Nonanatomic, sublobar “wedge” resection of lung cancer is generally considered a “compromise” pulmonary resection for primary treatment of lung cancer directed to the physiologically impaired patient who is at high risk for lobectomy.1,2 This assessment of the clinical utility of wedge resection is being challenged, particularly for the management of small peripheral lung cancer, where a generous wedge resection can be accomplished with acceptable surgical margins.
The goal of sublobar resection is lung parenchymal preservation, and as with the use of segmental breast-preserving resection of small breast cancers, limitation in the ability to control the tumor locally is appreciated as an important potential drawback. As with breast cancer, surgical margin status is at the heart of the matter of local recurrence, as is the poorly calculable presence of a locally aggressive tumor genotype, which may also be indicative of poor overall survival with these tumors once local recurrence manifests itself. Pathologic regional lymph node status and histologic, molecular, and biologic findings at the time of surgical resection suggestive of an aggressive tumor such as angiolymphatic invasion, visceral pleural invasion, and gene mutational findings are also independent predictors of survival following resection.
Nevertheless, local recurrence related to inadequate attention to surgical margins following lung cancer resection is an important problem leading to potential patient morbidities (i.e., bronchial obstruction, chest wall invasion, pleural effusion). Closeness to the resection margin and primary tumor size are intrinsic parameters related to the individual sublobar resection that may affect the adequacy of local care control. Intraoperative measures to avoid local recurrence such as enhancing the surgical margins of resection and using intraoperative radiobrachytherapy at the margin of surgical resection have also been investigated.3–5 In addition, postoperative radiotherapy directed to the staple line margins of resection has been explored.6 In this chapter, we review the basic strategies for successful open thoracotomy and VATS wedge resection of peripheral small lung malignancies (i.e., peripheral small primary lung cancer and pulmonary metastasis from remote primary cancers). We also direct attention to the primary use of wedge resection, namely, the diagnosis of suspicious pulmonary lesions suspected to be malignant (so-called indeterminate pulmonary nodules). Additionally, we review the outcomes reported in the literature for wedge resection and anatomic segmentectomy for lung malignancies, as well as the circumstances under which open versus VATS approaches to sublobar resection have differential value.
WHY DO WE CONSIDER “SUBLOBAR RESECTION” FOR PULMONARY MALIGNANCIES?
Over the years, several thoracic surgical investigators have questioned, “Why not consider sublobar resection for early-stage lung cancer, particularly among patients with impaired cardiopulmonary reserve who might not be candidates for lobectomy?” It is interesting to reflect on the evolutionary concepts of surgical resection for cancer that have developed since the “radical resection dogma” of Halsted established in the late 19th century and extending until now in some circles.7 The controversy over the ...