Lung cancer remains the leading cause of cancer-related mortality globally, with surgical resection representing the cornerstone of curative treatment for early-stage NSCLC. Historically, lobectomy has been the gold standard, according to perceptions of oncologic efficacy. However, concerns regarding pulmonary preservation and perioperative morbidity have catalyzed renewed interest in sublobar resections, including wedge resection and segmentectomy. Early randomized trials, notably the Lung Cancer Study Group (LCSG) trial of 1995, demonstrated higher recurrence rates with sublobar resections, establishing lobectomy as the preferred approach. Nevertheless, advances in preoperative imaging, staging accuracy, and minimally invasive techniques—specifically video-assisted thoracoscopic surgery (VATS)—have prompted reconsideration of this standard. Recent landmark randomized trials, notably JCOG 0802 and CALGB 140503, provided pivotal evidence supporting sublobar resection as oncologically comparable with lobectomy for small (≤2 cm), peripheral tumors, with the added benefits of reduced morbidity and better preservation of pulmonary function. However, these studies also identified increased locoregional recurrence rates associated with sublobar resections. Current guidelines, including the NCCN recommendations, now support sublobar resections as a viable alternative in carefully selected patients. Despite these advancements, ongoing debates persist regarding the optimal patient selection criteria, appropriate application in central tumors, management of tumors larger than 2 cm, and the significance of tumor features such as tumor spread through airspaces (STAS) and the consolidation-to-tumor ratio (CTR). Further investigation is required to refine patient selection and surgical techniques, particularly to clarify whether segmentectomy confers advantages over wedge resection and to determine the necessity and extent of mediastinal lymph node staging. This review critically examines historical and contemporary evidence informing the role of sublobar resections and highlights areas needing further research to optimize outcomes for early-stage NSCLC patients.
Citation: Boxiang Jiang, Jock Thacker, Christopher W. Towe. Evolving surgical standards in early-stage non-small cell lung cancer: A review of sublobar resections and future perspectives[J]. AIMS Medical Science, 2025, 12(3): 279-291. doi: 10.3934/medsci.2025019
Lung cancer remains the leading cause of cancer-related mortality globally, with surgical resection representing the cornerstone of curative treatment for early-stage NSCLC. Historically, lobectomy has been the gold standard, according to perceptions of oncologic efficacy. However, concerns regarding pulmonary preservation and perioperative morbidity have catalyzed renewed interest in sublobar resections, including wedge resection and segmentectomy. Early randomized trials, notably the Lung Cancer Study Group (LCSG) trial of 1995, demonstrated higher recurrence rates with sublobar resections, establishing lobectomy as the preferred approach. Nevertheless, advances in preoperative imaging, staging accuracy, and minimally invasive techniques—specifically video-assisted thoracoscopic surgery (VATS)—have prompted reconsideration of this standard. Recent landmark randomized trials, notably JCOG 0802 and CALGB 140503, provided pivotal evidence supporting sublobar resection as oncologically comparable with lobectomy for small (≤2 cm), peripheral tumors, with the added benefits of reduced morbidity and better preservation of pulmonary function. However, these studies also identified increased locoregional recurrence rates associated with sublobar resections. Current guidelines, including the NCCN recommendations, now support sublobar resections as a viable alternative in carefully selected patients. Despite these advancements, ongoing debates persist regarding the optimal patient selection criteria, appropriate application in central tumors, management of tumors larger than 2 cm, and the significance of tumor features such as tumor spread through airspaces (STAS) and the consolidation-to-tumor ratio (CTR). Further investigation is required to refine patient selection and surgical techniques, particularly to clarify whether segmentectomy confers advantages over wedge resection and to determine the necessity and extent of mediastinal lymph node staging. This review critically examines historical and contemporary evidence informing the role of sublobar resections and highlights areas needing further research to optimize outcomes for early-stage NSCLC patients.
| [1] | Bray F, Laversanne M, Sung H, et al. (2024) Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 74: 229-263. https://doi.org/10.3322/caac.21834 |
| [2] | Islami F, Baeker Bispo J, Lee H, et al. (2024) American Cancer Society's report on the status of cancer disparities in the United States, 2023. CA Cancer J Clin 74: 136-166. https://doi.org/10.3322/caac.21812 |
| [3] |
Ettinger DS, Wood DE, Aisner DL, et al. (2022) Non-small cell lung cancer, version 3.2022, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw 20: 497-530. https://doi.org/10.6004/jnccn.2022.0025 
|
| [4] |
Herrera LJ, Dadzie K (2024) The evolving field of sublobar resection: in search of the optimal operation or the optimal definition. J Thorac Dis 16: 3531-3534. https://doi.org/10.21037/jtd-24-267
|
| [5] |
Ginsberg RJ, Rubinstein LV, Lung Cancer Study Group (1995) Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Ann Thorac Surg 60: 615-623. https://doi.org/10.1016/0003-4975(95)00537-u
|
| [6] |
Altorki N, Wang X, Kozono D, et al. (2023) Lobar or sublobar resection for peripheral stage IA non-small-cell lung cancer. N Engl J Med 388: 489-498. https://doi.org/10.1056/NEJMoa2212083
|
| [7] |
Saji H, Okada M, Tsuboi M, et al. (2022) Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet 399: 1607-1617. https://doi.org/10.1016/S0140-6736(21)02333-3
|
| [8] |
Immerman SC, Vanecko RM, Fry WA, et al. (1981) Site of recurrence in patients with stages I and II carcinoma of the lung resected for cure. Ann Thorac Surg 32: 23-27. https://doi.org/10.1016/s0003-4975(10)61368-9
|
| [9] |
Gail MH, Eagan RT, Feld R, et al. (1984) Prognostic factors in patients with resected stage I non-small cell lung cancer. A report from the Lung Cancer Study Group. Cancer 54: 1802-1813. https://doi.org/10.1002/1097-0142(19841101)54:9<1802::aid-cncr2820540908>3.0.co;2-4
|
| [10] |
Jensik RJ, Faber LP, Milloy FJ, et al. (1973) Segmental resection for lung cancer. A fifteen-year experience. J Thorac Cardiovasc Surg 66: 563-572.
|
| [11] | Pastorino U, Valente M, Bedini V, et al. (1991) Limited resection for stage I lung cancer. Eur J Surg Oncol 17: 42-46. |
| [12] |
Errett LE, Wilson J, Chiu RC, et al. (1985) Wedge resection as an alternative procedure for peripheral bronchogenic carcinoma in poor-risk patients. J Thorac Cardiovasc Surg 90: 656-661.
|
| [13] |
Bennett WF, Smith RA (1979) Segmental resection for bronchogenic carcinoma: a surgical alternative for the compromised patient. Ann Thorac Surg 27: 169-172. https://doi.org/10.1016/s0003-4975(10)63261-4
|
| [14] |
Kirsh MM, Rotman H, Bove E, et al. (1976) Major pulmonary resection for bronchogenic carcinoma in the elderly. Ann Thorac Surg 22: 369-373. https://doi.org/10.1016/s0003-4975(10)64969-7
|
| [15] |
Hoffmann TH, Ransdell HT (1980) Comparison of lobectomy and wedge resection for carcinoma of the lung. J Thorac Cardiovasc Surg 79: 211-217.
|
| [16] |
Ettinger DS, Wood DE, Aisner DL, et al. (2023) NCCN guidelines® insights: non-small cell lung cancer, version 2.2023. J Natl Compr Canc Netw 21: 340-350. https://doi.org/10.6004/jnccn.2023.0020
|
| [17] | National Comprehensive Cancer Network, Non-Small Cell Lung Cancer (version 2.2011). Pennsylvania National Comprehensive Cancer Network, 2011. Available from: https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1450. (cited November 1, 2024) |
| [18] |
Kodama K, Higashiyama M, Okami J, et al. (2016) Oncologic outcomes of segmentectomy versus lobectomy for clinical T1a N0 M0 non-small cell lung cancer. Ann Thorac Surg 101: 504-511. https://doi.org/10.1016/j.athoracsur.2015.08.063
|
| [19] |
Okada M, Koike T, Higashiyama M, et al. (2006) Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study. J Thorac Cardiovasc Surg 132: 769-775. https://doi.org/10.1016/j.jtcvs.2006.02.063
|
| [20] |
Nakamura H, Kawasaki N, Taguchi M, et al. (2005) Survival following lobectomy vs limited resection for stage I lung cancer: a meta-analysis. Br J Cancer 92: 1033-1037. https://doi.org/10.1038/sj.bjc.6602414
|
| [21] |
Cao C, Chandrakumar D, Gupta S, et al. (2015) Could less be more?—A systematic review and meta-analysis of sublobar resections versus lobectomy for non-small cell lung cancer according to patient selection. Lung Cancer 89: 121-132. https://doi.org/10.1016/j.lungcan.2015.05.010
|
| [22] |
Cerfolio RJ, Ojha B, Bryant AS, et al. (2004) The accuracy of integrated PET-CT compared with dedicated PET alone for the staging of patients with nonsmall cell lung cancer. Ann Thorac Surg 78: 1017-1023. https://doi.org/10.1016/j.athoracsur.2004.02.067
|
| [23] | National Lung Screening Trial Research Team (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365: 395-409. https://doi.org/10.1056/NEJMoa1102873 |
| [24] |
de Koning HJ, van Der Aalst CM, de Jong PA, et al. (2020) Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med 382: 503-513. https://doi.org/10.1056/NEJMoa1911793
|
| [25] |
Blasberg JD, Seder CW, Leverson G, et al. (2016) Video-assisted thoracoscopic lobectomy for lung cancer: current practice patterns and predictors of adoption. Ann Thorac Surg 102: 1854-1862. https://doi.org/10.1016/j.athoracsur.2016.06.030
|
| [26] | Lim E, Batchelor TJP, Dunning J, et al. (2022) Video-assisted thoracoscopic or open lobectomy in early-stage lung cancer. NEJM Evid 1. https://doi.org/10.1056/EVIDoa2100016 |
| [27] |
Altorki NK, Yip R, Hanaoka T, et al. (2014) Sublobar resection is equivalent to lobectomy for clinical stage 1A lung cancer in solid nodules. J Thorac Cardiovasc Surg 147: 754-764. https://doi.org/10.1016/j.jtcvs.2013.09.065
|
| [28] |
Onaitis MW, Furnary AP, Kosinski AS, et al. (2020) Equivalent survival between lobectomy and segmentectomy for clinical stage IA lung cancer. Ann Thorac Surg 110: 1882-1891. https://doi.org/10.1016/j.athoracsur.2020.01.020
|
| [29] |
Landreneau RJ, Normolle DP, Christie NA, et al. (2014) Recurrence and survival outcomes after anatomic segmentectomy versus lobectomy for clinical stage I non-small-cell lung cancer: a propensity-matched analysis. J Clin Oncol 32: 2449-2455. https://doi.org/10.1200/JCO.2013.50.8762
|
| [30] |
Kates M, Swanson S, Wisnivesky JP (2011) Survival following lobectomy and limited resection for the treatment of stage I non-small cell lung cancer<=1 cm in size: a review of SEER data. Chest 139: 491-496. https://doi.org/10.1378/chest.09-2547
|
| [31] |
Lee BE, Altorki N (2023) Sub-lobar resection: the new standard of care for early-stage lung cancer. Cancers 15: 2914. https://doi.org/10.3390/cancers15112914
|
| [32] |
Detterbeck F, Ely S, Udelsman B, et al. (2024) So now we know-reflections on the extent of resection for stage I lung cancer. Clin Lung Cancer 25: e113-e123. https://doi.org/10.1016/j.cllc.2023.12.007
|
| [33] | National Comprehensive Cancer Network, Non-Small Cell Lung Cancer (version 8.2024). Pennsylvania National Comprehensive Cancer Network, 2024. Available from: https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf. (cited November 1, 2024) |
| [34] |
Altorki N, Wang X, Damman B, et al. (2024) Lobectomy, segmentectomy, or wedge resection for peripheral clinical T1aN0 non-small cell lung cancer: a post hoc analysis of CALGB 140503 (Alliance). J Thorac Cardiovasc Surg 167: 338-347.e1. https://doi.org/10.1016/j.jtcvs.2023.07.008
|
| [35] |
Towe CW, Grau-Sepulveda MV, Hartwig MG, et al. (2024) The society of thoracic surgeons database analysis: comparing sublobar techniques in stage IA lung cancer. Ann Thorac Surg 118: 665-671. https://doi.org/10.1016/j.athoracsur.2024.03.008
|
| [36] |
Li J, Wang Y, Li J, et al. (2022) Meta-analysis of lobectomy and sublobar resection for stage I non-small cell lung cancer with spread through air spaces. Clin Lung Cancer 23: 208-213. https://doi.org/10.1016/j.cllc.2021.10.004
|
| [37] |
Eguchi T, Kameda K, Lu S, et al. (2019) Lobectomy is associated with better outcomes than sublobar resection in spread through air spaces (STAS)-positive T1 lung adenocarcinoma: a propensity score–matched analysis. J Thorac Oncol 14: 87-98. https://doi.org/10.1016/j.jtho.2018.09.005
|
| [38] |
Shiono S, Endo M, Suzuki K, et al. (2020) Spread through air spaces affects survival and recurrence of patients with clinical stage IA non-small cell lung cancer after wedge resection. J Thorac Dis 12: 2247-2260. https://doi.org/10.21037/jtd.2020.04.47
|
| [39] | Lin H, Peng Z, Zhou K, et al. (2024) Differential efficacy of segmentectomy and wedge resection in sublobar resection compared to lobectomy for solid-dominant stage IA lung cancer: a systematic review and meta-analysis. Int J Surg 110: 1159-1171. https://doi.org/10.1097/JS9.0000000000000896 |
| [40] |
Jing W, Li Q, Liu M, et al. (2024) CTR > 0.7 predicts the subgroup of lung adenocarcinomas ≤2 cm at risk of poor outcome treated by sublobar resection compared to lobar resection. Cancer Imaging 24: 76. https://doi.org/10.1186/s40644-024-00717-4
|
| [41] |
Wu Y, Song W, Wang D, et al. (2023) Prognostic value of consolidation-to-tumor ratio on computed tomography in NSCLC: a meta-analysis. World J Surg Oncol 21: 190. https://doi.org/10.1186/s12957-023-03081-y
|
Boxiang Jiang, Jock Thacker, Christopher W. Towe. Evolving surgical standards in early-stage non-small cell lung cancer: A review of sublobar resections and future perspectives[J]. AIMS Medical Science, 2025, 12(3): 279-291. doi: 10.3934/medsci.2025019
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