Current state of anatomic lung resection in the management of early-stage non-small cell lung cancer. a narrative review

Background and Objective: A lot has changed since 1995, when the landmark paper established lobectomy as a standard of care for early-stage non-small cell lung cancer (NSCLC), defined at the time as a tumor less than 3 cm without lymph node involvement. Most notably, screening for lung cancer has become ubiquitous leading to the discovery of small lesions. Moreover, advanced diagnostic technologies allow precise tissue diagnosis in small peripheral nodules, establishing malignancy earlier. Numerous studies have brought sublobar resections to the forefront for surgical treatment of lung cancer. The change in practice patterns for surgical resection of NSCLC over the last decade requires in depth review of the current evidence that established the modern standard of care. We conducted an expert narrative review of landmark studies and new literature highlighting the range of surgical approaches for early-stage NSCLC. Methods: Two reviewers queried PubMed, Medline, and Cochrane library since inception for meta-analysis, retrospective, cohort, and randomized control studies. Exclusion criteria included case reports and non-English articles. Key Content and Findings: Retrospective studies showing non-inferior outcomes between lobectomies and segmentectomies using variable surgical approaches for T1_a-bN0 prompted three randomized control trials. Post-operative pulmonary function was improved with no change in 5-year survival in segmentectomies and/or sublobar resections for all studies. The JCOG0802/WJOG4607L study demonstrated astonishingly high 5-year survival in the segmentectomy group, on top of already excellent outcomes in the lobectomy group. CALGB 140503 trial showed reduced 30- and 90-day mortality in the sublobar resection group. Minimally invasive techniques have gained popularity, demonstrating lower morbidity and mortality as opposed to open thoracotomy. The robotic approach has become more popular, with some retrospective studies demonstrating lower rates of conversion to open and post-operative complications after pulmonary lobectomy when compared to video-assisted thoracic surgery (VATS). There is limited data for robotic segmentectomies, but the same benefits will likely hold true as the comparison between robotic and VATS lobectomies. Conclusions: Minimally invasive segmentectomy should be considered as a preferred surgical approach for early-stage NSCLC in experienced centers, specifically for small peripheral tumors. Robotic technology appears to offer advantages as a minimally invasive procedure of choice in the management of lung cancer.