Advancing techniques in lung cancer resection while respecting tissue planes: the anatomic partial lobectomy

A long-standing core tenet of surgical oncology has been the emphasis upon aggressively targeting and removing cancer cells, in order to optimize survival benefit and minimize risk of recurrence. Within thoracic surgical oncology, operative strategies for treating early-stage lung cancer are continually evolving, incorporating advancements such as minimally invasive surgery, enhanced recovery paradigms, and optimizing decision-making regarding the extent of resection. In 1995, the landmark study by Ginsberg and colleagues advocated lobectomy as the standard surgical procedure compared to limited resection, which included segmentectomy or wedge resection, for small non-small cell lung cancer (NSCLC) (1). This dogma has most recently evolved due to highly popularized work by both Altorki (2) and Saji (3), highlighting that sublobar resections can be used in appropriate circumstances to effectively treat early-stage NSCLC. This landscape continues to progress significantly with the advent of high resolution computed tomography and implementation of lung screening, leading to an increase in the diagnosis of early-stage disease (4,5) in patients who are otherwise symptoms-free and with good quality-of-life (6). As such, the concept of anatomic partial lobectomy (APL), defined as lesion-centered resection of anatomical sublobar parenchyma, was introduced. This novel approach is based on both oncologic margin and territory of corresponding bronchi and vessels (7,8); varying and expanding beyond the traditional segmental planes.

The article by Qiu et al., published in The Journal of Thoracic and Cardiovascular Surgery describes the rising utilization of APL in the treatment of early-stage lung cancer (9). In this study, investigators evaluated outcomes of 3,336 patients with NSCLC, the majority of whom were found to have stage IA disease (9). The concept of APL is facilitated by detailed preoperative planning, utilizing cross-sectional imaging, in order to define the “cutting plane” that would allow resection of tumor-centered bronchial and vascular structures. As such, the authors recommend the confirmation of oncological margins and vascular drainage of the targeted parenchyma in order to pursue an adequate resection. The population who underwent APL at this single center were young (median age 56 years old), and predominantly female (67.7%) with no smoking history (79.6%). Importantly, at least some extend of nodal dissection was performed in the vast majority of patients (95.4%), with systematic mediastinal dissection and sampling occurring in 40.9% and 44.1% of cases, respectively. The median number of lymph nodes excised in this cohort was 11, with an average of 4 stations examined.

Qiu and colleagues’ work, while extensive, lacks a comparative analysis with patients who underwent segmentectomy, wedge resection, and/or lobectomy in patients with similar disease status. One interesting aspect of the study remains the use of APL, which may, in theory, be associated with physiologic benefits compared to more extensive resections. This has been evaluated previously, highlighting that parenchymal preservation is beneficial to maintaining pulmonary function following resection up to 1 year after the operation (10); although not at the expense of an adequate margin to tumor ratio. This was also observed in another investigation which directly compared anatomical versus non-anatomical segmentectomies and showed that the latter was associated with a greater decrease in forced-expiration volume in 1 second post-operatively (11). In relation to potential oncologic benefits associated with APL, following anatomical planes may improve survival by adequately providing guidance in the resection of draining lymphatic basins as well as ensuring adequate margins are obtained. In a meta-analysis, patients with stage I NSCLC obtained higher survival rates when they received segmentectomy compared to wedge resection, when tumors were smaller than 2 cm (and greater than 1 cm) (12). This finding may be associated with the nature of the resection. However, while the comparison between wedge resection and segmentectomy has been explored, larger resections such as lobectomies, for small early-stage NSCLC, have not yielded superior survival benefits. This has been shown in large randomized controlled trials (RCTs) (2,3,13) of patients with T1aN0 NSCLC, in which sublobar resection, including wedge resection, was found to be non-inferior to lobectomy with respect to disease-free survival (2). In the study led by Altorki and colleagues, it is worth highlighting that a large portion of patients who underwent sublobar procedures received wedge resections. Of note, this clinical trial included patients with early-stage disease with negative nodal involvement, either clinically, or pathologically. As such, it is important to confirm that nodal evaluation during these cases is sufficient, in order to ensure that an oncologically adequate resection is performed.

The study by Qiu et al. highlights the safety and adequacy of nodal sampling in APL for lung cancer. However, the biological and physiological impact of this approach on oncologic outcomes, compared to traditional operations, remains unclear. One discussion point is the significance of targeted nodal dissection during anatomic resections compared to wedge resections. It is crucial to determine whether lymph node removal directly influences disease progression. For example, similar to findings in breast cancer, where removal of all nodal basins can be morbid, mapping lymph node harvest based on known drainage patterns in lung cancer patients has shown to improve outcomes (14). By mapping lymph node harvest based on known drainage patterns in patients with lung cancer, survival outcomes have been shown to improve due to the direct harvest of potentially occult disease (14). It is also possible that more targeted resection and specific selection of lymph nodes may impact immunogenicity and its potential in patients who warrant adjuvant immunotherapy (15).

Ultimately, adopting a patient- and disease-centered approach in thoracic surgical oncology is crucial. Ensuring appropriate resection margins with anatomical guidance can lead to significant survival benefits, particularly when paired with parenchymal preservation. The study by Qiu and colleagues provides valuable insights on this approach, and we await long term outcomes from this study, as well as direct comparison to wedge, segmentectomy, and lobectomy with great interest.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article has undergone external peer review.

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-612/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-612/coif). M.B.A. serves as an unpaid editorial board member of Journal of Thoracic Disease from August 2024 to July 2026. The other author has 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.

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