Comparison among stereotactic body radiation therapy, lobectomy, segmentectomy, and wedge resection for clinical stage I non-small cell lung cancer: a network meta-analysis

Introduction

Non-small cell lung cancer (NSCLC), which constitutes approximately 85% of all lung cancer cases, is associated with high prevalence and mortality rates worldwide (1,2). For early-stage NSCLC, there is no doubt that surgery has been the standard treatment method. In 1995, the Lung Cancer Study Group reported a randomized controlled trial (RCT) comparing lobectomy and sublobar resection, and lobectomy became the standard procedure for early-stage patients (3). However, with the development of surgery, an increasing number of studies have found that sublobar resection is not inferior to lobectomy. For individuals with clinical stage IA NSCLC <2 cm, wedge resection and lobectomy had similar outcomes regarding recurrence-free survival (RFS) (4). Compared to lobectomy, segmentectomy resulted in significantly higher 5-year overall survival (OS) for patients with small-peripheral NSCLC (5). There were differences between different lung resections, and not all early-stage NSCLC patients need to undergo lobectomy to achieve better treatment outcomes (4).

In recent years, stereotactic body radiation therapy (SBRT) has shown satisfactory effectiveness in the treatment of early-stage NSCLC (6). Although recommended as the standard care method for patients who were medically inoperable for various reasons, the favorable outcomes achieved with SBRT in inoperable cases suggest its potential applicability in surgical candidates as well (6,7). However, its comparison with surgical results has been controversial. A retrospective study, after conducting propensity score matching (PSM), revealed that there were no significant differences in OS and disease-free survival between SBRT and surgery (8). Even a previous pooled analysis of two randomized trials showed that compared to the surgical group, the SBRT group has a higher 3-year OS and RFS for operable stage I NSCLC (9). However, a meta-analysis summarizing 30 studies showed that for early-stage NSCLC patients, the 3-year OS and cancer-specific survival in the surgical group were better than those in the SBRT group (10). It is worth noting that previous studies viewed lung resections as a whole and compared its effectiveness with SBRT, without considering the heterogeneity between different lung resections. Therefore, the differences in effectiveness between specific lung resections and SBRT are unclear.

To evaluate the differences in effectiveness between specific lung resections and SBRT, this study conducted a network meta-analysis for comparing survival outcomes and treatment-related complication incidence among clinical stage I NSCLC patients who underwent SBRT or lung resections (lobectomy, segmentectomy, and wedge resection). We present this article in accordance with the PRISMA-NMA reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1568/rc) (11).

Methods

Data sources and searches

To identify the relevant studies, two authors (J.Z. and J.H.) independently searched the records in the electronic databases of PubMed, EMBASE, and The Cochrane Library. We used the following keywords: “Carcinoma, Non-Small-Cell Lung”, “stage I”, “lobectomy”, “segmentectomy”, “wedge resection”, and “stereotactic ablative radiotherapy”. All relevant articles were searched before February 8, 2025, and detailed search criteria can be found in the Appendix 1. To guarantee the comprehensiveness of this research, a thorough screening was conducted on the references cited in the retrieved articles. Additionally, unpublished studies listed in the ClinicalTrials.gov registry were meticulously examined. The protocol of this study has been registered in the International Prospective Register of Systematic Reviews (PROSPERO; number CRD42023412394).

Study selection criteria

The studies incorporated into this network meta-analysis were selected based on the following eligibility criteria: (I) patients diagnosed with clinical stage I NSCLC; (II) comparison of two or more treatment modalities among SBRT, lobectomy, segmentectomy, and wedge resection; (III) at least one outcome among OS, RFS, or treatment-related complication incidence was reported; (IV) cohort study or RCT. Studies were excluded from this network meta-analysis for the following reasons: (I) absence of full-text reports; (II) unavailability of valid data; (III) a low Newcastle-Ottawa Scale score for cohort studies (score <7). Initial screening was conducted based on the title and abstract, followed by a thorough examination of the entire study and a comprehensive assessment to exclude literature that did not meet the inclusion criteria. When there were disagreements regarding the selected research, the third author (H.Y.) independently conducted a check to eliminate discrepancies and reached a consensus.

Data extraction and quality assessment

Two authors (J.Z. and J.H.) independently extracted data for each included study into a spreadsheet, and the third author (H.Y.) resolved conflicts when disagreement occurred. The data extracted mainly contained the first author, publication year, country, research period, study design, clinical stage of each study, different treatments, number of patients, age, female proportion, radiologic tumor diameter, forced expiratory volume in one second (FEV1)%, and diffusion capacity of the lung for carbon monoxide (DLCO)% in different intervention groups. Since the included studies spanned a wide time range, some applied the 7th edition and others the 8th edition of the IASLC staging system. Therefore, we accepted the definition of clinical stage I NSCLC as reported by the original study authors and did not impose a unified staging definition. If a study used propensity score matching, the matched data were prioritized. The primary outcome was OS, and the secondary outcomes were RFS and treatment-related complication incidence. Engauge Digitizer 11.3 software was used when survival data could not be directly extracted (12). The quality of the included cohort studies and RCTs was evaluated using the Newcastle-Ottawa Quality Assessment Scale and Cochrane Collaboration’s tool, respectively (13,14). Studies with scores ≥7 and moderate risk or below were considered eligible for final inclusion in the network meta-analysis.

Statistical analysis

Stata software (version 17.0) was used to draw network plots of treatments. The thickness of lines between nodes and the size of the nodes represented the number of studies (15). The survival outcomes we analyzed were HR with 95% confidence intervals (CIs) for OS and RFS. Furthermore, we summarized the effect of treatments on treatment-related complication incidence using the odds ratio (OR) and the corresponding 95% CI. Bayesian hierarchical random effects model was used to perform network meta-analysis in R software (version 4.2.1; Package gemtc) (16). This method is widely used in network meta-analyses for comparing multiple treatments, especially when indirect evidence is involved (17,18). Random effects and consistency model were computed by using Markov chain Monte Carlo (MCMC) methods with Gibbs sampling based on simulations of 100,000 iterations, 50,000 adaptions and a thinning interval of 10 in each of 4 chains (19). Model convergence was assessed through iteration plots and Gelman-Rubin diagnostics (20). Within the bayesian framework, the network meta-analysis estimated the overall rankings of treatments by generating the cumulative ranking curve for each treatment (21). The greater the surface under the cumulative ranking curve (SUCRA), the higher the likelihood of an intervention being considered the most effective measure.

Three critical assumptions underlying the network meta-analysis are similarity (that requires all studies included within a network to be comparable in terms of key factors that can be potential treatment effect modifiers), homogeneity (no significant variation in treatment effects among studies of same comparison), and consistency (the direct and indirect results are consistent). The comparability of baseline characteristics among patient cohorts across different treatment modalities was evaluated using the independent samples T-test in SPSS software (version 25). To visually represent the distribution of patient characteristics, box plots were generated (Figure S1). I² statistic was used to assess heterogeneity in studies (22). Global inconsistency was assessed by comparing the deviance information criterion (DIC) of consistency and inconsistency models. A difference of less than 5 indicates adherence to the consistency assumption, allowing the use of a consistency model (23). Furthermore, the node-splitting approach was used to perform local inconsistency analysis within studies of closed loops in the network evidence plot (24). This involved generating effect size and CI for the indirect comparison to estimate inconsistency between direct and indirect comparison results. For publication bias analysis, an adjusted network funnel plot was plotted when the number of included studies exceeded 10.

Subgroup analysis

Three subgroup analyses were conducted, stratified by patient clinical stage (clinical IA stage and clinical stage I), regions (Asia and the West), and publication year (2009–2015 and 2016–2025). Subgroup analysis only focused on the primary outcome OS. Additionally, considering various surgical methods collectively, a pairwise meta-analysis was conducted to compare the effectiveness of SBRT and surgery in patients.

Results

Study selection

The literature selection process and reasons for study exclusion were shown in Figure 1. A total of 10,080 records were retrieved by database searching. After removing 4,020 duplications, 6,060 articles were screened for eligibility based on their titles and abstracts and 5,655 irrelevant articles were eliminated following application of the inclusion and exclusion criteria. After assessing the full-text articles, 375 articles were excluded due to the study population (128 records), interventions (103 records), outcomes (46 records), and study design (57 records) not meeting the standards, inability to obtain the full text (32 records), and inadequate research quality (9 records). Ultimately, 30 articles were included in the network meta-analysis.

Figure 1 PRISMA flow diagram of the study selection for this systematic review and network meta-analysis. PRISMA, preferred reporting items for systematic reviews and meta-analyses.

Study characteristics and baseline characteristics

The basic characteristics of enrolled studies and patients’ baseline characteristics were shown in Table 1. There were 28 retrospective cohort studies and 2 RCTs, respectively, conducted across diverse geographical regions, encompassing 5 studies in Europe (5,25-28), 9 in North America (29-37), and 16 in Asia (38-53). There were 14 studies comparing segmentectomy and lobectomy (25,31,33,36,42,43,45-49,51-53), 7 studies comparing SBRT with lobectomy (26-28,35,39,40,44), 4 studies comparing wedge resection vs. segmentectomy (30,38,41,50), 2 studies were enrolled that compared wedge resection with SBRT (32,34), and one study comparing wedge resection with lobectomy (5). Additionally, two three-arm trials were included (29,37). The period of these studies is 2009–2025. A total of 27 studies reported on OS, with 14 and 10 studies focusing on RFS and treatment-related complication incidence, respectively.

Quality assessment

Quality assessment scores were provided in Table 1. The evaluation results showed that 6 studies scored 7 points, 16 scored 8 points, and 6 scored 9 points. Two RCTs were both at moderate risk of bias.

Network meta-analysis results

The network evidence plots for each outcome were shown in Figure 2. The trajectory plot and convergence diagnosis plot showed that the model had satisfactory stability and convergence (Figures S2,S3).

Figure 2 Network evidence plots of treatment comparisons. Comparison of OS (A), RFS (B), and treatment-related complication incidence (C) in all NSCLC patients and in subgroup analysis of clinical stage IA NSCLC patients (D), Asian patients (E), Western patients (F), patients from 2009 to 2015 (G) and patients from 2016 to 2025 (H). NSCLC, non-small cell lung cancer; OS, overall survival; RFS, recurrence-free survival; SBRT, stereotactic body radiation therapy.

In terms of the OS, the pooled analysis indicated that lobectomy [hazard ratio (HR) 0.65, 95% CI: 0.53–0.79], segmentectomy (HR 0.64, 95% CI: 0.50–0.82), and wedge resection (HR 0.72, 95% CI: 0.55–0.93) were associated with superior OS in patients with clinical stage I NSCLC compared to SBRT. There were comparable OS among the three lung resections (Figure 3A). The treatments were ranked as follows: segmentectomy (SUCRA, 0.797), lobectomy (SUCRA, 0.747), wedge resection (SUCRA, 0.453), and SBRT (SUCRA, 0.003) (Figure 3B). The comparison-adjusted funnel plot indicated that there might be some publication bias in the included studies (Figure 3C).

Figure 3 Network meta-analysis of HR for OS. (A) Pooled HR (95% confidence intervals) for OS. (B) Cumulative ranking plot of every treatment. (C) Adjusted network funnel plot for assessing publication bias. HR <1 indicates that the former treatment is superior to the latter. HR, hazard ratio; L, lobectomy; OS, overall survival; S, segmentectomy; SBRT, stereotactic body radiation therapy; SUCRA, surface under the cumulative ranking curve; W, wedge resection.

In terms of the RFS, the pooled analysis showed that patients who underwent lobectomy (HR 0.65, 95% CI: 0.46–0.83) or segmentectomy (HR 0.68, 95% CI: 0.46–0.91) had superior RFS compared to those treated with SBRT. Patients who underwent wedge resection had similar RFS (HR 0.78, 95% CI: 0.49–1.12) to those treated with SBRT, and there were comparable RFS between different lung resections (Figure 4A). According to the ranking plot, the top-ranked treatment was lobectomy (SUCRA, 0.868), segmentectomy (SUCRA, 0.729), followed by wedge resection (SUCRA, 0.374), and finally SBRT (SUCRA, 0.029) (Figure 4B). Moreover, no publication bias was found in the selected studies (Figure 4C).

Figure 4 Network meta-analysis of HR for RFS. (A) Pooled HR (95% confidence intervals) for RFS. (B) Cumulative ranking plot of every treatment. (C) Adjusted network funnel plot for assessing publication bias. HR <1 indicates that the former treatment is superior to the latter. HR, hazard ratio; L, lobectomy; RFS, recurrence-free survival; S, segmentectomy; SBRT, stereotactic body radiation therapy; SUCRA, surface under the cumulative ranking curve; W, wedge resection.

Similar treatment-related complication incidence was found in each treatment group (Figure 5A). Wedge resection (SUCRA, 0.906) was associated with the lowest incidence of treatment-related complication, followed by segmentectomy (SUCRA, 0.582), lobectomy (SUCRA, 0.372), and SBRT (SUCRA, 0.140) (Figure 5B). The visual examination of the comparison-adjusted funnel plot did not indicate a significant publication bias in treatment-related complication incidence (Figure 5C).

Figure 5 Network meta-analysis of OR for treatment-related complication incidence. (A) Pooled OR (95% confidence intervals) for treatment-related complication incidence. (B) Cumulative ranking plot of every treatment. (C) Adjusted network funnel plot for assessing publication bias. OR <1 indicates that the former treatment is superior to the latter. L, lobectomy; OR, odds ratio; S, segmentectomy; SBRT, stereotactic body radiation therapy; SUCRA, surface under the cumulative ranking curve; W, wedge resection.

Subgroup analysis

In clinical stage IA patients, the OS of patients among the four treatments were comparable [lobectomy vs. segmentectomy: HR, 1.01 (0.94, 1.10); lobectomy vs. wedge resection: HR, 0.58 (0.31, 1.08); segmentectomy vs. wedge resection: HR, 0.57 (0.31, 1.07); lobectomy vs. SBRT: HR, 0.99 (0.85, 1.16); segmentectomy vs. SBRT: HR, 0.98 (0.83, 1.16); wedge resection vs. SBRT: HR, 1.71 (0.91, 3.26)] (Figure 6A). The ranking of effectiveness for OS in this subgroup was observed as follows: segmentectomy (SUCRA, 0.737), lobectomy (SUCRA, 0.622), wedge resection (SUCRA, 0.598), and SBRT (SUCRA, 0.043) (Figure 6B). Comparison-adjusted funnel plot showed no publication bias in the selected studies (Figure 6C). In Asian patients, both lobectomy and segmentectomy were associated with better OS compared to SBRT [lobectomy: HR, 0.71 (0.54, 0.95); segmentectomy: HR, 0.70 (0.52, 0.95); wedge resection: HR, 0.83 (0.55, 1.26)], while in Western patients, only lobectomy showed superior outcomes to SBRT [lobectomy: HR, 1.58 (1.11, 2.26); segmentectomy: HR, 1.57 (0.94, 2.63); wedge resection: HR, 1.43 (0.94, 2.18)] (Figure S4A). In Asian patients, the treatments ranked as segmentectomy, lobectomy, wedge resection, and SBRT (Figure S4B), while in Western patients, were lobectomy, segmentectomy, wedge resection, and SBRT (Figure S4C). Among patients from 2009 to 2015, lobectomy and segmentectomy exhibited superiority over SBRT, a trend similarly observed in the subgroup of patients from 2016 to 2025 (Figure S5A). Lobectomy showed better efficacy for the former, while segmentectomy was better for the latter (Figure S5B,S5C). There may be partial publication bias in included studies (Figure S6A-S6D). A total of 20 (8,26-28,32,34,35,37,39,40,44,54-62) studies were included in this pairwise meta-analysis. Pooled analysis revealed that surgery was significantly superior to SBRT in OS for clinical stage I NSCLC (HR 1.25, 95% CI: 0.83–1.89, P<0.01) (Figure S7).

Figure 6 Network meta-analysis of HR for OS in clinical stage IA non-small cell lung cancer patients. (A) Pooled HR (95% confidence intervals) for OS. (B) Cumulative ranking plot of every treatment. (C) Adjusted network funnel plot for assessing publication bias. HR <1 indicates that the former treatment is superior to the latter. HR, hazard ratio; L, lobectomy; OS, overall survival; S, segmentectomy; SBRT, stereotactic body radiation therapy; SUCRA, surface under the cumulative ranking curve; W, wedge resection.

Similarity, homogeneity and consistency

The results of the similarity assessment showed differences in age, tumor diameter, FEV1%, and DLCO% among patients in different treatment groups (Table S1). Heterogeneity was detected in the direct comparisons of SBRT vs. lobectomy (I²=96%) and wedge resection vs. SBRT (I²=90%) in the OS, SBRT vs. lobectomy in the RFS (I²=90%), SBRT vs. lobectomy (I²=99%) and wedge resection vs. segmentectomy (I²=74%) in the treatment-related complication incidence (Table S2). The results of local inconsistency indicated that P values were all >0.05 (Figures S8,S9). Additionally, the results of global inconsistency showed that the difference of DIC values between the consistent and inconsistent models was <5 (Table S3), satisfying the consistency assumption.

Discussion

This systematic review and network meta-analysis were conducted to assess the survival outcomes and treatment-related complication incidence among patients with clinical stage I NSCLC treated with SBRT, lobectomy, segmentectomy, or wedge resection. The study had the following key findings. First, lobectomy and segmentectomy demonstrated superior OS and RFS to SBRT in patients with clinical stage I NSCLC. Second, no significant disparities were observed in treatment-related complication incidence among the patients treated with the four distinct treatments. Third, for clinical stage IA NSCLC patients, SBRT may be comparable to specific lung resections in OS.

SBRT has become the standard treatment for stage I NSCLC patients who are not candidates for surgery due to poor general health or comorbidities because of its high local control rate and low toxicity (63,64). In addition, during the study period from 2012 to 2018 in the United States, about 8.9% of patients treated with SBRT had refused a clinician-recommended surgery (65). Surgical anxiety, the need for postoperative hospitalization, and the convenience of SBRT may explain why more patients are opting for SBRT. Therefore, an increasing number of studies comparing SBRT and surgery to determine which is more effective for early-stage NSCLC patients. Many retrospective studies have reported comparable survival outcomes between SBRT and surgery in operable stage I NSCLC patients (8,54,58-61). However, some studies using PSM have found that patients in the surgical group have significantly higher OS than those in the SBRT group (27,55,65). In contrast, a pooled analysis involving 58 operable NSCLC patients demonstrated a significantly higher 3-year OS in the SBRT group compared to the surgery group (surgery group:79%, SBRT group: 95%; P=0.037) (9). Due to the limited sample size, caution should be exercised in interpreting these findings. Most previous studies compared the differences in the effectiveness of various surgeries as a whole with SBRT, with limited research focusing on comparisons between specific lung resections and SBRT. By conducting a network meta-analysis, our study systematically collated and evaluated these specific comparative findings. We found that lobectomy, segmentectomy, and wedge resection were superior to SBRT in OS of patients. No significant difference in OS was observed among patients who underwent the three lung resections. More importantly, the SUCRA values indicated that patients in the segmentectomy group may have better OS, followed by the lobectomy, wedge resection, and SBRT groups. The finding was consistent with the Japan Clinical Oncology Group (JCOG) 0802 trial, which showed that segmentectomy significantly improved the OS of clinical stage IA NSCLC patients compared with lobectomy (47). In addition, a supplementary analysis of the JCOG 0802 indicated that the non-lung cancer death was associated with the number of resected segments. The more segments resected, the higher the incidence of non-lung cancer mortality (66). Compared to lobectomy, segmentectomy preserves more lung parenchyma, leading to lower mortality from other causes. As for the SBRT, our findings were consistent with most previous studies that the SBRT was associated with inferior OS, whether compared to surgery as a whole or to specific lung resection (27,34,57).

Early-stage NSCLC patients undergoing surgery may have a lower recurrence rate due to the complete resection in primary tumor and the accurate assessment of lymph node statuses. This study revealed that lobectomy and segmentectomy provided better RFS compared to SBRT, while the RFS in patients who underwent wedge resection was comparable to that of SBRT. No significant difference in RFS was observed among patients who underwent the three lung resections. This result was consistent with the post-hoc analysis results of Cancer and Leukemia Group B (CALGB) 140503 (29), which showed that lobectomy, segmentectomy, and wedge resection provided comparable RFS. Notably, based on the SUCRA values, the lobectomy group may have the best RFS, followed by segmentectomy, wedge resection, and SBRT, which differed to that the segmentectomy ranked first in OS. Compared with segmentectomy, the complete removal of a lung lobe significantly reduces the risk of local recurrence and improves the RFS of patients (47). Such discrepancies between OS and RFS in lobectomy and segmentectomy were also found in JCOG0802 trial. As a non-anatomical resection, wedge resection is associated with higher recurrence rate. Therefore, the RFS of patients underwent wedge resection was slightly inferior to that of the lobectomy and segmentectomy groups, and similar to that of the SBRT group.

While differences in effectiveness between SBRT and lung resections were observed, the treatment-related complication incidence were comparable between them for patients with early-stage NSCLC. SBRT delivers a very precise and high dose of radiation to a lung tumor in a small number of fractions and achieves more than 90% of local control rate (67). However, patients were prone to developing radiation pneumonia and radiation dermatitis after SBRT (26,32,57). In lung resection groups, the common treatment-related complication incidence of lobectomy included atrial fibrillation and pneumonia, while air leak was more likely to occur in segmentectomy and wedge resection (5,36,41,48). Although most studies indicated that treatment-related complications were more frequent and severe in surgery group (44,59,61), this study only investigated the incidence of treatment-related complications. Patients treated with SBRT may experience milder symptoms of complications, but the frequency of occurrence could be similar. Our analysis aimed to provide an overall estimate of the incidence of treatment-related complications, rather than a strict type-by-type comparison among lung resections and SBRT.

Although surgical resection remains the standard treatment for patients with stage I NSCLC, many previous studies have shown that for selected patients, SBRT may achieve comparable outcomes under specific conditions (68). Paul and colleagues demonstrated that for patients with tumors ≤2 cm, cancer-specific survival was not significantly different between surgery and SABR (68). Similarly, the revised STARS trial confirmed that there was no significant difference in OS between the surgical group and the SBRT group when only patients with clinical stage IA NSCLC with a tumor diameter <3 cm were included (69). In contrast, when clinical stage IB patients with tumor diameter >3 cm but ≤4 cm were included, the OS of patients in the SBRT group decreased significantly compared to those in the surgical group (44). This may be explained by the better prognosis of stage IA patients, which allows SBRT to demonstrate more pronounced benefits, whereas the poorer prognosis of stage IB patients and the limited tumor control of SBRT contribute to inferior outcomes. Considering the impact of tumor stage and histological features on treatment effectiveness, we performed several subgroup analyses. For clinical stage IA NSCLC patients, the OS of patients treated with SBRT and the three lung resections were similar, consistent with previous studies. Moreover, prior studies have suggested that for early-stage NSCLC patients unwilling to undergo lobectomy or at high operative risk, SBRT is an excellent alternative (70), for which our meta-analysis further provides evidence-based support. However, despite the similar HR for OS between SBRT and surgery, our study found that SBRT had the lowest SUCRA value, indicating a lower overall effectiveness in comparison with the surgical treatments. This suggests that while SBRT may offer comparable OS to surgery, its overall treatment effectiveness, considering factors such as local control and complication rates, does not reach the level of surgery. In addition, the impact of tumor components on effectiveness is also worth paying attention to. For patients with subsolid NSCLC, 5-year all-cause survival for surgical patients and those who underwent SBRT were found to be similar. However, in solid NSCLC patients, SBRT significantly reduces the 5-year all-cause survival compared to surgery (71). At present, there is a lack of sufficient literature to explore the impact of different tumor components on the effectiveness of different treatments, and further related research is needed.

Several inevitable limitations exist in our study. First, because the majority of the included studies were retrospective in nature, systematic differences inevitably existed in treatment selection and baseline characteristics, which may have influenced the comparability between groups. Consequently, this network meta-analysis does not fully satisfy the similarity hypothesis between studies, as patients using different treatment methods are difficult to be completely consistent in age, tumor size, FEV1%, and DLCO%. Second, subgroup analysis stratified by stage only includes clinical stage IA NSCLC patients. Some characteristics, like the proportion of solid component, potentially influence the efficacy in different treatments. Third, some of the data included in the study were extracted through software or converted into mean and standard deviation through statistical calculations (72,73), resulting in potential biases. This method was essential because in some cases, raw data cannot be directly obtained.

Conclusions

For clinical stage I NSCLC patients, lobectomy and segmentectomy are superior to SBRT. Wedge resection is associated with similar RFS but better OS to SBRT. No significant difference in treatment-related complication incidence was observed among the three lung resections and SBRT groups. In clinical stage IA NSCLC, SBRT may provide comparable OS to lung resections.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-NMA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1568/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1568/prf

Funding: This study was supported by “Qimingxing” Research Fund for Young Talents (HXQMX0034), and by the College Students’ Innovative Entrepreneurial Training Plan Program in Sichuan Province (No. S202310634110).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1568/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2024;74:229-63. [Crossref] [PubMed]
2. Chen P, Liu Y, Wen Y, Zhou C. Non-small cell lung cancer in China. Cancer Commun (Lond) 2022;42:937-70. [Crossref] [PubMed]
3. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995;60:615-23. [Crossref] [PubMed]
4. Puri V, Crabtree TD, Bell JM, et al. Treatment Outcomes in Stage I Lung Cancer: A Comparison of Surgery and Stereotactic Body Radiation Therapy. J Thorac Oncol 2015;10:1776-84. [Crossref] [PubMed]
5. Bertolaccini L, Cara A, Chiari M, et al. Real-world survival outcomes of wedge resection versus lobectomy for cT1a/b cN0 cM0 non-small cell lung cancer: a single center retrospective analysis. Front Oncol 2023;13:1226429. [Crossref] [PubMed]
6. Ricardi U, Filippi AR, Guarneri A, et al. Stereotactic body radiation therapy for early stage non-small cell lung cancer: results of a prospective trial. Lung Cancer 2010;68:72-7. [Crossref] [PubMed]
7. Ricardi U, Badellino S, Filippi AR. Stereotactic body radiotherapy for early stage lung cancer: History and updated role. Lung Cancer 2015;90:388-96. [Crossref] [PubMed]
8. Tomita N, Okuda K, Osaga S, et al. Surgery versus stereotactic body radiotherapy for clinical stage I non-small-cell lung cancer: propensity score-matching analysis including the ratio of ground glass nodules. Clin Transl Oncol 2021;23:638-47. [Crossref] [PubMed]
9. Chang JY, Senan S, Paul MA, et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol 2015;16:630-7. [Crossref] [PubMed]
10. Viani GA, Gouveia AG, Yan M, et al. Stereotactic body radiotherapy versus surgery for early-stage non-small cell lung cancer: an updated meta-analysis involving 29,511 patients included in comparative studies. J Bras Pneumol 2022;48:e20210390. [Crossref] [PubMed]
11. Hutton B, Salanti G, Caldwell DM, et al. The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 2015;162:777-84. [Crossref] [PubMed]
12. Tierney JF, Stewart LA, Ghersi D, et al. Practical methods for incorporating summary time-to-event data into meta-analysis. Trials 2007;8:16. [Crossref] [PubMed]
13. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 2010;25:603-5. [Crossref] [PubMed]
14. Higgins JP, Altman DG, Gøtzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928. [Crossref] [PubMed]
15. Chaimani A, Higgins JP, Mavridis D, et al. Graphical tools for network meta-analysis in STATA. PLoS One 2013;8:e76654. [Crossref] [PubMed]
16. Ades AE, Sculpher M, Sutton A, et al. Bayesian methods for evidence synthesis in cost-effectiveness analysis. Pharmacoeconomics 2006;24:1-19. [Crossref] [PubMed]
17. Nopsopon T, Lassiter G, Chen ML, et al. Comparative efficacy of tezepelumab to mepolizumab, benralizumab, and dupilumab in eosinophilic asthma: A Bayesian network meta-analysis. J Allergy Clin Immunol 2023;151:747-55. [Crossref] [PubMed]
18. Zhao Y, Liu J, Cai X, et al. Efficacy and safety of first line treatments for patients with advanced epidermal growth factor receptor mutated, non-small cell lung cancer: systematic review and network meta-analysis. BMJ 2019;367:l5460. [Crossref] [PubMed]
19. Salanti G. Indirect and mixed-treatment comparison, network, or multiple-treatments meta-analysis: many names, many benefits, many concerns for the next generation evidence synthesis tool. Res Synth Methods 2012;3:80-97.
20. Brooks SP, Gelman A. General Methods for Monitoring Convergence of Iterative Simulations. J Comput Graph Stat 1998;7:434-55.
21. Salanti G, Ades AE, Ioannidis JP. Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial. J Clin Epidemiol 2011;64:163-71. [Crossref] [PubMed]
22. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ 2003;327:557-60. [Crossref] [PubMed]
23. Dias S, Sutton AJ, Ades AE, et al. Evidence synthesis for decision making 2: a generalized linear modeling framework for pairwise and network meta-analysis of randomized controlled trials. Med Decis Making 2013;33:607-17. [Crossref] [PubMed]
24. Dias S, Welton NJ, Caldwell DM, et al. Checking consistency in mixed treatment comparison meta-analysis. Stat Med 2010;29:932-44. [Crossref] [PubMed]
25. Brunelli A, Rushwan A, Stefanou D, et al. Minimally invasive segmentectomy and lobectomy for peripheral stage IA1-2 non-small-cell lung cancer: a case-matched cohort study from a UK Centre. Interdiscip Cardiovasc Thorac Surg 2023;37:ivad204. [Crossref] [PubMed]
26. de Ruiter JC, van der Noort V, van Diessen JNA, et al. The optimal treatment for patients with stage I non-small cell lung cancer: minimally invasive lobectomy versus stereotactic ablative radiotherapy - a nationwide cohort study. Lung Cancer 2024;191:107792. [Crossref] [PubMed]
27. Detillon DDEMA, Aarts MJ, De Jaeger K, et al. Video-assisted thoracic lobectomy versus stereotactic body radiotherapy for stage I nonsmall cell lung cancer in elderly patients: a propensity matched comparative analysis. Eur Respir J 2019;53:1801561. [Crossref] [PubMed]
28. Mokhles S, Verstegen N, Maat AP, et al. Comparison of clinical outcome of stage I non-small cell lung cancer treated surgically or with stereotactic radiotherapy: results from propensity score analysis. Lung Cancer 2015;87:283-9. [Crossref] [PubMed]
29. Altorki N, Wang X, Damman B, et al. 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 2024;167:338-347.e1. [Crossref] [PubMed]
30. Altorki NK, Kamel MK, Narula N, et al. Anatomical Segmentectomy and Wedge Resections Are Associated with Comparable Outcomes for Patients with Small cT1N0 Non-Small Cell Lung Cancer. J Thorac Oncol 2016;11:1984-92. [Crossref] [PubMed]
31. Chan EG, Chan PG, Mazur SN, et al. Outcomes with segmentectomy versus lobectomy in patients with clinical T1cN0M0 non-small cell lung cancer. J Thorac Cardiovasc Surg 2021;161:1639-1648.e2. [Crossref] [PubMed]
32. Grills IS, Mangona VS, Welsh R, et al. Outcomes after stereotactic lung radiotherapy or wedge resection for stage I non-small-cell lung cancer. J Clin Oncol 2010;28:928-35. [Crossref] [PubMed]
33. Landreneau RJ, Normolle DP, Christie NA, et al. 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 2014;32:2449-55. [Crossref] [PubMed]
34. Parashar B, Port J, Arora S, et al. Analysis of stereotactic radiation vs. wedge resection vs. wedge resection plus Cesium-131 brachytherapy in early stage lung cancer. Brachytherapy 2015;14:648-54. [Crossref] [PubMed]
35. Sebastian NT, Merritt RE, Abdel-Rasoul M, et al. Recurrence After Stereotactic Body Radiation Therapy Versus Lobectomy for Non-Small Cell Lung Cancer. Ann Thorac Surg 2020;110:998-1005. [Crossref] [PubMed]
36. Shapiro M, Weiser TS, Wisnivesky JP, et al. Thoracoscopic segmentectomy compares favorably with thoracoscopic lobectomy for patients with small stage I lung cancer. J Thorac Cardiovasc Surg 2009;137:1388-93. [Crossref] [PubMed]
37. Varlotto J, Fakiris A, Flickinger J, et al. Matched-pair and propensity score comparisons of outcomes of patients with clinical stage I non-small cell lung cancer treated with resection or stereotactic radiosurgery. Cancer 2013;119:2683-91. [Crossref] [PubMed]
38. Akamine T, Yotsukura M, Yoshida Y, et al. Feasibility and effectiveness of segmentectomy versus wedge resection for clinical stage I non-small-cell lung cancer. Eur J Cardiothorac Surg 2023;63:ezad018. [Crossref] [PubMed]
39. Eba J, Nakamura K, Mizusawa J, et al. Stereotactic body radiotherapy versus lobectomy for operable clinical stage IA lung adenocarcinoma: comparison of survival outcomes in two clinical trials with propensity score analysis (JCOG1313-A). Jpn J Clin Oncol 2016;46:748-53. [Crossref] [PubMed]
40. Hamaji M, Chen F, Matsuo Y, et al. Video-assisted thoracoscopic lobectomy versus stereotactic radiotherapy for stage I lung cancer. Ann Thorac Surg 2015;99:1122-9. [Crossref] [PubMed]
41. Handa Y, Tsutani Y, Mimae T, et al. Surgical Procedure Selection for Stage I Lung Cancer: Complex Segmentectomy versus Wedge Resection. Clin Lung Cancer 2021;22:e224-33. [Crossref] [PubMed]
42. Kodama K, Higashiyama M, Okami J, et al. Oncologic Outcomes of Segmentectomy Versus Lobectomy for Clinical T1a N0 M0 Non-Small Cell Lung Cancer. Ann Thorac Surg 2016;101:504-11. [Crossref] [PubMed]
43. Koike T, Kitahara A, Sato S, et al. Lobectomy Versus Segmentectomy in Radiologically Pure Solid Small-Sized Non-Small Cell Lung Cancer. Ann Thorac Surg 2016;101:1354-60. [Crossref] [PubMed]
44. Lin Q, Sun X, Zhou N, et al. Outcomes of stereotactic body radiotherapy versus lobectomy for stage I non-small cell lung cancer: a propensity score matching analysis. BMC Pulm Med 2019;19:98. [Crossref] [PubMed]
45. Nomori H, Yamazaki I, Machida Y, et al. Lobectomy versus segmentectomy: a propensity score-matched comparison of postoperative complications, pulmonary function and prognosis. Interact Cardiovasc Thorac Surg 2022;34:57-65. [Crossref] [PubMed]
46. Okada M, Mimae T, Tsutani Y, et al. Segmentectomy versus lobectomy for clinical stage IA lung adenocarcinoma. Ann Cardiothorac Surg 2014;3:153-9. [Crossref] [PubMed]
47. Saji H, Okada M, Tsuboi M, et al. 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 2022;399:1607-17. [Crossref] [PubMed]
48. Song CY, Sakai T, Kimura D, et al. Comparison of perioperative and oncological outcomes between video-assisted segmentectomy and lobectomy for patients with clinical stage IA non-small cell lung cancer: a propensity score matching study. J Thorac Dis 2018;10:4891-901. [Crossref] [PubMed]
49. Tsubokawa N, Mimae T, Saeki A, et al. Feasibility and comparative prognosis of segmentectomy versus lobectomy in centrally located small and solid dominant cN0 non-small cell lung cancer. J Thorac Cardiovasc Surg 2025;169:427-435.e2. [Crossref] [PubMed]
50. Tsutani Y, Kagimoto A, Handa Y, et al. Wedge resection versus segmentectomy in patients with stage I non-small-cell lung cancer unfit for lobectomy. Jpn J Clin Oncol 2019;49:1134-42. [Crossref] [PubMed]
51. Tsutani Y, Miyata Y, Nakayama H, et al. Oncologic outcomes of segmentectomy compared with lobectomy for clinical stage IA lung adenocarcinoma: propensity score-matched analysis in a multicenter study. J Thorac Cardiovasc Surg 2013;146:358-64. [Crossref] [PubMed]
52. Yamashita S, Chujo M, Kawano Y, et al. Clinical impact of segmentectomy compared with lobectomy under complete video-assisted thoracic surgery in the treatment of stage I non-small cell lung cancer. J Surg Res 2011;166:46-51. [Crossref] [PubMed]
53. Zhong C, Fang W, Mao T, et al. Comparison of thoracoscopic segmentectomy and thoracoscopic lobectomy for small-sized stage IA lung cancer. Ann Thorac Surg 2012;94:362-7. [Crossref] [PubMed]
54. Ackerson BG, Tong BC, Hong JC, et al. Stereotactic body radiation therapy versus sublobar resection for stage I NSCLC. Lung Cancer 2018;125:185-91. [Crossref] [PubMed]
55. Crabtree TD, Puri V, Robinson C, et al. Analysis of first recurrence and survival in patients with stage I non-small cell lung cancer treated with surgical resection or stereotactic radiation therapy. J Thorac Cardiovasc Surg 2014;147:1183-1191; discussion 1191-2. [Crossref] [PubMed]
56. Matsuo Y, Chen F, Hamaji M, 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;50:2932-8. [Crossref] [PubMed]
57. Miki Y, Yamashita H, Nakajima J, et al. Retrospective comparison between definitive stereotactic body radiotherapy and radical surgery for 538 patients with early-stage non-small cell lung cancer in a single institution. J Cancer Res Ther 2023;19:1350-5. [Crossref] [PubMed]
58. Miyazaki T, Yamazaki T, Nakamura D, et al. Surgery or stereotactic body radiotherapy for elderly stage I lung cancer? A propensity score matching analysis. Surg Today 2017;47:1476-83. [Crossref] [PubMed]
59. Tamura M, Matsumoto I, Tanaka Y, et al. Comparison Between Stereotactic Radiotherapy and Sublobar Resection for Non-Small Cell Lung Cancer. Ann Thorac Surg 2019;107:1544-50. [Crossref] [PubMed]
60. van den Berg LL, Klinkenberg TJ, Groen HJM, et al. Patterns of Recurrence and Survival after Surgery or Stereotactic Radiotherapy for Early Stage NSCLC. J Thorac Oncol 2015;10:826-31. [Crossref] [PubMed]
61. Yuan XS, Chen WC, Lin QR, et al. A propensity-matched analysis of stereotactic body radiotherapy and sublobar resection for stage I non-small cell lung cancer in patients at high risk for lobectomy: the results in a Chinese population. J Thorac Dis 2021;13:1822-32. [Crossref] [PubMed]
62. Yun J, Cho JH, Hong TH, et al. Sublobar Resection versus Stereotactic Body Radiation Therapy for Clinical Stage I Non-Small Cell Lung Cancer: A Study Using Data from the Korean Nationwide Lung Cancer Registry. Cancer Res Treat 2023;55:1171-80. [Crossref] [PubMed]
63. Raz DJ, Zell JA, Ou SH, et al. Natural history of stage I non-small cell lung cancer: implications for early detection. Chest 2007;132:193-9. [Crossref] [PubMed]
64. Ball D, Mai GT, Vinod S, et al. Stereotactic ablative radiotherapy versus standard radiotherapy in stage 1 non-small-cell lung cancer (TROG 09.02 CHISEL): a phase 3, open-label, randomised controlled trial. Lancet Oncol 2019;20:494-503. [Crossref] [PubMed]
65. Udelsman BV, Canavan ME, Zhan PL, et al. Overall survival in low-comorbidity patients with stage I non-small cell lung cancer who chose stereotactic body radiotherapy compared to surgery. J Thorac Cardiovasc Surg 2024;167:822-833.e7. [Crossref] [PubMed]
66. Hattori A, Suzuki K, Takamochi K, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer with radiologically pure-solid appearance in Japan (JCOG0802/WJOG4607L): a post-hoc supplemental analysis of a multicentre, open-label, phase 3 trial. Lancet Respir Med 2024;12:105-16. [Crossref] [PubMed]
67. Sun B, Brooks ED, Komaki RU, et al. 7-year follow-up after stereotactic ablative radiotherapy for patients with stage I non-small cell lung cancer: Results of a phase 2 clinical trial. Cancer 2017;123:3031-9. [Crossref] [PubMed]
68. Paul S, Lee PC, Mao J, et al. Long term survival with stereotactic ablative radiotherapy (SABR) versus thoracoscopic sublobar lung resection in elderly people: national population based study with propensity matched comparative analysis. BMJ 2016;354:i3570. [Crossref] [PubMed]
69. Chang JY, Mehran RJ, Feng L, et al. Stereotactic ablative radiotherapy for operable stage I non-small-cell lung cancer (revised STARS): long-term results of a single-arm, prospective trial with prespecified comparison to surgery. Lancet Oncol 2021;22:1448-57. [Crossref] [PubMed]
70. Chen H, Louie AV. SABR vs. Limited Resection for Non-small Cell Lung Cancer: Are We Closer to an Answer? Curr Treat Options Oncol 2016;17:27. [Crossref] [PubMed]
71. Henschke CI, Yip R, Sun Q, et al. Prospective Cohort Study to Compare Long-Term Lung Cancer-Specific and All-Cause Survival of Clinical Early Stage (T1a-b; ≤20 mm) NSCLC Treated by Stereotactic Body Radiation Therapy and Surgery. J Thorac Oncol 2024;19:476-90. [Crossref] [PubMed]
72. Luo D, Wan X, Liu J, et al. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res 2018;27:1785-805. [Crossref] [PubMed]
73. Wan X, Wang W, Liu J, et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014;14:135. [Crossref] [PubMed]