Nasser Altorki, MD
Nasser Altorki, MD, a thoracic surgeon and Chief of the Division of Thoracic Surgery at NewYork Presbyterian/Weill Cornell Medicine, has long championed the progress of minimally invasive lung surgery, tirelessly seeking the most optimal techniques for treating lung cancer. For decades, the gold standard in treating early-stage lung cancer has been a lobectomy, a surgical practice rooted in the landmark 1995 clinical trial that pitted lobectomy against sublobar procedure. The findings of this study were striking, revealing a stark contrast between the two approaches: the sublobar group exhibited a threefold higher tumor recurrence rate and a staggering 50% increase in mortality.
However, the landscape of cancer treatment has undergone a transformative evolution since the 1990s. The emergence of more potent staging techniques and advanced imaging modalities, including the indispensable CT scans, has sparked a wave of contemplation among medical experts. This evolution led Dr. Altorki to initiate a seminal study reexamining lobectomy versus sublobar resection for the treatment of peripheral stage IA non-small-cell lung cancer (NSCLC).
“We started a randomized trial in 2007 asking the question whether it is still necessary to remove the entire lobe for the small lesions, now that we have better imaging and we pick up the tumor at a much earlier stage,” Dr. Altorki says.
We started a randomized trial in 2007 asking the question whether it is still necessary to remove the entire lobe for the small lesions, now that we have better imaging and we pick up the tumor at a much earlier stage.
— Dr. Nasser Altorki
The study, which was published in New England Journal of Medicine, was conducted from 2007 to 2017 and included co-investigators from Duke University as well as investigators from 83 hospitals across the United States, Canada, and Australia. Six hundred and ninety-seven NSCLC patients were randomized to receive either sublobar resection or standard lobectomy. Eligible patients were clinically staged as T1aN0 (tumors ≤2 cm) or smaller, with confirmed lack of lymph node involvement and negative scans for metastases. Additionally, eligible patients’ tumors had to be located peripherally, in the outer third of the lungs, where the risk of tumor spread is lower. The primary end point was disease-free survival, and relapse-free survival. Secondary endpoints were overall survival, locoregional and systemic recurrence and expiratory flow rates at six months postoperatively.
“The trial results showed that sublobar resection was non-inferior or similar to lobectomy for the primary endpoint of disease-free survival, and also for the secondary endpoint of overall survival,” says Dr. Altorki. “Additionally, there was no difference between the two groups in the rate of metastatic disease or cancer recurrence or second primary lung cancers.”
Over a median follow-up period of seven years after surgery, the two groups did not differ significantly in terms of disease-free or overall survival, including disease-free survival and tumor recurrence. The sublobar group had modestly better lung function at six months post-surgery. This slight difference and additional unmeasured benefits to removing less tissue from the lung have shifted current surgical practices toward favoring sublobar resection as the new standard for early-stage lung cancer cases.
These study results are changing how surgeons approach treating early-stage lung cancer.
The study results, which were met with a great deal of anticipation, have drastically changed how surgeons like Dr. Altorki approach this patient population. “This is a practice-changing study,” shares Dr. Altorki. “These results align with a trial in early-stage lung cancer patients in Japan, published last year, that found that a sublobar technique called segmentectomy had comparable outcomes to standard lobectomy, and even brought a modestly better chance of overall survival.”
The trial results showed that sublobar resection was non-inferior or similar to lobectomy for the primary endpoint of disease-free survival, and also for the secondary endpoint of overall survival.
— Dr. Nasser Altorki
Worldwide, lung cancers are diagnosed in more than two million people, and nearly as many die of the disease each year. Most cases fall into the category known as NSCLC, which in its earliest stage—small and localized—is often treated with surgery alone.
“These results tell us that patients don’t always have to have a full lobe of their lungs removed to cure their cancer,” shares Dr. Altorki, who is focused on continually advancing how NewYork-Presbyterian/Weill Cornell Medicine provides care to patients with lung cancer.
Although this study vastly changes the treatment of early-stage lung cancer, Dr. Altorki urges caution when performing a sublobar resection. “This is not an invitation to do a sublobar resection on everyone,” he says. “This is a highly selected group of patients. You need to make sure the lymph nodes are being examined by a pathologist and are free of cancer. Whether that is done during the operation or before the operation makes no difference. But we need to make sure of that because in some patients, when the lymph nodes are examined, roughly 10-15% have metastatic disease. These are important considerations before moving forward with sublobar resection.”
Dr. Altorki shares that he is planning to begin conducting research toward prevention of lung cancer. “We're thinking about prevention of lung cancer by vaccines, if possible,” he says. “We have a grant from the National Cancer Institute looking at vaccines as a modality to intercept early-stage pre-cancer from proceeding to cancer. I am excited as we are in the early stages of this important work.”
