Lobar or sublobar resection for stage I lung cancer: that is (still) the question!

Lobar or sublobar resection for stage I lung cancer: that is (still) the question!

Alfonso Fiorelli1, Domenico Loizzi2, Mario Santini1

1Thoracic Surgery Unit, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy;2Thoracic Surgery Unit, Università degli Studi di Foggia, Foggia, Italy

Correspondence to: Alfonso Fiorelli, MD, PhD. Thoracic Surgery Unit, Università della Campania Luigi Vanvitelli, Piazza Miraglia, 2, I-80138 Naples, Italy. Email: alfonso.fiorelli@unicampania.it.

Provenance: This is an invited Editorial commissioned by the Section Editor Laura Chiara Guglielmetti (University Hospital Zurich, Zurich, Switzerland).

Comment on: Dziedzic R, Zurek W, Marjanski T, et al. Stage I non-small-cell lung cancer: long-term results of lobectomy versus sublobar resection from the Polish National Lung Cancer Registry. Eur J Cardiothorac Surg 2017;52:363-9.

Submitted Nov 14, 2017. Accepted for publication Nov 21, 2017.

doi: 10.21037/jtd.2017.11.127

Lung cancer causes more than 1.4 million deaths annually (1). Surgery is the main treatment given with curative intent and lobectomy with lymph node resection is the standard procedure for early Stage of non-small-cell lung cancer (NSCLC), having a 5-year survival rates of up to 70% (2). This assumption is based on the results of the randomized controlled trial (RCT) reported by the Lung Cancer Study Group (LCSG) in 1995 (3). The authors compared overall survival of lobectomy versus limited resection (wedge resection and segmentectomy) for the management of Stage I NSCLC. They evaluated 495 patients with clinical stage IA NSCLC, of these 247 resulted to have a pathologic stage pIA. Limited resection compared to lobectomy presented a poorer 5-year survival rate (56% vs. 73%; P=0.06), a lower freedom from recurrence rate (62% vs. 78%, P=0.04), and three-fold increase in local recurrence rates (5.4% vs. 1.9%, P=0.009).

In the two decades since this trial, the increased screening programs using low-dose computed tomography (CT) scan, the advances in minimally invasive surgical techniques, and the significant progress in comprehending the biology of NSCLC have fueled a renewed interest in sublobar resection, especially segmentectomy, for management of early lung cancer in medically fit patients who can tolerate lobectomy. Multiple retrospective studies published in the last 20 years have contradicted the results from the LCSG, showing that intentional anatomic sublobar resection may be similar in survival to lobectomy for the management of stage I tumors ≤2 cm (4-8). These results were also supported by several meta-analyses. In 2005, Nakamura et al. (9) analyzed all studies published between 1970 and 2004 showing that sublobar resection had similar survival to lobectomy. In 2012, Fan et al. (10) conducted a meta-analysis including published studies between 1990 and 2010 and found that the outcome of sublobar resection was similar to that of lobectomy only for Stage IA patients. Similarly, Bao et al. (11) stratified the outcome of segmentectomy and lobectomy according to the size of the tumor. They found a similar survival for ≤2 cm Stage I NSCLC while segmentectomy had a worse survival than lobectomy for >2 cm Stage I NSCLC. In line with Bao’s study (11), Kates et al. (12) found similar survival rates among patients undergoing sublobar resection vs. lobectomy for ≤1 cm Stage I tumors. Additionally, other two recent meta-analyses published in 2015 (13) and in 2017 (14) showed that intentional segmentectomy for early-stage NSCLC had overall disease-free survival similar to lobectomy. Based on these evidences and on the insights of breast surgical oncologists considering lesser resection for small breast cancer, there is the growing perception that smaller lung cancer might be successfully managed with less radical resection being oncological equivalent to lobectomy but having the advantages of lung function preservation and less perioperative complications.

However, the clinical dilemma on the best treatment for these tumors (sublobar or lobar resection) is far from being solved. In fact, several studies using Surveillance, Epidemiology, and End Results (SEER) database found the superior of lobectomy over segmentectomy and these results are extended also to ≤1 cm Stage I NSCLC (15,16). The same results were also confirmed by two meta-analyses. Zhang et al. (17) evaluated 19 relevant studies published in the last decade, of which four studies privileged lobectomy, and the others 15 studies found no difference in survival. However, after pooling these studies together, sublobar resection presented a poorer overall survival or cancer-specific survival than lobectomy. Similarly, Liu et al. (18) found that in Stage IA patients sublobar resection causes a lower survival rate than lobectomy.

To try to answer the question whether a sublobar resection is as good as a lobectomy for patient with Stage I NSCLC, Dziedzic et al. (19) conducted a retrospective study using the data from the Polish National Lung Cancer Registry. They included 6,905 patients with pathological Stage I NSCLC in their analysis and used propensity score match analysis to correct the bias of patient selection and create comparable samples of patients who underwent lobectomy, segmentectomy, and wedge resection on the basis of several covariates. The end-point was the overall survival. Lobectomy and segmentectomy presented no significant difference in 5 years survival rate while wedge resection had a lower 5-year survival rate than lobectomy and segmentectomy. These results confirmed that segmentectomy must be clearly divided from wedge resection as curative treatment of NSCLC since it is more likely to provide sufficient margins and allows access to subsegmental and hilar lymph nodes. Despite all, the results of Dziedzic’s study should be considered with caution before drawing definitive conclusions on the oncologically validity of segmentectomy. The authors (19)evaluated in their analysis only the overall survival but no data on the cancer specific survival, recurrence rates, and adjuvant treatment after surgery were reported. Differences in overall survival may be misleading compared with cancer specific survival, as patients died due to causes unrelated to NSCLC and the oncological efficacy of the different surgical procedures. Conversely, recurrence rates are not strongly affected by the medical comorbidities and are, therefore, an easier point for comparison the oncological outcome between sublobar and lobar resection. In addition, the administration of adjuvant therapies after surgery as radiotherapy, chemotherapy or biological therapy in presence of recurrences could affect the overall survival independently from the type of resections. Despite adenocarcinoma was the main histological type, the different histological subtypes of adenocarcinoma as well as the radiological characteristics of the tumor, the Standard Uptake Value on PET scan, and the indications for segmentectomy were not evaluated and not used as covariates in the propensity score matching analysis. In theory, patients undergoing segmentectomy could have a pure Ground-glass Opacity (GGO) or a tumor with a low standardized uptake value (SUV) value or an indolent tumor; thus, their good survival could be due to the favorable biology of the tumor rather than oncological validity of the resection. SUV value is a predictive factor of the aggressiveness of the tumor (20) and the new classification system proposed by International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) reported that papillary, micropapillary, or solid adenocarcinoma may have significantly worse prognosis than lepidic predominant adenocarcinoma (21).

In conclusion, sublobar resection for intentionally treating patients with sub-centimeters NSCLC who are able to tolerate lobectomy remains highly controversial. Currently, two prospective, randomized, multi-institutional phase III trials are being conducted by the Cancer and Leukemia Group B (CALGB 140503) and the Japan Clinical Oncology Group (JCOG 0802) (22) to evaluate the efficacy of intentional sublobar resections for ≤2 cm Stage I tumors and their conclusions, when available, will help to clarify this issue. Until these trials are complete, the LCSG study (3) is the only randomized trial showing the superiority of lobectomy over sublobar resections for early stage lung cancer and this conclusion cannot be strongly questioned by the current studies (23,24). Conversely, as recommended by the NCCN, the British Thoracic Society (BTS), ERS/European Society of Thoracic Surgeons (ESTS), and the American College of Chest Physicians (ACCP) sublobar resection is an alternative to lobectomy (I) for patients with resectable lung cancer but impaired lung function or comorbidities or (II) for patients with pure GGO lesser than 2 cm in size, or having a slow, indolent growth observed during CT scan surveillance (25).




Conflicts of Interest: The authors have no conflicts of interest to declare.


  1. Torre LA, Bray F, Siegel RL, et al. Global cancer statistics, 2012. CA Cancer J Clin 2015;65:87-108. [Crossref] [PubMed]
  2. Fiorelli A, Sagan D, Mackiewicz L, et al. Incidence, Risk Factors, and Analysis of Survival of Unexpected N2 Disease in Stage I Non-Small Cell Lung Cancer. Thorac Cardiovasc Surg 2015;63:558-67. [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;60:615-22; discussion 622-3. [Crossref] [PubMed]
  4. Martin-Ucar AE, Nakas A, Pilling JE, et al. A case-matched study of anatomical segmentectomy versus lobectomy for stage I lung cancer in high-risk patients. Eur J Cardiothorac Surg 2005;27:675-9. [Crossref] [PubMed]
  5. Okada M, Koike T, Higashiyama M, et al. Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study. J Thorac Cardiovasc Surg 2006;132:769-75. [Crossref] [PubMed]
  6. Kilic A, Schuchert MJ, Pettiford BL, et al. Anatomic segmentectomy for stage I non-small cell lung cancer in the elderly. Ann Thorac Surg 2009;87:1662-6; discussion 1667-8.
  7. 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]
  8. Altorki NK, Yip R, Hanaoka T, et al. Sublobar resection is equivalent to lobectomy for clinical stage 1A lung cancer in solid nodules. J Thorac Cardiovasc Surg 2014;147:754-62; Discussion 762-4. [Crossref] [PubMed]
  9. Nakamura H, Kawasaki N, Taguchi M, et al. Survival following lobectomy vs limited resection for stage I lung cancer: a meta-analysis. Br J Cancer 2005;92:1033-7. [Crossref] [PubMed]
  10. Fan J, Wang L, Jiang GN, et al. Sublobectomy versus lobectomy for stage I non-small-cell lung cancer, a meta-analysis of published studies. Ann Surg Oncol 2012;19:661-8. [Crossref] [PubMed]
  11. Bao F, Ye P, Yang Y, et al. Segmentectomy or lobectomy for early stage lung cancer: a meta-analysis. Eur J Cardiothorac Surg 2014;46:1-7. [Crossref] [PubMed]
  12. Kates M, Swanson S, Wisnivesky JP. 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 2011;139:491-6. [Crossref] [PubMed]
  13. Cao C, Chandrakumar D, Gupta S, et al. 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 2015;89:121-32. [Crossref] [PubMed]
  14. Bedetti B, Bertolaccini L, Rocco R, et al. Segmentectomy versus lobectomy for stage I non-small cell lung cancer: a systematic review and meta-analysis. J Thorac Dis 2017;9:1615-23. [Crossref] [PubMed]
  15. Dai C, Shen J, Ren Y, et al. Choice of Surgical Procedure for Patients With Non-Small-Cell Lung Cancer ≤ 1 cm or > 1 to 2 cm Among Lobectomy, Segmentectomy, and Wedge Resection: A Population-Based Study. J Clin Oncol 2016;34:3175-82. [Crossref] [PubMed]
  16. Whitson BA, Groth SS, Andrade RS, et al. Survival after lobectomy versus segmentectomy for stage I non-small cell lung cancer: a population-based analysis. Ann Thorac Surg 2011;92:1943-50. [Crossref] [PubMed]
  17. Zhang Y, Sun Y, Wang R, et al. Meta-analysis of lobectomy, segmentectomy, and wedge resection for stage I non-small cell lung cancer. J Surg Oncol 2015;111:334-40. [Crossref] [PubMed]
  18. Liu Y, Huang C, Liu H, et al. Sublobectomy versus lobectomy for stage IA (T1a) non-small-cell lung cancer: a meta-analysis study. World J Surg Oncol 2014;12:138. [Crossref] [PubMed]
  19. Dziedzic R, Zurek W, Marjanski T, et al. Stage I non-small-cell lung cancer: long-term results of lobectomy versus sublobar resection from the Polish National Lung Cancer Registry. Eur J Cardiothorac Surg 2017;52:363-9. [Crossref] [PubMed]
  20. Fiorelli A, Rizzo A, Messina G, et al. Correlation between matrix metalloproteinase 9 and 18F-2-fluoro-2-deoxyglucose-positron emission tomography as diagnostic markers of lung cancer. Eur J Cardiothorac Surg 2012;41:852-60. [Crossref] [PubMed]
  21. Travis WD, Brambilla E, Noguchi M, et al. International association for the study of lung cancer/american thoracic society/european respiratory society international multidisciplinary classification of lung adenocarcinoma. J Thorac Oncol 2011;6:244-85. [Crossref] [PubMed]
  22. Nakamura K, Saji H, Nakajima R, et al. A phase III randomized trial of lobectomy versus limited resection for small-sized peripheral non-small cell lung cancer (JCOG0802/WJOG4607L). Jpn J Clin Oncol 2010;40:271-4. [Crossref] [PubMed]
  23. Sihoe AD, Van Schil P. Non-small cell lung cancer: when to offer sublobar resection. Lung Cancer 2014;86:115-20. [Crossref] [PubMed]
  24. Fiorelli A, Caronia FP, Daddi N, et al. Sublobar resection versus lobectomy for stage I non-small cell lung cancer: an appropriate choice in elderly patients? Surg Today 2016;46:1370-82. [Crossref] [PubMed]
  25. Charloux A, Quoix E. Lung segmentectomy: does it offer a real functional benefit over lobectomy? Eur Respir Rev 2017;26:170079. [Crossref] [PubMed]
Cite this article as: Fiorelli A, Loizzi D, Santini M. Lobar or sublobar resection for stage I lung cancer: that is (still) the question! J Thorac Dis 2018;10(1):38-41. doi: 10.21037/jtd.2017.11.127

Download Citation