Surgical Challenge of Sublobar Resection for Early-stage Non-small Cell Lung Cancer: Current Status and Future Perspectives

Lobectomy and lymph node dissection have long been the standard surgical procedures for clinical stage IA lung cancer, based on a randomized trial published in 1995. That randomized trial showed better overall survival (OS) and recurrence-free survival (RFS) with lobectomy than with limited resection (segmentectomy or wide wedge resection) for clinical T1N0 non-small cell lung cancer. In addition, a three-fold higher rate of locoregional recurrence after limited resection was observed. However, recent advances in diagnostic imaging, such as thin-section computed tomography (TSCT), have improved the accuracy of clinical staging and the assessment of ground-glass opacity (GGO) in lung cancer, which is now recognized as being associated with less invasive pathology and a favorable prognosis. Subsequently, to evaluate the efficacy of sublobar resection for early-stage lung cancer, three major JCOG trials (JCOG0802/WJOG4607L, JCOG0804/WJOG4507L, and JCOG1211) were conducted. These studies stratified patients according to the consolidation-to-tumor ratio (CTR) on preoperative TSCT findings. These studies have recently disclosed their results, and they support the efficacy of sublobar resection, although several questions remain in daily clinical practice. In this perspective article, we summarize the current status and optimal surgical strategy for early-stage lung cancer based on these randomized controlled trials and discuss future perspectives, including the potential expansion of segmentectomy to larger or node-positive lung tumors.