Thread by @BrendonStilesMD

Great to see the results of JCOG0802 published in @TheLancet. This is a practice changing trial (for at least some parts of the world) of lobectomy vs. segmentectomy for peripheral stage I lung cancer </=2cm. #lcsm #tssmn

The authors suggest that segmentectomy should now be the standard surgical procedure for these patients.

The results are truly outstanding with 5 year overall survival >90% in both arms, new standards for early stage lung cancer.

However, before adopting "less than lobectomy" for all patients w/ small tumors, we should consider a few caveats. This was a population w/ high rates of non-smokers and part solid lesions, almost all adenocarcinomas. After randomization, 6% of patients were found to be pN+.

Locoregional failure was actually higher with segmentectomy, 11% vs. 5% (p=0.0018) while the difference in pulmonary function was not as great as expected (-8.5% FEV1 @12 months segment, -12% FEV1 lobectomy).

Additionally, although OS result favored segmentectomy, this was largely driven by deaths from other cancers. The potential causative biology of this difference is challenging to understand and could be spurious.

For those who are already out stumping that lobectomy is HARMFUL, the authors point out the following:

So how to interpret this and put into practice? For small, part solid lesions (that are PET low or negative), I have already largely adopted sublobar resection based on low rates of LN metastases. I don't believe this study provides complete evidence for solid, PET avid lesions.

It should also be noted, that the careful technique of segmentectomy and anatomic nodal dissection reported in this trial is quite oncologically distinct from a wedge resection or SBRT. This paper gives no insight into whether those procedures are equivalent to lobectomy.

Both segmentectomy and lobectomy are EXCEEDINGLY safe in this population as previously reported in @AATSJournals. That combined with minimal loss of lung function and excellent survival, should ensure that (for now) surgery remains SOC for operable lung cancer. #lcsm

We will eagerly await mature results of CALGB 140503 trial (which allowed wedge) to see if results in JCOG0802 hold up in a North American population of patients.

If NOT, will be tough to know whether wedge or different biology was driver. Let's see.