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Sawabata et al. Pulmonary wedge resection for NSCLC

first multicenter prospective study in 1995 that compared reference data of pulmonary wedge/sublobar resection
wedge/sublobar pulmonary resection to lobectomy. [55] of NSCLC. The ASOCOG Z4032 results revealed a
In this study, the rate of local recurrence was 17% in local control rate of 71% and a 3-year survival rate of
patients who received wedge/sublobar resections (40 76% in the wedge/sublobar resection group. Although
wedge resections) in contrast to 6% for the lobectomy the local control rate was not different regardless of
group (P = 0.008). The 3- and 5-year survival rates of brachytherapy administration, it was higher among
the wedge/sublobar resection group were 79% and cases with cytological malignant positive surgical
48%, respectively. Although the survival rate was not margins that receive I-125 brachytherapy. Thus I-125
statistically significant between the groups (P = 0.1), brachytherapy was proven to be effective.
wedge/sublobar resection has not been accepted as a
standard therapy for clinical stage I NSCLC. The Kanetsu Lung-cancer Study Group (KLSG)
conducted a one arm multicenter prospective study
A number of clinical trials have now been conducted to (KLSG0801) to investigate the feasibility of wedge/
evaluate the usefulness of various surgical strategies sublobar pulmonary resection among patients with
for treating early sage lung cancer. Recently, a phase limited cardio-pulmonary preservation in Japan. [61] This
III randomized trial (JCOG0802/WJOG4607L) was study uncovered grade 3 morbidity in only 2 cases
conducted in Japan to evaluate the non-inferiority of (7%), a calculated 3-year surgical margin control rate of
overall survival of limited resection (segmentectomy) 97%, a calculated 3-year local recurrence control rate
over lobectomy in patients with small peripheral NSCLC of 76%, and a calculated 3-year overall survival rate
(2 cm or less, the proportion of maximum diameter of of 79%, supporting the feasibility of wedge/sublobar
the tumor itself to consolidation > 0.5). In addition, pulmonary resection for NSCLC. In the KLSG0801
[56]
a non-randomized confirmatory study (JCOG0804/ study, surgical margin cytology was carried out in
WJOG4507L) has been conducted to evaluate the 21 (67%) and margin-distance was measured in all
efficacy and safety of limited resection (wedge resection (100%) cases. The calculated 3-year overall survival
in general) in patients with small (2 cm or less) peripheral rate was 88% for negative margin cytology in contrast
radiological noninvasive lung cancer, diagnosed by to 20% for those with positive margins. This finding
preoperative thin-section CT scan images. Another suggests the importance of determining surgical
[57]
confirmatory trial (JCOG1211) has been conducted margin cytology during pulmonary wedge resection
to confirm the efficacy of limited resection (lung of NSCLC. Furthermore, 80% of cases that revealed
segmentectomy) in patients with GGO-predominant malignant positive margin cytology possessed M/T
lung cancers of less than or equal to 3 cm in diameter ratio of greater than 1, which further emphasizes the
based on thin-section CT scans. In South America, a importance of performing pulmonary wedge resection
[58]
randomized phase III trial has also been conducted to with sufficient parenchymal surgical margin-distance.
compare the efficacy of different types of surgeries used The results of a prospective study of wedge/sublobar
to treat patients with stage IA NSCLC. Wedge resection resection for clinical stage I NSCLC are summarized
[59]
or segmentectomy may be less invasive surgeries with in Table 4.
fewer side effects and improve recovery than lobectomy
for NSCLC, but it is not yet known whether wedge Stereotactic body radiation therapy
resection or segmentectomy are more effective than A prospective multicenter study of SBRT demonstrated
lobectomy in treating stage IA NSCLC. However, there a 3-year recurrence-free survival rate of 48-80%, 3-year
have been only three completed multicenter prospective overall survival rate of 56-90%, and tumor control rate
studies of pulmonary wedge resections, including the of 86-98% with acceptable rates of adverse effects
LCSG study. [55,60,61] [Table 5]. [62-64] In addition, a recent prospective phase
III study with SBRT and lobectomy arms suggests
The American College of Surgeons Oncology Group SBRT could be an option for treating operable stage
(ACOSOG) completed a multicenter prospective I NSCLC; however, a limitation of this study was the
study named Z4032. [60] The ACOSOG Z4032 was a small sample size. [64]
randomized phase III trial comparing sublobar resection
to sublobar resection plus brachytherapy (wire of I-125 Besides, there are technical limitations associated with
implantation at the site of surgical margin) in patients SBRT such as “no-fly-zone” and irradiation of hilar
with stage I NSCLC who were considered high-risk for tumors, and complications such as pulmonary fibrosis
lobectomy. The study was closed to accrual in January and hemoptysis, which should be considered when
2010 after a planned enrollment of 222 evaluable comparing surgery to SBRT. In addition, patients with
patients. Although the study failed to reveal the efficacy unknown histologic diagnosis received SBRT in most
of I-125 brachytherapy, its results are important of the studies.
18 Mini-invasive Surgery ¦ Volume 1 ¦ March 31, 2017