 

 

 

The Lancet's contemporaneous review " When less is more in thoracic surger y" rated the results as " remarkable "

The Lancet's contemporaneous review " When less is more in thoracic surger y" rated the results as " remarkable "

 

It has been nearly a year since Professor Hisao Asamura, the JCOG research chairman and current director of the Lung Cancer Staging Committee of the World Federation for the Study of Lung Cancer, first introduced the results of the 0802 study at the annual meeting of the American Society for Thoracic Surgery in May 2021.

It has been nearly a year since Professor Hisao Asamura, the JCOG research chairman and current director of the Lung Cancer Staging Committee of the World Federation for the Study of Lung Cancer, first introduced the results of the 0802 study at the annual meeting of the American Society for Thoracic Surgery in May 2021.

 

Compared to the previously published preprint article, the final version continues the indications for segmentectomy in the conclusion that segmentectomy should be the standard procedure for small peripheral non-small cell lung cancer, but further fleshes out the study design details and protocol implementation, and supplemented the as-treated analysis of the primary endpoint on the basis of the per-protocal analysis

Compared to the previously published preprint article, the final version continues the indications for segmentectomy in the conclusion that segmentectomy should be the standard procedure for small peripheral non-small cell lung cancer, but further fleshes out the study design details and protocol implementation, and supplemented the as-treated analysis of the primary endpoint on the basis of the per-protocal analysis

 

At this important point in the release of the final version, it is very meaningful to re-read the wonderful design, extraordinary results, and unbiased discussions of the researchers after the 0802 study

At this important point in the release of the final version, it is very meaningful to re-read the wonderful design, extraordinary results, and unbiased discussions of the researchers after the 0802 study

1.

1.

Since the previous JCOG0804 study had a solid component ratio (CTR) <= 0.

Since the previous JCOG0804 study had a solid component ratio (CTR) <= 0.

 

The primary endpoint was positive, with a higher 5-year OS rate in the segmentectomy group compared with the lobectomy group, 94.

The primary endpoint was positive, with a higher 5-year OS rate in the segmentectomy group compared with the lobectomy group, 94.

 

The secondary endpoint, 5-year RFS, was nearly identical between the two groups , 88.
0% in the segmentectomy group and 87.
9% in the lobectomy group
.
About 12% of patients in both groups had recurrence within 5 years
.

The secondary endpoint, 5-year RFS, was nearly identical between the two groups , 88.
0% in the segmentectomy group and 87.
9% in the lobectomy group
.
About 12% of patients in both groups had recurrence within 5 years
.
The 5-year RFS, the secondary endpoint, was nearly identical between the two groups

 

In addition, in terms of pulmonary function 1 year after surgery, the postoperative pulmonary function after segmentectomy was 3.
5% higher than that after lobectomy, and the pulmonary function advantage was not high, which did not reach the expected 10% improvement
.

In addition, in terms of pulmonary function 1 year after surgery, the postoperative pulmonary function after segmentectomy was 3.
5% higher than that after lobectomy, and the pulmonary function advantage was not high, which did not reach the expected 10% improvement
.
Did not meet the projected 10% improvement

 

Local recurrence was higher in the segmentectomy group at 10.
5% versus 5.
4% in the lobectomy group
.
The probability of local recurrence in the segmentectomy group was approximately doubled
.

Local recurrence was higher in the segmentectomy group at 10.
5% versus 5.
4% in the lobectomy group
.
The probability of local recurrence in the segmentectomy group was approximately doubled
.
Higher in segmentectomy group

 

In terms of subgroup analysis, almost all subgroups pointed to better OS for segmentectomy
.
Including pure solid nodules with CTR=1, the OS of segmentectomy is still higher than that of lobectomy
.

In terms of subgroup analysis, almost all subgroups pointed to segmentectomy for better OS
.
Including pure solid nodules with CTR=1, the OS of segmentectomy is still higher than that of lobectomy
.

.
Including pure solid nodules with CTR=1, the OS of segmentectomy is still higher than that of lobectomy
.

 

 

In addition, the lobectomy subgroup appeared to have an increased probability of death due to non-lung cancer at follow-up
.
Including second primary lung cancer, respiratory and cerebrovascular diseases
.

In addition, the lobectomy subgroup appeared to have an increased probability of death due to non-lung cancer at follow-up
.
Including second primary lung cancer, respiratory and cerebrovascular diseases
.
Blood vessel

 

 

The final conclusion of 0802 was that, since the OS achieved a positive result of non-inferiority, segmentectomy should still be the criterion for peripheral lung cancer with CTR > 0.
5 and total diameter <= 2 cm, despite the less-than-expected pulmonary function protection of segmentectomy.
surgical approach
.

The final conclusion of 0802 0802 is: The final conclusion is: Due to the positive result of non-inferiority of OS, segmentectomy should still be CTR>0.
5 and total diameter <=2cm despite the less than expected pulmonary function protection of segmentectomy standard surgical approach for peripheral lung cancer
.
Segmentectomy should still be the standard procedure for peripheral lung cancer with a CTR > 0.
5 and a total diameter <= 2 cm
.

 

In addition, 0802 also has some other useful information : for peripheral small lung cancer with CTR>0.
5 and <=2cm , the probability of hilar lymph node metastasis (N1) and mediastinal lymph node metastasis (N2) is very low, about approx.
3%
.
The probability of distant metastases was even lower, with only 1 in 1106 patients developing distant metastases (stage IV)
.

In addition to this, 0802 also has some other useful information : : For peripheral small lung cancer with CTR>0.
5, and <=2cm , hilar lymph node metastasis (N1) and longitudinal The probability of phrenic lymph node metastasis (N2) is very low, about 3%
.
The probability of distant metastases was even lower, with only 1 in 1106 patients developing distant metastases (stage IV)
.
CTR>0.
5, and <=2cm

 

 

2.
Why can 0802 use segmentectomy as a standard procedure?

2.
Why can 0802 use segmentectomy as a standard procedure? 2.
Why can 0802 use segmentectomy as a standard procedure?

 

 

At the beginning of the study design, the JCOG team envisioned four possible outcomes around overall survival and postoperative respiratory function
.
Professor Asamura took Japanese judo as an example.
Once a contestant obtains a "one book" (a form of scoring) on ​​the field, the competition will be won, and "one book" is equivalent to the superiority design of the research
.
However, 0802 adopts another design, which means that in the absence of "one book", obtaining two "skills" is equivalent to obtaining "one book", that is, if the oncological efficacy of segmentectomy is non-inferior , and the difference of FEV1 relative to the lobe group at 6 months or 12 months exceeded 10%, which is equivalent to obtaining two "technical skills" and "one book", we can think that segmentectomy is superior to Lobectomy
.

At the beginning of the study design, the JCOG team envisioned four possible outcomes around overall survival and postoperative respiratory function
.
Professor Asamura took Japanese judo as an example.
Once a contestant obtains a "one book" (a form of scoring) on ​​the field, the competition will be won, and "one book" is equivalent to the superiority design of the research
.
However, 0802 adopts another design, which means that in the absence of "one book", obtaining two "skills" is equivalent to obtaining "one book", that is, if the oncological efficacy of segmentectomy is non-inferior , and the difference of FEV1 relative to the lobe group at 6 months or 12 months exceeded 10%, which is equivalent to obtaining two "technical skills" and "one book", we can think that segmentectomy is superior to Lobectomy
.

 

 

However, segmentectomy finally exceeded most people's expectations.
In a non-inferiority study, the superiority of the primary endpoint was achieved, and "one" was achieved, which directly won
.
In terms of football that everyone is more familiar with, it is equivalent to the Champions League final.
The coach and fans hope that their team will tie the opponent 0:0 in the away game, and will win 1:0 after gaining home advantage in the next game, and the total score will be 1:0.
The final victory, but 0802 just tells a story of winning both away and home
.

However, segmentectomy finally exceeded most people's expectations.
In a non-inferiority study, the superiority of the primary endpoint was achieved, and "one" was achieved, which directly won
.
However, segmentectomy finally exceeded most people's expectations.
In a non-inferiority study, the superiority of the primary endpoint was achieved, and "one" was achieved, which directly won
.
In terms of football that everyone is more familiar with, it is equivalent to the Champions League final.
The coach and fans hope that their team will tie the opponent 0:0 in the away game, and will win 1:0 after gaining home advantage in the next game, and the total score will be 1:0.
The final victory, but 0802 just tells a story of winning both away and home
.

 

  

3.
What important inspirations did 0802 bring?

3.
What important inspirations did 0802 bring? 3.
What important inspirations did 0802 bring?

 

 

First, in terms of local recurrence, the recurrence rate of the segmental group was almost twice that of the lobe, but it did not have a significant impact on OS
.
This result deserves our careful consideration
.
The margin control of segmentectomy can be further improved through the planning of preoperative 3D reconstruction.
Then, what about lymph node dissection?

First, in terms of local recurrence, the recurrence rate of the segmental group was almost twice that of the lobe, but it did not have a significant impact on OS
.
This result deserves our careful consideration
.
The margin control of segmentectomy can be further improved through the planning of preoperative 3D reconstruction.
Then, what about lymph node dissection? The segmental group had almost twice the recurrence rate as the lobar group, but did not have a significant effect on OS
.

 

 

0802 did not give data on intersegmental lymph nodes, but patients with lymph node metastasis during follow-up accounted for a large proportion of local recurrences, indicating that the strategy of lymph node dissection should also be determined
.
A considerable part of the pulmonary nodules within 2 cm may not undergo systematic and thorough cleaning, which saves time and conforms to the concept of minimally invasive, but it should not be too optimistic
.
Intraoperative frozen pathology of lymph nodes is necessary in some cases
.
At the same time, because the lung segment group has been actively re-treated for recurrence, the actual benefit of OS has been brought, which reflects the value of individualized management
of early stage lung cancer .

0802 did not give data on intersegmental lymph nodes, but patients with lymph node metastasis during follow-up accounted for a large proportion of local recurrences, indicating that the strategy of lymph node dissection should also be determined
.
A considerable part of the pulmonary nodules within 2 cm may not undergo systematic and thorough cleaning, which saves time and conforms to the concept of minimally invasive, but it should not be too optimistic
.
Intraoperative frozen pathology of lymph nodes is necessary in some cases
.
At the same time, because the lung segment group has been actively re-treated for recurrence, the actual benefit of OS has been brought, which reflects the value of individualized management
of early stage lung cancer .
manage

 

 

Then came the subgroup analysis results, and the results of pure solid tumors in the segmental group were surprising
.
Pure solid nodules tend to be more poorly differentiated than partially solid nodules.
Many doctors tend to perform sublobar resection only in GGO.
The results of 0802 are helpful for the indication of segmentectomy in solid nodules.
expansion
in.
But then again, how many of the local recurrences are solid nodules? If the vast majority are solid nodules and GGOs rarely recur, does that mean that the indications for sublobar resection can be extended to larger GGOs? Preliminary results from JCOG1211 showed that for GGO within 3 cm and CTR < 0.
5, the 5-year RFS and 5-year OS of segmentectomy were both above 98%
.
Then, for peripheral pulmonary nodules within 3cm, as long as they contain GGO components and are not pure solid, segmentectomy can be used as a standard surgical plan?

Then came the subgroup analysis results, and the results of pure solid tumors in the segmental group were surprising
.
Pure solid nodules tend to be more poorly differentiated than partially solid nodules.
Many doctors tend to perform sublobar resection only in GGO.
The results of 0802 are helpful for the indication of segmentectomy in solid nodules.
expansion
in.
But then again, how many of the local recurrences are solid nodules? If the vast majority are solid nodules and GGOs rarely recur, does that mean that the indications for sublobar resection can be extended to larger GGOs? Preliminary results from JCOG1211 showed that for GGO within 3 cm and CTR < 0.
5, the 5-year RFS and 5-year OS of segmentectomy were both above 98%
.
Then, for peripheral pulmonary nodules within 3cm, as long as they contain GGO components and are not pure solid, segmentectomy can be used as a standard surgical plan? Indications for segmentectomy for enlargement in solid nodules
.
Will segmentectomy be used as a standard surgical plan for peripheral pulmonary nodules within 3cm, as long as they contain GGO components and are not pure solid?

 

At the end of this article, the author provides the original journal text and Chinese translation of the article JCOG0802 , and you are welcome to reference, collect and forward it!

At the end of this article, the author provides the original journal text and Chinese translation of the article JCOG0802 , and you are welcome to reference, collect and forward it! Journal original text and Chinese translation and Chinese translation

 

 

Pay attention to the new frontier public account of tumor, and reply " 0802 " to get it!

Pay attention to the new frontier public account of tumor, and reply " 0802 " to get it! 0802

 

Source: Qiu Bin ,  a thoracic surgeon at the frontier of pulmonary nodules , left a

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