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P. Van Schil
Moderator of
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ORAL 05 - Surgery (ID 97)
- Event: WCLC 2015
- Type: Oral Session
- Track: Treatment of Locoregional Disease – NSCLC
- Presentations: 8
- Moderators:P. Van Schil, F.(. Kong
- Coordinates: 9/07/2015, 10:45 - 12:15, 201+203
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- Abstract
Background:
Identifying surgical non-small cell lung cancer (NSCLC) patients with poor prognosis remains a priority in clinical oncology given their high 5-year mortality. [18]F-FDG PET/CT can add important biological information of glucose metabolism to conventional imaging modality. Pretreatment maximal standard uptake value (SUV~max~), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) may predict prognosis in NSCLC patients. Thus, we performed this meta-analysis to explore the prognostic value of SUV~max~, MTV and TLG on disease-free survival (DFS) and overall survival (OS) in surgical NSCLC patients.
Methods:
A systematic search of MEDLINE, EMBASE and Cochrane Library was performed. Inclusion criteria were: pathologically confirmed NSCLC; [18]F-FDG PET used as an initial imaging tool before treatments; patients underwent curative surgery without neoadjuvant therapy; prospective or retrospective studies reported; complete survival data. Three investigators reviewed and scored each article independently on four dimensions: the scientific design, the generalizability of the results, the analysis of the study data and the PET reports. DFS and OS were considered as the outcome. The correlation of SUV~max~, MTV or TLG with survival was measured by hazard ratio (HR). Sub-group analyses were performed according to the histological subtype and pathological stage. The inter-study heterogeneity was evaluated with the Cochrane’s Q test as well as I[2]. The possibility of publication bias was assessed by visual inspection of a funnel plot and Begg’s test. “Trim and fill” procedure that considers the possibility of hypothetical “missing” studies that might exist was performed to further assess the possible effect of publication bias.
Results:
Thirty studies with 5011 patients were included for the meta-analysis. The mean quality score was 77.5%, ranging from 70.0% to 87.5%. Only one study was prospectively designed. SUV~max~ was measured in 28 studies, all of which were normalized by body weight. MTV was measured in 6 studies and TLG was measured in 5 studies. Adjusted HRs could be determined for 20 studies. For DFS, the combined HRs were 2.61 (95%CI 2.20-3.11, unadjusted) and 3.04 (95%CI 2.24-4.11, adjusted) for SUV~max~, 2.27 (95%CI 1.77-2.90, unadjusted) and 2.49 (95%CI 1.23-5.04, adjusted) for MTV, 2.46 (95%CI 1.91-3.17, unadjusted) and 2.97 (95%CI 1.68-5.28, adjusted) for TLG, respectively. For OS, the pooled HRs were 2.22 (95%CI 1.90–2.61, unadjusted) and 1.61 (95%CI 1.32-1.96, adjusted) for SUV~max~, 3.40 (95%CI 2.27-5.09, unadjusted) and 1.91 (95%CI 1.13-3.22, adjusted) for MTV, and 3.85 (95%CI 2.52-5.86, unadjusted) and 1.76 (95%CI 0.96-3.21, adjusted) for TLG, respectively. When the publication bias was detected by Begg’s test, “trim and fill” procedure was performed and similar HRs were obtained. The predictive role of SUV~max~, MTV and TLG remained similar in the sub-group analysis.
Conclusion:
High values of SUV~max~, MTV and TLG predicted a higher risk of disease recurrence or death in patients with surgical NSCLC. It is suggested that FDG PET/CT be used to select patients at high risk of disease recurrence or death and may benefit from more aggressive treatments. Further individual patient data should be analyzed to determine the optimal threshold value.
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ORAL05.02 - Quality of Resection in Pathological N2 NSCLC in the Phase 3 Lung Adjuvant Radiotherapy Trial (Lung ART): An Important Factor (ID 1001)
11:16 - 11:27 | Author(s): P. Thomas, J. Edwards, P. Van Schil, R. Rami-Porta, G. Goma, A. Dunant, C. Le Pechoux
- Abstract
- Presentation
Background:
The main objective of the ongoing phase III Lung Adjuvant Radiotherapy Trial (Lung ART) is to study the impact of post-operative conformal radiotherapy (PORT) on disease-free survival (DFS) in a population of patients with completely resected pathologically proven N2 non-small cell lung cancer (NSCLC), with or without induction or adjuvant chemotherapy. Quality of surgical resection and extent of lymph node dissection are critically important in the interpretation of results.
Methods:
A surgical advisory committee composed of 4 international expert thoracic surgeons meets regularly in order to establish the quality of resection, taking into consideration the International Association for the Study of Lung Cancer and European Society of Thoracic Surgeons published guidelines. The committee reviews anonymized surgical and pathological reports, and establishes whether tumor resection can be considered complete (no residual tumor and adequate lymph node assessment), uncertain (highest mediastinal nodal station involved, incomplete nodal exploration, involved N2 removed in fragments) or incomplete (presence of residual tumor). Nodal exploration is evaluated according to recommendations and classified as sampling, selective dissection or extensive dissection.
Results:
As of April 15th 2015, 298 patients have been included in the Lung ART trial and 116 patients’ reports have been analyzed by the surgical advisory committee. The basic characteristics are specified in the following table:
Nodal dissection was performed according to lobar location specific recommendations in most patients: for instance, station 7 was explored in 91% patients and right inferior paratracheal station 4R in 93% of right side tumours. Nodal dissection was performed according to recommendations in 71% pts; 16% patients had sampling, 22% a selective dissection and 62% a systematic dissection. Resection was considered complete (R0) in 43%, uncertain in 42%, microscopically incomplete (R1) in 14% and macroscopically incomplete (R2) in 1 patient. The most frequent reason for “uncertain resection” was involvement of the highest mediastinal lymph node.Total n=116 Frequency Percent Induction chemotherapy no 89 77% yes 27 23% Type of surgery for right-side tumors 70 60% lobectomy 49 70% bilobectomy 9 13% pneumonectomy 5 7% other 7 10% for left-side tumors 46 40% lobectomy 34 74% pneumonectomy 10 22% other 2 4% Tumor Size (mm) Median size (range) 35 [0*-105] Number of mediastinal lymph nodes examined Median number (range) 10 [1-37] Number of mediastinal lymph nodes involved Median number (range) 1[0*-15] Number of mediastinal nodal stations involved 0* 5 4% 1 79 68% 2 20 17% >2 12 11% * patients with downstaging after induction chemotherapy
Conclusion:
Most adjuvant trials have included completely resected patients, without monitoring of the quality of nodal exploration and resection. This analysis outlines the importance of an external committee evaluating the quality of resection in stage IIIA-N2 NSCLC, and the findings of this audit will be useful in the interpretation of the results of the trial.
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ORAL05.03 - Transcervical Mediastinal and Hilar Lymphadenectomy (TCML) Provides Accurate Pre-Treatment Cancer Staging and Facilitates Resection (ID 561)
11:27 - 11:38 | Author(s): R.B. Cameron, M. Fishbein, W..D. Wallace, G. Hoal, M. Doyle, L. Hua-Feng, J. Benfield
- Abstract
Background:
We sought to show that TransCervical Mediastinal and hilar Lymphadenectomy (TCML), using standard mediastinoscopy equipment, reliably accesses both mediastinal and hilar lymph node stations, provides accurate pre-treatment cancer staging, and facilitates Minimally-Invasive Cancer Resection (MICR) via removal of nodes traditionally dissected during definitive cancer resection.
Methods:
We reviewed our prospective databases for patients who had TCML - complete removal of lymph node tissue (not sampling) using a standard mediastinoscope +/- video-assistance. Pathological findings from TCML and definitive cancer resections were correlated. TCML's impact on cancer resection was assessed.
Results:
From 2004-2011, 372 patients, mean age 68.4 (28-93) years, 239 (64%) males and 133 (36%) females, had TCML. Cancer diagnoses included lung 306 (82.3%) and other 37 (17.8%). Median surgical time was 93 mins (supervised residents). There were no intra-operative complications or deaths and only 9 (2.4%) postoperative complications. The mean number of individual lymph nodes removed was 31.2/patient (range 7-78). The total and mean numbers of nodal stations removed/patient are shown the Figure (mean = 7), and specific lymph node stations removed are shown in the Table. Although hilar nodes were removed in <43%, in specific circumstances, such as RUL tumors with neg. mediastinal nodes, hilar nodes were removed in 20/29 (69%) of cases. MICR immediately after TCML usually was technically easier and faster because of the hilar dissection When resections were delayed 3-7 days, TCML was less technically beneficial because of inflammation and scarring, and delays >1 week resulted in significant detrimental effects on resection. Complete removal of all nodal tissue was confirmed during definitive cancer resection in >98% thereby providing accurate pre-resection cancer staging. Figure 1Data represents the percentage of the 372 TCML cases with the specified lymph node stations surgically addressed
Right (%) Left (%) Midline (%) Level 1 4.3 0.54 Level 2 78.23 38.17 Level 4 97.58 94.62 Level 10 43.01 24.19 Level 11 28.49 9.41 Level 12 (upper lobe) 10.75 3.23 Level 12 (lower lobe) 0.27 0.54 Level 12 (middle lobe) 1.35 N/A Level 8 2.69 3.49 Level 9 0.00 0.27 Level 5 2.51 Level 6 4.03 Level 3 (anterior) 5.38 Level 3 (posterior) 1.62 Level 7 95.43
Conclusion:
TCML is safe, accurate and feasible without elaborate instrumentation. TCML is capable of reliably accessing not only mediastinal but also hilar nodal stations and facilitates MICR if performed within 7 days of TCML.
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ORAL05.04 - Discussant for ORAL05.01, ORAL05.02, ORAL05.03 (ID 3294)
11:38 - 11:48 | Author(s): I. Opitz
- Abstract
- Presentation
Abstract not provided
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ORAL05.05 - Trimodality Therapy in the Treatment of Stage IIIA Non-Small Cell Lung Cancer (NSCLC): A National Cancer Database Analysis (ID 2962)
11:48 - 11:59 | Author(s): M. Behera, C. Steuer, F. Fernandez, Y. Liu, C. Fu, T.W. Gillespie, K.A. Higgins, N. Saba, R.N. Pillai, S. Force, S. Pakkala, D. Shin, T.K. Owonikoko, C.P. Belani, W.J. Curran, F. Khuri, S.S. Ramalingam
- Abstract
Background:
Significant controversy remains regarding the care of patients (pts) with clinical stage IIIA NSCLC. While multi-modality therapy is an acceptable strategy in selected pts, the optimal approach is not firmly established. We analyzed outcomes and predictors associated with trimodality therapy (TT) in the National Cancer Database (NCDB), an oncology outcomes database administered by the American College of Surgeons and the American Cancer Society.
Methods:
The NCDB was queried from 2003-2011 for NSCLC pts diagnosed with stage IIIA-N2 disease and treated with chemotherapy and radiation (CRT). Data was extracted on patient demographics, tumor pathology, treatments and outcomes. Three cohorts of pts were studied - CRT only/no surgery (NS), CRT + lobectomy (L) and CRT + pneumonectomy(P). The univariate and multivariable analyses (MV) were conducted using Cox proportional hazards model and log rank tests. All analyses were performed using SAS Version 9.3.
Results:
A total of 29,584 pts were included in this analysis: NS-91.7%, L-7%, and P-1.5%. Pt characteristics: median age 66 years (yrs); males 56%; whites 86%; academic centers 27%; metro locations 78%; government insured 63%; Charlson/Deyo comorbidity score 0 in 66%. Pts < 60 yrs were more likely to receive TT- L (47%), P (60%) vs. NS (29%); p<0.001. Pts in academic centers were more likely to get TT than NS (42% vs. 25%). On MV analysis, L and P had significantly better survival vs. NS: HR 0.43 (0.38-0.48) and HR 0.57 (0.46-0.71) respectively; p <0.001. The median survival of L, P and NS were 44.5 m vs. 25.6 m vs. 15.7 m (p<0.001) and 5- year survival rates (SR) were 44% vs. 33% vs. 14% respectively. 30-day mortality was higher in P vs. L [7% vs. 2.6%; OR 0.26(0.16-0.45); p<0.001]. Pts with <2 lymph nodes (LN) had better survival than pts with >2 LNs in L (50% vs. 37%; 60m vs. 38.8m) but worse in NS (13.8% vs.16.4%; 15.3m vs.18.5m). On MV analysis of LNs, L had better survival than NS: HR 0.4 (0.35-0.46) in <2 LN pts and HR 0.56 (0.46-0.69) in ≥2 LN pts; p<0.001. In pts with <2 LN, L had better survival than P (60m vs. 25.5m; p<0.0001). L and P had better SR than NS in all ages: 48% vs.37% vs. 19% in ≤60 yrs; 42% vs. 30% vs.14% in 61-70 yrs, 36% vs.19% vs. 10% in >70 yrs.
Conclusion:
TT was utilized in less than 10% of pts with stage IIIA-N2 disease, suggesting high degree of pt selection. In this selected group, TT was associated with favorable outcomes relative to CRT alone.
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- Abstract
- Presentation
Background:
Video-assisted thoracoscopic lobectomy(VATS) is preferred over thoracotomy for the treatment of early stage non-small cell lung cancer (NSCLC). However, little evidenceindicated its perioperative and oncologic outcomes for advanced-stage NSCLC and the result of VATS surgery may be overestimated since the majority of patients were stage I patients in previous studies. Therefore, we evaluate whether VATS lobectomy for locally advanced NSCLC could be performed safely and with acceptable short- and long-term outcomes when compared with standard thoracotomy on a well-balanced population from a multi-institutional database.
Methods:
Tumors that are greater than 5 cm in diameter, T3 or T4 tumors, tumors after neo-adjuvant treatment, and/or tumors with lymph node metastasis are defined to be locally advanced. By using a multi-institutional prospective database of high level comprehensive cancer hospitals, we analyzed locally advanced NSCLC patients who underwent lobectomy. VATS lobectomies were all performed by an improved technique, which had achieved proficiency that has been published previously. Using propensity-matched analysis based on preoperative variables, perioperative outcomes, oncologic efficacy and long-term survival were compared between VATS lobectomy and thoracotomy.
Results:
Matching based on propensity scores produced 125 patients in each group. Patient and tumor characteristics were similar. Conversion rate from VATS to thoracotomy is 9.6%. There were no intraoperative deaths and 1 perioperative death in each group. Postoperative outcomes like median operative time, blood loss and tube duration were similar between VATS and thoracotomy, Hospital length of stay was shorter after VATS than thoracotomy(10.4d vs 11.4d, p<0.01). VATS group had significant lower level of postoperative pain than thoracotomy group (p<0.01). The overall incidence of postoperative complications was 28.8% (36/125) and 36.0% (45/125)in the VATS group and in the thoracotomy group, respectively(p = 0.14).Similar number of lymph nodes (16.2vs 14.8, p= 0.148)and nodal stations (5.72 vs 5.66, p= 0.781) were removed by VATS and thoracotomy. Similar proportion of patients accepted postoperative chemotherapy (73.6% vs 72.0%, p= 0.776) , and completed similar cycles of postoperative chemotherapy (2.47 vs.2.35, p = 0.602) in the two groups. Median follow-up was 36.6 months. There were no significant differences in locoregional and distant recurrence patterns between the two groups. Disease-free survival(DFS) at 3-years were 50.1% and 47.3%, 5- years were 40.0% and 37.0% in the VATS and thoracotomy groups, respectively (p=0.878). Overall survival(OS) at 3-years were 75.0% and 68.9%, 5-years were 42.2% and 43.1% in the VATS and thoracotomy groups, respectively (p =0.551). Multivariate Cox regression analyses of DFS and OS confirmed the noninferiority of VATS, and showed that significant predictors of worse DFS and OS were advanced pathologic stage (HR,2.235; 95% CI,1.564 to 3.193; p<0.001), and without postoperative chemotherapy (HR,1.594; 95% CI,1.095 to 2.321; p=0.015).
Conclusion:
VATS lobectomy for locally advanced stage NSCLC can be performed safely, with shorter length of hospital stay, lower level of pain and showed similar long-term survivals compared to thoracotomy. With continued experience and optimized technique, VATS lobectomy can be performed in majority of cases without compromising the perioperative outcomes and oncologic efficacy. This work was supported by a funding named‘Beijing Municipal Science and Technology Project (D141100000214004)
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- Abstract
- Presentation
Background:
Individual academic societies have published different recommendations about definitions and requirement of nodal assessment. It's generally agreed that radical mediastinal lymphadenectomy will provide accurate information for pathological staging and guiding adjuvant therapy. However it is not clearly established whether mediastinal lymphadenectomy compliant with international criteria will improve the oncological outcomes of clinical early-stage lung cancer. This retrospective study was aimed to compare the long-term survival between the cases treated with lymphadenectomy fulfilling the NCCN criteria and other cases not met the criteria in clinical early-stage lung cancer patients.
Methods:
During the investigation period, 712 consecutive cases of clinical N0/1 entered the analysis, confirming as 152 cases of pN2 (pathological N2) and 560 of pN0-1 (pathological N0-1) disease after surgery. Group A was defined as the cases fulfilling the National Comprehensive Cancer Network (NCCN) lymphadenectomy criteria (≥three stations of N2 nodes dissection) and Group B was those who did not meet the criteria. Two groups were stratified by pN status and the outcomes were analyzed and multivariate Cox regression was performed to determine prognostic factors.
Results:
5-year Overall survival (OS) and 5-year disease-free survival (DFS) were significantly different between two groups at cN0/1-pN2 status (5-year OS rates, 50±5% vs. 25±9%, p=0.006; 5-year DFS rates, 31.0±4% vs. 13±7%, p=0.014), but not at pN0-1 status (Figure 1). T staging and lymphadenectomy fulfilling NCCN criteria were prognostic factors in cN0/1-pN2 group by multivariate regression analysis. Furthermore, the cases treated with ≥ 4 stations of mediastinal lymph nodes dissection could not achieve better survival benefit compared to those harvesting 3 stations of N2 node in cN0/1-pN2 group (the 5-year OS rates, 46±6% vs. 59±9%, p=0.152).The spreading pattern of mediastinal nodes among pN2 cases was featured by tumor location. The most frequent involved station for right upper lobe-located lung cancer was 4R (83.7%), followed by 7 (37%) and 2R (14.0%). The top 3 involved stations for other cancer locations were 7 (75%), 4R (25%) and 2R (6.3%) for right middle lobe; 7 (81.6%), 4R (34.2%) and 2R (10.5%) for right lower lobe; 5+6 (90.9%), 4L (22.7%) and 7 (4.5%) for left upper lobe; 7 (66.7%), 5+6 (42.4%) and 8 (9.1%) for left lower lobe. Figure 1
Conclusion:
Mediastinal lymphadenectomy fulfilling with NCCN criteria may only improve the survival of pathological upstaging subgroup (cN0/1-pN2) among patients with clinical early-stage lung cancer. More extended dissection of mediastinal lymph node (≥ 4 stations) may not further improve the outcome in this group.
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ORAL05.08 - Discussant for ORAL05.05, ORAL05.06, ORAL05.07 (ID 3295)
12:21 - 12:31 | Author(s): E. Ruffini
- Abstract
- Presentation
Abstract not provided
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Author of
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PC 01 - Pro vs Con: Surgery vs. SBRT in Operable NSCLC / Pro vs Con: SBRT for Non-Biopsied Lung Nodules (ID 47)
- Event: WCLC 2015
- Type: Pro Con
- Track: Treatment of Localized Disease - NSCLC
- Presentations: 1
- Moderators:D. Harpole, P. Yang, P. Bonomi, A. Wozniak
- Coordinates: 9/07/2015, 14:15 - 15:45, 601+603
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PC01.02 - Surgery vs. SBRT in Operable NSCLC - Surgery (ID 2027)
14:40 - 15:00 | Author(s): P. Van Schil
- Abstract
- Presentation
Abstract:
Surgery vs. SBRT in operable NSCLC Surgery Over the last years stereotactic radiotherapy (SRT) has emerged as an alternative treatment to surgical resection for treatment of localized, early-stage non-small cell lung cancer (NSCLC). Precise delivery of high-dose radiotherapy has become possible to eradicate the primary tumor (1). SRT has mainly been applied for functionally inoperable patients with severe cardiopulmonary morbidity. Recently, the question has emerged whether SRT is also a valid oncological treatment in technically and functionally operable patients. At the present time, no randomized studies are available directly comparing SRT and surgical resection with systematic lymph node dissection. Several trials were initiated but they were closed prematurely due to poor accrual. SRT is certainly emerging as a valid therapeutic option. However, from a thoracic surgical point of view several concerns remain when applying SRT to operable early-stage NSCLC: precise pathology is not obtained in all cases, no precise information is available on locoregional lymph node involvement making it difficult to recommend adjuvant chemotherapy in specific cases, and in general, different criteria are applied when comparing results of surgery and SRT. This applies specifically to the definition of local recurrence which gives rise to a potential comparison bias and limits the accuracy of long-term evaluation (2, 3). Moreover, thoracic surgeons are more and more confronted with “salvage surgery” after previous radiotherapy when no other therapeutic options are available (4). Technically, these resections can be very challenging. As no high-grade evidence is available, different opinions prevail in present-day literature. In a pooled analysis of two randomised trials comparing SRT with lobectomy for stage I NSCLC that closed prematurely due to poor accrual, the authors concluded that SRT could be an option for treating operable stage I NSCLC. However, as the authors indicate themselves, because of small patient sample size and short follow-up time, further randomized studies should be performed before more definite recommendations can be made (5). In contrast, in a recent propensity score analysis 41 patients who underwent video-assisted (VATS) lobectomy were matched with 41 patients treated with SRT for stage I NSCLC (6). Significant differences were found in overall survival, cause-specific survival, recurrence-free survival, local and distant control favoring VATS lobectomy. Conclusion of this study was that VATS lobectomy may offer a significantly better long-term outcome than SRT in potentially operable patients with biopsy-proven clinical stage I NSCLC. In another propensity score analysis long-term survival was compared between SRT and sublobar resection for stage I NSCLC in patients at high risk for lobectomy (7). In 53 matched pairs the difference in overall survival was not significant and the cumulative incidence of cause-specific death was comparable between both groups. Conclusion of this study was that SRT can be an alternative treatment option to sublobar resection for patients who cannot tolerate lobectomy because of medical comorbidities. In June 2015 the “Comité de l’Evolution des Pratiques en Oncologie (CEPO) from Québec, Canada published its recommendations regarding the use of SRT (8). For medically operable patients with T1-2N0M0 NSCLC surgery remains the standard treatment due to the lack of scientifically valid comparative data. For medically inoperable patients with T1-2N0M0 NSCLC or medically operable patients who refuse surgery, SRT should be preferred to external beam radiotherapy, a biological equivalent dose (BED) of at least 100 Gy should be administered, and the choice of using SRT should be discussed within a tumor board. Radiotherapy should not be considered for patients whose life expectancy is very limited because of comorbidities. In conclusion, surgical resection remains the treatment of choice for patients with early-stage NSCLC who are functionally operable. After discussion within a multidisciplinary tumor board SRT may be considered for functionally compromised patients who cannot tolerate lobectomy. Further evidence is needed requiring cooperation between radiation oncologists and thoracic surgeons when designing comparative trials with strict inclusion criteria and precise definitions of endpoints. In this way a scientifically valid comparison between SRT and surgical treatment is provided. References 1. Louie AV, Palma DA, Dahele M, Rodrigues GB, Senan S. Management of early-stage non-small cell lung cancer using stereotactic ablative radiotherapy: controversies, insights, and changing horizons. Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology. 2015;114(2):138-47. Epub 2014/12/17. 2. Van Schil PE, Van Meerbeeck J. Surgery or radiotherapy for early-stage lung cancer--a potential comparison bias. The Lancet Oncology. 2013;14(10):e390. Epub 2013/09/03. 3. Van Schil PE. Results of surgery for lung cancer compared with radiotherapy: do we speak the same language. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2013;8(2):129-30. Epub 2013/01/19. 4. Van Schil PE. Salvage surgery after stereotactic radiotherapy: a new challenge for thoracic surgeons. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2010;5(12):1881-2. Epub 2010/11/26. 5. Chang JY, Senan S, Paul MA, Mehran RJ, Louie AV, Balter P, et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. The Lancet Oncology. 2015;16(6):630-7. Epub 2015/05/20. 6. Hamaji M, Chen F, Matsuo Y, Kawaguchi A, Morita S, Ueki N, et al. Video-assisted thoracoscopic lobectomy versus stereotactic radiotherapy for stage I lung cancer. The Annals of thoracic surgery. 2015;99(4):1122-9. Epub 2015/02/11. 7. Matsuo Y, Chen F, Hamaji M, Kawaguchi A, Ueki N, Nagata Y, et al. Comparison of long-term survival outcomes between stereotactic body radiotherapy and sublobar resection for stage I non-small-cell lung cancer in patients at high risk for lobectomy: A propensity score matching analysis. Eur J Cancer. 2014;50(17):2932-8. Epub 2014/10/05. 8. Boily G, Filion E, Rakovich G, Kopek N, Tremblay L, Samson B, et al. Stereotactic Ablative Radiation Therapy for the Treatment of Early-stage Non-Small-Cell Lung Cancer: CEPO Review and Recommendations. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer. 2015;10(6):872-82. Epub 2015/05/23.
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