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Sawabata et al. Pulmonary wedge resection for NSCLC

an acceptable alternative treatment for selected patients noninvasive (35 patients, 12.1%) and invasive (254
with T1N0M0 disease. Koike et al. [38] studied 74 patients patients, 87.9%) adenocarcinomas were 97.1%
who received intentional limited resections for T1N0M0 and 92.4%, respectively, and the difference was not
(< 2 cm) disease, and uncovered that the calculated statistically significant. It is currently widely accepted
3-year and 5-year survival rates were 94.0% and 89.1%, that the radiologic criteria of a consolidation/tumor
respectively, which did not significantly differ from those ratio of 0.25 or less in clinical T1a and 0.50 in clinical
of a lobectomy group. They therefore concluded that T1a-b are both able to define a homogeneous group
in patients with peripheral T1N0M0 NSCLC whose of patients with an excellent prognosis before surgery.
maximum tumor diameter was 2 cm or less, the outcome
of limited pulmonary resection is comparable with that Margin-distance is an indicator of recurrence among
of pulmonary lobectomy. Okada et al. [39] also examined patients with solid but not GGO predominant lesions. In
260 sublobar resections, including 30 wedge resections, the study by Moon et al., [41] there was no recurrence in
in comparison to 260 lobectomies, and found that DFS GGO-predominant tumors after sublobar resection, and
and overall survivals were similar in both groups. The this was not influenced by margin-distance. However,
5-year DFS and overall survival were 85.9% and 89.6%, for solid-predominant tumors, the 5-year recurrence-
respectively for the sublobar resection group, and 83.4% free survival after sublobar resection according to
and 89.1%, respectively for the lobar resection group. margin-distances of less than 5 mm and more than 5 mm
The conclusion was that sublobar resection should be were 24.2% and 79.6 %, respectively (P = 0.001). The
considered as an alternative for stage IA NSCLC 2 conclusion therefore was as follows that the distance
cm or less, even in low-risk patients. [39] These results between the tumor and resection margin does not
could lay the foundation for starting new randomized affect the recurrence after R0 sublobar resection in
controlled trials, which could revolutionize lung cancer patients with clinical N0 GGO-predominant lung cancer
surgery in this era of early detection. In this context, a less than 3 cm but margin distance is a significant risk
phase III randomized trial of lobectomy versus limited factor for recurrence after sublobar resection in patients
resection (segmentectomy) for small (2 cm or less) with clinical N0 solid-predominant lung cancer. [41]
peripheral NSCLC (JCOG0802/WJOG4607L) has been
conducted in Japan. Stereotactic body radiation therapy
Because conventional 2-dimentional radiation therapy
Pulmonary wedge resection for GGO of lung cancer has resulted in inadequate rates of local
predominant lesions control and adverse effects, it is being replaced by
In the 2010s, there was an increase in the number SBRT, which is mainly administered for stage I lung
of articles that examined GGO lesions in regard to cancer with acceptable morbidity and local control
surgery. Asamura et al. [40] conducted a prospective rates. [42,43] Among inoperable patients, the mortality
multi-institutional study whereby image diagnosis was and severe morbidity from SBRT were few, and the
used to define early (noninvasive) adenocarcinomas 5-year survival rate was less than 20% (17-19%). [44-46]
of the lung (Japan Clinical Oncology Group 0201). Additionally, in non-biased patients with stage IA
This study demonstrated that a consolidation/tumor NSCLC, mortality and severe morbidity seldom
ratio on thin-section computed tomography (CT) occurred, but controllable radiation pneumonitis
scans of 0.25 or less for cT1a (less than or equal to developed in up to 20% of the patients, and the median
2.0 cm) lesions was a better radiologic criterion for 5-year survival rate was 39% (ranged, 30-73%). [47-50] It
early pathology than a ratio of 0.50 or less for T1a-b has also been reported that the outcome of surgery is
[51-53]
(less than or equal to 3.0 cm) tumors. This criterion superior to SBRT.
was used for prognostic evaluation of 545 patients with
adenocarcinoma who underwent lobectomy and lymph Comparison of pulmonary wedge resection
node dissection. Using a consolidation/tumor ratio of and radiation therapy
0.25 or less, the overall survival and 5-year relapse- Clinical observational studies that compared the
free survival of the patients were 90.6% and 84.7%, outcomes of pulmonary wedge resection to SBRT
respectively. With a ratio 0.5 or less for T1a-b lesions, suggest SBRT is inferior [11,13,18] but comparable
the 5-year overall survival for radiologic noninvasive to wedge/sublobar pulmonary resection among
(121 patients, 22.2%) and invasive (424 patients, operable [53] and elderly [54] patients.
77.8%) adenocarcinomas was 96.7% and 88.9%,
respectively, and this difference was statistically PROSPECTIVE CLINICAL STUDIES
significant (P < 0.001, log-rank test). However, when a
consolidation/tumor ratio of 0.25 or less for clinical T1a Pulmonary wedge resection
was used, the 5-year overall survival rates of radiologic The Lung Cancer Study Group (LCSG) conducted the
Mini-invasive Surgery ¦ Volume 1 ¦ March 31, 2017 17