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Figure 1. A: uniportal video-assisted thoracic surgery (VATS) instrumentation during left anatomical segmentectomy; B: preservation of
left lower lobe S6 and S8 segments after S9+10 anatomical segmentectomy by uniportal VATS

THE ROLE OF SUBLOBAR RESECTION IN LUNG CANCER
Sublobar resections (SLR) include both non-anatomical wedge resections and anatomical resections of
segments and subsegments with isolated division of both vascular and bronchial structures (i.e., anatomical
segmentectomy). These procedures have specially spread within the last decade due to the diffusion and
development of minimally invasive thoracic procedures, and the concept of “lung-sparing surgery”, which
means preserving as much lung parenchyma as possible [Figure 1] [5,21-24] .

Main expected benefit of SLR when compared to lobectomy, is the preservation of higher amount of lung
parenchyma, thus the absolute loss of postoperative lung function should be lower than for lobar and
supralobar resections. This is why it has been considered an appropriate resection for compromised patients
who cannot tolerate a standard lobectomy. Most published studies have not addressed the functional
[25]
repercussion, but Charloux et al. , in 2017, reported a lower decrease in postoperative forced espiratory
volume at first second (FEV1) at 12 months in SLR compared to lobectomy (5% vs. 11%, respectively). They
also reported lower decrease in global pulmonary function in patients with diminished preoperative lung
function who undergone SLR, and a direct relationship between the number of resected segments and
functional loss.

Anatomical segmentectomy has been used in the treatment of several pathologies, mainly benign lesions
[26]
centrally located in the lobe, pulmonary metastasis, and early stage lung cancer . In the Lung Cancer
Study Group report in 1995, SLR (i.e., anatomical and wedge) showed a higher recurrence and death rate
in tumors less than 3 cm diameter, so lobectomy was set as the standard surgical treatment for early stage
[3]
lung cancer . Since then, many studies have shown that anatomical SLR have comparable DFS and OS
than lobectomy for tumors less than 2 cm [4-8,21] . Thus, sublobar anatomical resections have been already
included in main clinical guidelines (National Comprehensive Cancer Network -NCCN, European Society
of Medical Oncology -ESMO) as an accepted procedure for early stage adenocarcinoma less than 2 cm, in
peripheral location without nodal involvement, especially when ground-glass appearance or long duplication
time have been observed [27,28] . Most published studies are case series or comparative unicentric studies,
so there is still a real lack of multicenter studies and randomized trials that specifically address these
issues. Two prospective multicenter randomized trials are ongoing now comparing lobectomy to SLR: the
Japanese Cooperative Oncological Group (JCOG) 0802 study was launched in Japan in 2009 to evaluate the
[29]
overall survival of patients after segmentectomy and lobectomy for NSCLC . There are 71 centers where
1,100 individuals will be recruited. A similar study is pending in the USA (Cancer and Leukemia Group B