Stereotactic Body Radiation Therapy and Wedge Resection are Both Validated Options in Limited Operable Non-Small Cell Lung Cancer

The current standard in the treatment of operable early-stage non-small cell lung cancer (NSCLC) is lobectomy and systematic hilar and mediastinal lymph node dissection. In (many) patients not suitable for lobectomy or with small (<2cm) peripheral NSCLC, atypical lung resections (such as segmentectomy and wedge resection) are proposed, as well as, radical radiotherapy. No observed difference in overall survival (OS) between lobectomy and stereotactic body radiotherapy (SBRT), introduced SBRT as the standard treatment for early-stage inoperable NSCLC resulting in a high local control rate, preserved quality of life, and low treatment toxicity. The question of whether there is a role for SBRT in the treatment of operable NSCLC remains open. Many retrospective studies compared surgery to SBRT for this clinical scenario, and the results imply that sub-lobar resections have superior OS than SBRT. However, there are many controversies for that conclusion. Patients opting for surgery often have better physical condition than SBRT patients, have less comorbidities, and are of younger age. Many SBRT patients do not have prior tumor biopsy confirmation, and, finally, SBRT lacks pathologic lymph node assessment leading to potential understaging. The limitations of the studies are also numerous. Most of them are retrospective, the sample sizes are relatively small, tumor localizations, size, and patohistological type are very heterogeneous and could impact survival. Therefore, there is a low analysis sensitivity as well as publication bias. The ongoing studies (POSITIVL, VALOR, and STABLE-MATES) are specially designed to prospectively compare surgery to SBRT, and (hopefully) answer this question.