Similar Disease Free Survival With Sublobar Resection We Must Do More скачать в хорошем качестве

Similar Disease Free Survival With Sublobar Resection We Must Do More

Mark G. Kris, MD, discusses a recent paper and accompanying editorial on the similar observed disease-free benefits with sublobar and lobar resection. https://www.medscape.com/viewarticle/... -- TRANSCRIPT -- This is Mark Kris from Memorial Sloan Kettering, commenting on the publication of a paper by Nasser Altorki and the accompanying editorial by Valerie Rusch in the February 9th print edition of The New England Journal of Medicine. Dr Altorki reports on a trial by the Alliance group that compared sublobar resection with lobar resection. The idea there was that if you have a small tumor in the periphery of the lung, by removing less of the lung but doing it completely, you could achieve comparable results to doing the general standard of care, a lobectomy. In both cases, procedures are accompanied by a complete nodal sampling and/or a resection. They found identical disease-free survival (the main endpoint of the trial) of 64% at 5 years. I think that's a very important result. There is a huge amount of concern that, with lung cancer surgery, patients will be debilitated and breathing will be impaired, even when cured, for life going forward. I think there is good evidence in this paper that doing a smaller resection preserves the most lung, preserves the most lung function, and gives you an equal benefit in disease-free survival. There are a couple of caveats, though. They were very precise in the tumors that were studied. They were all 2 cm or less on CT scan, all in the outer third of the lung, and all peripheral. I think that's an important point that Dr Rusch brought out in her editorial — and I'd like to quote her directly — that the patients in this trial "were selected meticulously and included very, very strict criteria for lymph node staging and complete resection." I think this paper is important in that it takes away more of the fear of resection. It makes intuitive sense to remove less lung, and it sounds like you can do that with equal benefit. There's another side to this paper, and I'm looking more to the medical oncology community and the multidisciplinary community here, that despite these successful surgeries, only 64% of patients were disease free at 5 years. In a recent paper by Sobrero in the Journal of Clinical Oncology, and I'll quote that again: "You're cured till you're not." Almost one third of these patients are not going to be cured with this surgery. Why is that important? When you look at the pattern of recurrence, it's systemic in the majority of cases. Our surgeons are very meticulous. They have excellent technique and process in doing these surgeries, but that's not enough. People are still dying of metastatic disease. To my mind, all these patients should be potential candidates for additional therapies. Now, do we have additional therapies for these tiny tumors? No, but I think people are shocked when they see that number. One third of the patients will not be cured despite a complete resection of a 2-cm or smaller tumor at the time of diagnosis. We need to do more. How can we do more? Number one, we need to screen more. We need to find more tiny tumors and get people at least to that 64% level. Screening is the best way to do that. I urge you in all your patients appropriate for screening, in speaking to your colleagues in other medical specialties that have patients who are appropriate for lung cancer screening, please do lung cancer screening. Follow the guidelines; do low-dose helical CT screening. Number two, for those patients going to surgery, make sure that the precision surgery, the term coined by Dr Rusch here, is indeed the one followed. These patients need to be carefully selected. They need to be meticulously cared for to get these results that were in the Alliance trial. Lastly, the patients are still succumbing to metastatic cancer. The medical oncology community has to come up with ways to treat these patients. I think the early ideas to go forward would be to go after patients who have a driver where you would have a very high likelihood of benefit; to go after patients with very high PD-L1, where you have a very high likelihood of benefit from a checkpoint inhibitor; and to go after patients with poor prognostic signs, things like lymphovascular invasion, poor differentiation, and things that have been shown in earlier trials to predict worse outcome. Congratulations to Dr Altorki and to Dr Rusch. I think their papers really add to the literature, help take away some of the fear of patients in this area, and set the stage for us to work harder, to screen more, and to find therapies to prevent metastatic spread in patients with early-stage lung cancers. https://www.medscape.com/viewarticle/...