Key Points

• The recently completed JCOG 0802 and CALGB/Alliance 140503 randomized trials comparing sublobar resection to lobectomy for small peripheral lung cancers have established sublobar resection as the standard of care for select patients with peripheral, node negative NSCLC up to 2 cm.
• Lobectomy remains the standard of care for patients with larger tumors, central tumors or nodal involvement.
• Questions remain about the benefits of sublobar resection in lung preservation, and regarding advantages of segmentectomy over non-anatomic wedge resection.

The use of sublobar resection as definitive management of resectable non-small cell lung cancer (NSCLC) has been a controversial topic throughout the history of surgery for lung cancer. Based largely on a single randomized control trial published in 1995, lobectomy has long been considered the gold standard treatment for resectable lung cancer confined to a single lobe. Accordingly, sublobar resection was considered a so-called compromise operation by many surgeons, one that was employed only for the management of small peripheral lung cancers present in patients with significant impairment in cardiopulmonary reserve who cannot withstand the physiologic rigors of lobectomy.

The increasingly common finding of sub-centimeter malignant lesions identified through computed tomographic (CT) chest scanning, whether found incidentally or as part of a formal screening program, led many surgeons to reassess the need for total lobectomy for the management of smaller peripheral NSCLCs. In this setting, a question frequently asked today is, “Could anatomic segmentectomy or extended nonanatomic wedge resection be adequate for cure of the patient’s lung cancer?” We review the clinical information that is available today to the physician who is formulating an opinion regarding the appropriate use of sublobar resection for the small, peripherally located NSCLC.

In 2022/23, two large, multi-centre randomized control trials were published showing equivalent outcomes for sublobar resection for peripheral, node negative NSCLC up to 2 cm in size, compared to lobectomy. For selected patients with tumors meeting these characteristics, sublobar resection can now be viewed as the standard of care. However, for larger tumors, central tumors or lymph node involvement, lobectomy remains the standard of care for patients who can tolerate the larger resection.

Segmentectomy demands a thorough knowledge of the three-dimensional bronchovascular anatomy of the lung. The anatomic detail makes segmentectomy significantly more challenging than lobectomy. The technical details of the most commonly performed segmental resections are described elsewhere in this text.