Sublobar Resection for Lung Cancer Can Be Safe in Patients With IPF and UIP

In a very select group of patients with lung cancer with underlying idiopathic pulmonary fibrosis (IPF) and usual interstitial pneumonia (UIP), sublobar lung resection can be safely performed, according to meta-analysis findings published in BMJ Open Respiratory Research.

Patients with lung cancer and IPF and UIP who undergo surgical resection face significant risk for postoperative acute exacerbations (AEs) and in-hospital morbidity and mortality. Investigators conducted a review and meta-analysis to explore outcomes in these patients (adults only), searching Cochrane Library, LILACS, EMBASE, and MEDLINE databases for studies in all languages published since the year 2000. The primary endpoint was incidence of AE of UIP in postoperative lung cancer resection. The secondary endpoint was overall survival.

With respect to the primary outcome, the reviewers identified 10 studies (n=2202 patients) reporting postoperative AE rates of UIP, with 231 patients experiencing in-hospital AEs. The post lung cancer resection AE rate was 14.6% (95% CI, 9.8-20.1%; I²=74%) in the random effects model. Lobar vs sublobar resection postoperative AEs of UIP were compared in 14 studies of 2472 patients. Using the fixed effects model, investigators found sublobar resection was significantly associated with reduced risk for postoperative AEs (odds ratio [OR], 0.521; 95% CI, 0.339-0.803; P =.0031; I²=0.0%)

With respect to the secondary endpoint, the researchers identified 8 studies in which 886 of a total of 2128 patients survived to 5 years post lung cancer resection, for a 47.4% survival rate according to the fixed effects model (95% CI, 39.4-43.6). Notably, following lung cancer resection in patients with UIP, the extent of resection was not significantly associated with overall survival (hazard ratio for sublobar resection, 0.978; 95% CI, 0.521-1.833; P =.9351; I²=71%) in the random effects model.

In the 2 studies comparing wedge vs segmental resection relative to postoperative AE of UIP, the association between segmental resection and increased odds of postoperative AE was statistically non-significant (OR, 1.874; 95% CI, 0.727-4.834; P =.194; I²=0.0%) in the fixed effects model. Additionally, although wedge resection was associated with lower mortality from respiratory failure vs lobectomy, the wedge resection had a 5-year survival of 33.2% compared with 68.4% for lobectomy.

Review and meta-analysis limitations include lack of level I randomized evidence addressing outcomes or utility of prophylaxis to offset postoperative morbidity and mortality; lack of studies reporting on uniform mortality rates and disease-free interval stratified according to extent of resection; differences in data collection for the secondary vs primary endpoint; and the fact that a single study accounted for the vast majority of patients in all analyses (80% postoperative AE rates of UIP, 67% sublobar resection relative to postoperative AE of UIP, 83% 5-year overall survival, 95% wedge vs segment resection).

The investigators concluded that “In a super-selected, appropriately investigated, and preoptimised group of patients, anatomical lung resection can be safely performed. Judicious use of sublobar resection can be considered in small cancers in patients deemed too high risk for formal lobectomy.” The study authors also added that “With the advent of worldwide screening incentives for lung cancer, the incidence of this high-risk group of patients is going to rise.”