Systematic Review of the Comparative Studies of Image-guided Thermal Ablation, Stereotactic Radiosurgery, and Sublobar Resection for Treatment of High-Risk Patients with Stage I Non-Small Cell Lung Cancer

The Clinical Practice Standards Committee of the American Association for Thoracic Surgery assembled an expert panel and conducted a systematic review of the literature detailing studies directly comparing treatment options for high-risk patients with stage I non-small cell lung cancer (NSCLC). A systematic search was performed to identify publications comparing outcomes following image-guided thermal ablation (IGTA), stereotactic ablative radiotherapy (SABR), and sublobar resection—the main treatment options applicable to high-risk patients with stage I NSCLC. There were no publications detailing completed randomized controlled trials comparing these treatment options. Several retrospective studies with comparisons were identified, some of which used large, population-based registries. The findings in 18 of these studies are summarized in this Expert Review article. Registry studies comparing IGTA with SABR in propensity-score matched patients with stage I NSCLC found no difference in overall survival. The use of thermal ablation was less frequent and had wider variation depending on geographic region as compared with SABR, however. Studies yielding high-quality data comparing SABR with sublobar resection have been limited. When comparing sublobar resection with IGTA, sublobar resection was associated with superior primary tumor control and overall survival in the retrospective cohort studies. Retrospective comparative studies are difficult to assess due to the inherent biases or treatment selection and the definitions of loco-regional control. Prospective randomized trials are needed to fully evaluate the outcomes of treatment options applicable to high-risk patients with early-stage lung cancer.