Sublobar resection is quickly becoming the standard of care for early-stage lung cancers in patients who are good candidates for surgery. While the adoption of sublobar resection at larger academic medical centers has been brisk, the pace has been slower in smaller community practices. This may be due to the increased technical challenges that come with sublobar resection.
“When we say, ‘early stage,’ we are looking at localized tumors, less than 2 centimeters in size,” said Muhammad S. Ali, MD, MS, FCCP, Assistant Professor of Clinical Medicine and Clinical Cardiothoracic Surgery at Weill Cornell Medical College. “The evidence [for sublobar resection] is very strong, it’s just the inertia of clinical practice.”
Dr. Ali will chair a panel discussion exploring the latest developments in sublobar resection during Early-Stage Lung Cancer: Strategies in the Age of Sublobar Resection at 3:15 pm CT on Monday, October 20, in McCormick Place, Lakeside Center, Room 451B. Presentations will focus on patient selection and technical challenges in sublobar resection, as well as robotic bronchoscopic lung marking to facilitate sublobar resection.
“As a thoracic surgeon, the easiest thing for you to do is a lobar resection because you take the lobe out, close up the patient, and you’re done,” Dr. Ali said. “Sublobar can be technically harder because you have to locate the tumor, take it out with robotic or minimally invasive techniques, then wait for pathology to confirm that you have a clear margin. There is more work, more nuance with sublobar resection, but you can take the tumor out without sacrificing a lot of healthy lung tissue. Sublobar is something to consider, especially for patients who have borderline lung function to begin with.”
Lobar resection was pioneered in the 1980s following publication of a single paper, Dr. Ali noted, and the procedure quickly became the standard of care. Sublobar resection is based on two recent studies, both showing similar and robust evidence favoring the less invasive approach. Sublobar resection is relatively straightforward in an open procedure, he added, when the surgeon can palpate the affected lobe to locate the tumor.
“When you combine sublobar resection with minimally invasive approaches, robotic surgery, or video-assisted thoracic surgery, you don’t have the luxury of palpating the lung, which makes it harder to locate these tiny nodules,” Dr. Ali explained. “Using robotic bronchoscopy, we drive right down to the tumor and inject dye. When we come in via [the] thoracoscopic route, the tumor lights up. You can see right where it is, and the chances are high that you can take the tumor out without having to remove a lot of healthy lung.”
That’s not to say that all patients with early-stage lung cancer are good candidates for sublobar resection. Some individuals with comorbidities are poor candidates for surgery regardless of the approach and are better treated with radiation therapy.
Most early-stage lung cancers are diagnosed in individuals with present or past smoking history whose lungs are already compromised, Dr. Ali said. Resecting an entire lobe is almost certain to remove the tumor but may leave patients dependent on oxygen.
“The goal with sublobar resection is to take out only as much tissue as is absolutely necessary, leaving behind whatever functional lung they may have left,” he said. “For patients with borderline lung function, taking as little lung as possible should be the way to go.”
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