1344 ª 2023 by The Society of Thoracic Surgeons 0003-4975/$36.

00
Published by Elsevier Inc. https://doi.org/10.1016/j.athoracsur.2022.08.044

Lung: Research

Wedge Resection vs Lobectomy for Clinical

Stage IA Non-Small Cell Lung Cancer With
Occult Lymph Node Disease
Peter J. Kneuertz, MD,1 Mahmoud Abdel-Rasoul, MS, MPH,2 Desmond M. D’Souza, MD,1
Susan D. Moffatt-Bruce, MD, PhD,3 and Robert E. Merritt, MD1

ABSTRACT

BACKGROUND Sublobar resection is increasingly performed for stage Ia non-small cell lung cancer, but pathologic
lymph node upstaging remains a common clinical scenario. This study compares the long-term prognosis of patients
with clinical stage Ia disease and occult lymph node disease undergoing wedge resection vs lobectomy.

METHODS The National Cancer Database was queried for patients treated with wedge resection or lobectomy for
clinical stage Ia (cT1N0) non-small cell lung cancer and who were pathologically upstaged with either pN1/pN2 disease.
Overall survival (OS) was compared by extent of resection using inverse probability treatment weighting–adjusted Cox
regression analyses.

RESULTS Of 5437 clinical stage Ia patients included, 3408 (62.7%) were found to have occult pN1 and 2029 (37.3%) to have
occult pN2. Of 5437 patients, 93.5% (5082) were treated with lobectomy and 6.5% (355) underwent wedge resection. Lo-
bectomy was associated with improved OS compared with wedge resection for patients with occult pN1 disease (median OS,
70.0 months [95% CI, 66.6-77.4] vs 36.4 months [95% CI, 24.2-45.6]; P < .001) but not for pN2 disease (median OS, 48.2.1
months [95% CI, 43.8-52.9] vs 43.7 months [95% CI, 31.2-62.4]; P [ 0.24). On inverse probability treatment weighting–adjusted
multivariable analysis, adjusting for demographics, comorbidities, margin status, and pathologic T and N stage, lobectomy
remained associated with improved survival (adjusted hazard ratio, 0.73; 95% CI, 0.60-0.89; P [ .0016).

CONCLUSIONS Lobectomy is associated with improved survival in clinical stage Ia non-small cell lung cancer patients
with occult lymph node disease. These data may aid the decision for completion lobectomy for patients with unan-
ticipated N1 lymph node upstaging.

(Ann Thorac Surg 2023;115:1344-52)

ª 2023 by The Society of Thoracic Surgeons

L obectomy has been established as the standard

treatment for early-stage non-small lung cancer
(NSCLC) in the Lung Cancer Study Group trial,
which showed a 30% higher recurrence rate and worse
survival after sublobar resection.1 Multiple studies have
since shown that sublobar resection may be oncologi-
cally equivalent to lobectomy for select patients with
small peripheral tumors.2-4 The application of sublobar
resection has significantly increased over the past
decade.5 The Alliance140503 clinical trial evaluating
the long-term outcomes of sublobar resection compared
with lobectomy for patients with stage IA1-2 disease has
been completed, and results are expected in the near
future.
Despite the availability of current staging modalities
including positron emission tomography and invasive
preoperative lymph node staging, pathologic lymph
node upstaging remains a common clinical scenario. The
rate of occult lymph node disease that is discovered on
the pathology has been reported in 5% to 13% of stage I
NSCLC patients after sublobar resection and may exceed
20% after lobectomy with adequate lymph node
dissection.6-8 For patients who were subjected to sub-
lobar resection and upstaged, a completion lobectomy

Accepted for publication Aug 29, 2022.

Presented at the Fifty-eighth Annual Meeting of The Society of Thoracic Surgeons, Virtual Meeting, Jan 29-30, 2022.
1
Division of Thoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio; 2Center for Biostatistics,
Department of Biomedical Informatics, The Ohio State University, Columbus, Ohio; and 3Department of Surgery, University of Ottawa, Ottawa, Ontario,
Canada
Address correspondence to Dr Kneuertz, Division of Thoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Doan
Hall N846, 410 W 10th Ave, Columbus, OH 43210; email: peter.kneuertz@osumc.edu.
Ann Thorac Surg
2023;115:1344-52
FIGURE 1 Consolidated Standards of Reporting Trials flow diagram outlining the patient selection process. (IPTW, inverse
probability treatment weighting; NSCLC, non-small cell lung cancer.)
may be considered based on their lymph node disease.9
A previous study showed no prognostic advantage of
lobectomy vs segmentectomy in stage I NSCLC patients
with pathologic nodal upstaging.10 However the benefit
of lobectomy vs wedge resection in patients with
unsuspected lymph node disease remains ill-defined
and has to be weighed against the risk of the redo
surgery.11
This current study was designed to examine the long-
term survival after wedge resection and lobectomy for
patients diagnosed with clinical stage Ia NSCLC and
found to have occult lymph node disease on pathology
using the National Cancer Database (NCDB). In an effort
to account for the inherent differences in patient selec-
tion by procedure type in a nonrandomized study, we
sought to limit these as best as possible using statistical
means of a propensity score–weighted analysis.
PATIENTS AND METHODS
The NCDB was queried for all patients with clinical stage
IA NSCLC diagnosed between 2004 and 2018. The NCDB
is a comprehensive nationwide cancer outcomes data-
base, jointly sponsored by the Commission on Cancer of
KNEUERTZ ET AL 1345
OCCULT LYMPH NODE DISEASE
the American College of Surgeons and the American
Cancer Society, that captures approximately 70% of all
newly diagnosed cancers in the United States with over
1500 reporting institutions.
We selected patients with pathologically confirmed,
invasive NSCLS based on International Classification of
Diseases, Ninth Revision histology codes (8046, 8070-8,
8140-7, 8251-5,8310, 8323, 8333, 8480-1, 8490, 8550,
8560, 8572). The study cohort was limited to patients
with clinical stage Ia (cT1N0) disease who had upfront
surgery with a pulmonary resection by either lobectomy/
bilobectomy or wedge resection and who were upstaged
based on the presence of lymph node disease on pa-
thology (pN1 or pN2). We further excluded patients with
incomplete pathologic staging information and/or T3/T4
tumors on pathology. The selection process is summa-
rized in Figure 1.
Clinical characteristics for analysis included de-
mographics, Charlson Comorbidity Index scores, socio-
economic status, and tumor descriptors. Clinical and
pathologic stage were recorded using the American Joint
Committee on Cancer sixth and seventh edition TNM
staging manual. Treatment data were extend of resec-
tion, margin status, and adjuvant therapy. The primary
1346 KNEUERTZ ET AL Ann Thorac Surg
OCCULT LYMPH NODE DISEASE 2023;115:1344-52

TABLE 1 Demographics and Clinical Characteristics of Patients Undergoing Lobectomy vs Sublobar Resection for Clinical
Stage IA and Pathologic N1/N2 Lymph Node Upstaging

Inverse Probability Treatment Weighting

Unadjusted Adjusted

Wedge Lobectomy Lobectomy

Variable (n ¼ 355) (n ¼ 5082) P Wedge (%) (%) P

Mean age at diagnosis, y (SE) 68.4 (0.48) 66.1 (0.13) <.001 66.47 (0.64) 66.47 (0.14) .9996
Sex
Female 199 (56.06) 2791 (54.92) .6772 52.29 54.13 .5766
Male 156 (43.94) 2291 (45.08) 47.71% 45.87
Race
White 313 (88.17) 4355 (85.69) .2828 86.27 85.74 .8824
Black 31 (8.73) 482 (9.48) 9.85 9.65
Other/unknown 11 (3.1) 245 (4.82) 3.89 4.61
Facility type
Community/comprehensive 234 (65.92) 3322 (65.72) .9393 66.77 66.06 .8206
community/integrated
Academic/research program 121 (34.08) 1733 (34.28) 33.23 33.94
Insurance type
Governmental/other 270 (76.06) 3404 (66.98) .0004 67.73 67.96 .9438
Private 85 (23.94) 1678 (33.02) 32.27 32.04
Median income
<$38,000 54 (16.56) 797 (17.79) .5768 15.81 17.73 .4266
‡$38,000 272 (83.44) 3684 (82.21) 84.19 82.27
Residence
Metropolitan 304 (88.63) 4088 (83.12) .0248 84.85 83.75 .8580
Urban 33 (9.62) 733 (14.9) 13.75 14.40
Rural 6 (1.75) 97 (1.97) 1.40 1.85
Charlson-Deyo score
0 166 (46.76) 2540 (49.98) .6469 47.34 49.16 .9401
1 123 (34.65) 1680 (33.06) 35.39 33.58
2 49 (13.8) 619 (12.18) 12.35 12.52
‡3 17 (4.79) 243 (4.78) 4.91 4.74
Primary site
Upper lobe 214 (60.28) 3110 (61.2) .4472 61.76 61.67 .8384
Middle lobe 14 (3.94) 290 (5.71) 4.36 5.59
Lower lobe 120 (33.8) 1597 (31.42) 32.10 31.10
Other 7 (1.97) 85 (1.67) 1.78 1.63
Laterality
Left 159 (44.79) 2235 (43.98) .2111 45.97 44.31 .4575
Right 194 (54.65) 2839 (55.86) 53.53 55.51
Unknown 2 (0.56) 8 (0.16) 0.50 0.18
Tumor size
£1 cm 25 (7.04) 135 (2.66) <.0001 2.93 2.92 .9827
>1 cm to £2 cm 145 (40.85) 1455 (28.63) 30.32 29.91
>3 cm to £3 cm 81 (22.82) 1677 (33.00) 32.78 33.35
>3 cm 23 (6.48) 673 (13.24) 14.02 12.88
Unknown 81 (22.82) 1142 (22.47) 19.94 20.94
Histology
Adenocarcinoma 91 (81.97) 4015 (79) .1679 83.06 78.49 .1633
Squamous cell carcinoma 51 (14.37) 919 (18.08) 13.81 18.62
Not otherwise specified 13 (3.66) 148 (2.91) 3.13 2.89
Tumor grade
Well differentiated 31 (8.73) 327 (6.43) .0071 9.52 6.52 .0055
Moderately differentiated 162 (45.63) 2620 (51.55) 43.13 51.46
Poorly/undifferentiated 133 (37.46) 1888 (37.15) 39.14 37.48

Values are n (%) unless otherwise defined.

Ann Thorac Surg KNEUERTZ ET AL 1347
2023;115:1344-52 OCCULT LYMPH NODE DISEASE

TABLE 2 Comparison of Pathologic Staging and

Outcomes

Inverse Probability Treatment

Weighting Adjusted

Variable Sublobar Lobectomy P

TNM pathologic T stage

pT1, % 59.01 63.71 .1488
pT2, % 40.99 36.29
TNM pathologic N stage
N1, % 40.66 64.86 <.001
N2, % 59.34 35.14
Mean lymph node count (SE) 7.19 (0.40) 11.77 (0.12) <.001
Surgical margins status
R0, % 89.57 95.14 <.001
R1-2, % 7.80 4.48
Unknown, % 2.63 0.38
Readmission within 30 days
No readmission, % 93.98 92.66 .8621
Planned readmission, % 1.94 2.28
Unplanned readmission, % 3.03 4.05
FIGURE 2 Inverse probability treatment weighting–adjusted Kaplan-Meier
Unknown, % 1.05 1.01 overall survival curves of lobectomy vs wedge resection for clinical stage Ia
Thirty-day mortality, % 4.49 1.50 .0013 non-small cell lung cancer and pN1 lymph node disease.
Adjuvant therapy
Systemic therapy after surgery, % 71.93 69.43 .4146

and after adjusting for IPTW. The IPTW-adjusted stan-

outcome was overall survival (OS), which was calculated
from the date of diagnosis to the date of last follow-up or
death. Perioperative outcomes were 30-day read-
missions and 30-day mortality.
A crude analysis of baseline characteristics between
patients treated with lobectomy or wedge resection was
performed first. Categorical variables are summarized as
frequencies and percentages and compared between
facility types using the c2 test or Fisher’s exact test
where relevant. Continuous variables are summarized as
means and SEs or medians and interquartile ranges and
compared using Student’s t test or Wilcoxon rank sum
test where relevant.
To account for treatment selection bias and minimize
confounding by tumor characteristics, we applied a
propensity score methodology with inverse probability
dardized differences were all <0.10. Categorical vari-
ables were compared between surgery groups after
adjusting for IPTW using Rao-Scott c2 tests. IPTW-
adjusted linear regression models were used to test for
differences in continuous variables.
Survival analyses were performed using the Kaplan-
Meier method and compared between sublobar resec-
tion and lobectomy patients using the log-rank test.
TABLE 3 Inverse Probability Treatment Weighting–
adjusted Overall Survival Estimates Comparing
Lobectomy vs Sublobar Resection in Patients With
Pathologic N1 and N2 Lymph Node Upstaging
Lobectomy
Wedge Resection (Weighted P (Log
Pathologic N1 (Weighted n ¼ 128) n ¼ 2808) Rank)

treatment weighting (IPTW) to balance the baseline Median 36.4 (24.2-45.6) 70.0 (66.6-77.4) <.001
survival, mo
characteristics between groups, as previously
Three-year 51.3 (41.0-60.7) 69.9 (68.1-71.6)
described.12 IPTW was estimated using logistic survival, %
regression analysis including the following differential Five-year 34.1 (23.9-44.4) 55.7 (53.6-57.8)
survival, %
patient and disease characteristics (P  .2) and
disregarding outcomes: age, sex, race, Charlson-Deyo Lobectomy
Wedge Resection (Weighted P (Log
Comorbidity Index score, and tumor size. Stabilized
Pathologic N2 (Weighted n ¼ 188) n ¼ 1521) Rank)
IPTW was calculated for each patient by dividing the
Median 43.7 (31.2-62.4) 48.2 (43.8-52.9) .2385
predicted probability of patient treatment group as survival, mo
estimated from a crude multinomial logistic regression Three-year 58.1 (49.4-65.8) 58.8 (56.2-61.4)
survival, %
model by their respective predicted probability from the
Five-year 42.6 (33.4-51.5) 44.5 (41.6-47.4)
multivariable-adjusted multinomial logistic regression survival, %
model. The stabilized weights for each patient were used
as the final IPTW. Balance between study groups was Values in parentheses are 95% CI.

assessed by estimating standardized differences before

1348 KNEUERTZ ET AL
OCCULT LYMPH NODE DISEASE
FIGURE 3 Inverse probability treatment weighting–adjusted Kaplan-Meier
overall survival curves of lobectomy vs wedge resection for clinical stage Ia
non-small cell lung cancer and pN2 lymph node disease.
IPTW-adjusted Cox proportional hazards regression
models were fit to assess the association of the extent of
resection among other clinicopathologic factors with
survival. Variables associated with survival on a uni-
variate analysis were assessed for association with the
outcome, potential confounding, and effect modification
resulting in the final doubly robust–adjusted multivari-
able Cox regression models presented. Hypothesis testing
for main outcomes was conducted at a 5% type I error
rate. The statistical analysis was designed and conducted
by an experienced and impartial biostatistician (M.A.)
using SAS version 9.4 (SAS Institute, Cary. NC).
RESULTS
In the NCDB 5437 patients met the selection criteria and
were included in the analysis (Figure 1). All patients
were diagnosed clinical stage Ia NSCLC and underwent
either lobectomy (5082 [93.5%]) or wedge resection
(355 [6.5%]) and had lymph node disease on pathology.
Most patients had unsuspected pN1 (3408 [62.7%]) and
fewer had pN2 (2029 [37.3%]) lymph node disease. The
first unadjusted comparison showed expected
differences in demographics and clinical disease
characteristics between the groups (Table 1). After
IPTW adjustments the groups showed a similar
distribution of the clinical baseline characteristics, with
a mean age of 66 years and a slight female
predominance (Table 1). Charlson-Deyo Comorbidity
Index scores were well balanced between the groups
(Table 1). Most patients had adenocarcinoma histology
and had a tumor size between 2 and 3 cm (Table 1).
Ann Thorac Surg
2023;115:1344-52
The frequency of N1 lymph node disease was higher in
the lobectomy as compared with the wedge group
(64.9% vs 40.1%, P < .001), and vice versa for N2
disease (Table 2). Although the rate of pathologic T1
and T2 tumors was evenly distributed between groups,
lobectomy patients with occult lymph node disease
had a higher rate of complete R0 resection (95.1% vs
89.6%, P < .001).
After pathologic N1 upstaging, lobectomy patients
had a significantly longer median OS of 70 months vs
36.4 months for the wedge resection group (P < .001)
(Figure 2). The 5-year OS estimate was 21.6% higher for
lobectomy as compared with wedge resection patients
with occult N1 disease (55.7% vs 34.1%, P < .001). Dif-
ferential survival rates between lobectomy and wedge
resection in the IPTW-adjusted analysis are presented in
Table 3. For patients who were staged N2 on surgical
pathology, survival was overall much lower (Table 3).
Although the median survival for pN2 patients was still
longer in the lobectomy group (48.2 months vs 43.7
months for sublobar, P ¼ .24) than for the wedge
resection group, the survival curves intersected after 6
years out from surgery and were not statistically
different (Figure 3). There was also no significant
difference in survival in patients with occult pN1 and
pN2 after wedge resection. The 5-year survival after
pN2 upstaging was similarly low, and below 50% in both
groups (Table 3).
We then tested the association of wedge resection
vs lobectomy with survival in an IPTW-adjusted
multivariable analysis and including both clinical fac-
tors in the model that may be confounders as well as
the margin status and pertinent pathologic prognostic
factors (Table 4). Lobectomy remained an independent
predictor of survival with a hazard ratio of 0.73
(95% CI, 0.60-0.89; P ¼ .0016) or a 27% decreased
risk of early death relative to sublobar resection.
A sensitivity analysis revealed that the survival
difference between lobectomy and wedge resection
in patients with occult lymph node disease persisted
when 30-day perioperative deaths were excluded
from the model. The other main prognostic factors in
the model were pathologic T stage and N stage,
margin status, and receipt of adjuvant chemotherapy
(Table 4).
COMMENT
This study compared the long-term outcomes of pa-
tients with clinical stage Ia NSCLC with occult lymph
node disease. The results demonstrate that pathologic
lymph node upstaging of N1 disease occurs almost
twice as often as N2 disease. Lobectomy was associ-
ated with longer OS compared with sublobar resection
for patients with occult N1 disease, even in a
Ann Thorac Surg KNEUERTZ ET AL 1349
2023;115:1344-52 OCCULT LYMPH NODE DISEASE

TABLE 4 Multivariate Survival Analysis of Patients With Clinical Stage IA Non-Small Cell Lung Cancer and Pathologic
Lymph Node Upstaging

Inverse Probability Treatment Weighting

Unadjusted Adjusteda

Parameter Hazard Ratio (95% CI) P Hazard Ratio (95% CI) P

Age 1.01 (1.01-1.02) <.001 1.01 (1.01-1.02) <.001

Sex
Female 0.74 (0.68-0.81) <.001 0.74 (0.68-0.81) <.001
Male Reference Reference
Race
Black 0.94 (0.80-1.10) .4155 0.96 (0.81-1.13) .5954
Other/unknown 0.60 (0.47-0.77) <.001 0.61 (0.48-0.77) <.001
White Reference Reference
Charlson-Deyo score
0 0.60 (0.49-0.72) <.001 0.60 (0.49-0.75) <.001
1 0.68 (0.56-0.82) <.001 0.68 (0.55-0.85) <.001
2 0.79 (0.64-0.97) .0243 0.80 (0.63-1.01) .0606
‡3 Reference Reference
Tumor size
£1 cm 0.97 (0.72-1.32) .8638 1.02 (0.75-1.39) .9052
>1 cm to £2 cm 1.06 (0.91-1.23) .4778 1.07 (0.92-1.25) .3822
>2 cm to £3 cm 1.29 (1.11-1.49) .0007 1.31 (1.13-1.51) <.001
3D cm 1.22 (1.02-1.46) .0293 1.23 (1.02-1.48) .0295
Unknown Reference Reference
Procedure
Lobectomy 0.81 (0.69-0.96) .0122 0.73 (0.60-0.89) .0016
Wedge Reference Reference
Surgical margins
Negative 0.67 (0.56-0.80) <.001 0.67 (0.54-0.82) .0001
Unknown 0.69 (0.36-1.31) .2527 0.72 (0.36-1.45) .3549
Positive Reference Reference
Adjuvant therapy
No 1.68 (1.53-1.84) <.001 1.68 (1.52-1.85) <.001
Yes Reference Reference
Pathologic T stage
pT1 0.85 (0.70-0.95) .003 0.85 (0.76-0.95) .003
pT2 Reference Reference
Pathologic N stage
N1 0.66 (0.61-0.73) <.001 0.68 (0.62-0.74) <.001
N2 Reference Reference

a
Additional factors included in model were insurance, urban/rural, and facility type.

propensity-weighted comparison accounting for clin- pertains to prognosis but also in providing the indi-
ical differences. When controlling for all pathologic cation of adjuvant therapy. A quality lymph node
prognostic factors, lobectomy remained associated dissection of the mediastinal nodes may be accom-
with improved survival relative to sublobar resection plished independently of the extent of parenchymal
for clinical stage Ia disease. The study is important, in resection, and its importance cannot be over-
particular when considering sublobar resection in pa- emphasized. This study highlights that most occult
tients who are lobectomy candidates. The survival lymph node disease is detected in N1 lymph nodes.6
advantage associated with lobectomy in the setting of Lymphatic drainage is generally directed from the
occult lymph node disease underscores the use of periphery to the hilar lymph nodes,13 which are
intraoperative frozen pathology to identify nodal dis- naturally dissected and removed during a lobectomy
ease in the operating room and supports a potential procedure but need to be actively sought out
role for completion lobectomy for patients with un- during wedge resection.14 Although sublobar
suspected lymph node disease. resections are increasingly considered for small-
Lymph node metastases are a key differentiating stage Ia NSCLC, their risk of occult lymph node me-
factor of early-stage lung cancer, not only as it tastases should not be underestimated. Even for
1350 KNEUERTZ ET AL
OCCULT LYMPH NODE DISEASE
tumors < 2 cm in size, it has been demonstrated that
the extent of lymph node dissection during sublobar
resection affects prognosis, and removal of 4 or more
regional lymph node stations is associated with
improved cancer-specific survival.15
Intraoperative frozen section analysis may further
enhance the appropriate selection of patients for
wedge resection. The concept of intraoperative frozen
section pathology assessment has proven to be a reli-
able basis for selective lymph node sampling in the
American College of Surgery Oncology Group Z0030
trial, which resulted in no differences in survival when
compared with complete lymphadenectomy.16
Intraoperative pathologic frozen sections of regional
lymph nodes may also be used to guide surgeons in
the extent of parenchymal resection in patients who
are candidates for anatomic resections to avoid a
higher incidence of locoregional recurrence. Li and
colleagues17 used routine intraoperative
sections of N1 lymph nodes in 74 NSCLC patients
and found occult lymph node disease in 6.7% of
patients that resulted in a modification
planned operative strategy toward larger parenchymal
resection. Using intraoperative sentinel
identification, Nomori and associates9 showed that
lymphatic flow may frequently travel
adjacent segments and join the lymphatic network at
the roots of the lobar bronchi. Handa
colleagues18 reported 99 patients undergoing sublobar
resection for stage Ia NSCLC and found
intraoperative frozen sections were used to convert
4% of patients to lobectomy based on upstaging of
N1 lymph nodes. Similarly Gossot and colleagues19
reported a 5.1% conversion rate to lobectomy in 280
sublobar resection patients based on intraoperative
frozen section pathology.
The prognostic difference of lobectomy and sub-
lobar resection in the presence of occult N1 disease in
this study may guide decisions for completion lo-
bectomy after wedge resection. To date, few studies
have evaluated the role of completion lobectomy af-
ter wedge resection, and the extent of the initial
lymph node dissection during sublobar resection
needs to be considered in the risk-to-benefit equa-
tion. A completion lobectomy may be safely per-
formed after a wedge resection after discovery of
unanticipated N1 lymph nodes disease. A previous
study showed no prognostic advantage of lobectomy
vs segmentectomy in stage I patients with pathologic
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Ann Thorac Surg
2023;115:1344-52
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The NCDB is a joint project of the Commission on Cancer of the American
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FUNDING SOURCES
The authors have no funding sources to disclose.
DISCLOSURES
Robert E. Merritt is a speaker for Surgical Intuitive Inc. Desmond M. D’Souza
is a proctor for Surgical Intuitive Inc. All other authors declare that they have
no conflicts of interest.
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8. Kneuertz PJ, Cheufou DH, D’Souza DM, et al. Propensity-score adjusted
comparison of pathologic nodal upstaging by robotic, video-assisted thor-
acoscopic, and open lobectomy for non-small cell lung cancer. J Thorac
Cardiovasc Surg. 2019;158:1457-1466.
9. Nomori H, Mori T, Izumi Y, Kohno M, Yoshimoto K, Suzuki M. Is
completion lobectomy merited for unanticipated nodal metastases after
radical segmentectomy for cT1 N0 M0/pN1-2 non-small cell lung cancer?
J Thorac Cardiovasc Surg. 2012;143:820-824.
10. Razi SS, Nguyen D, Villamizar N. Lobectomy does not confer survival
advantage over segmentectomy for non-small cell lung cancer with
ª 2023 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
Is Sublobar Resection Applicable to
T1c Non-Small Cell Lung Cancer?
INVITED COMMENTARY:
A quarter of a century after the results of the Lung
Cancer Study Group,1 sublobar resection for periphery-
located non-small cell lung cancer 2 cm is about to
become the standard procedure based on large pro-
spective randomized trials in Japan2 and North
America.3 Stage IA includes tumors >2 cm (T1c);
however, is sublobar resection applicable to T1c tumors?
In this issue of The Annals of Thoracic Surgery,
Kneuertz and colleagues4 performed a unique study and
demonstrated the significance of wedge resection for
nodal-upstaged clinical stage IA tumors. The authors
allowed tumor diameters of up to 3 cm instead of 2 cm as
eligible cases and identified patients who underwent
lung resection for clinical stage IA non-small cell lung
cancer diagnosed as stage N1/N2 on postoperative pa-
thology. The patients were divided into wedge resection
and lobectomy groups, and their prognoses were eval-
uated; segmentectomy cases were excluded.
KNEUERTZ ET AL 1351
OCCULT LYMPH NODE DISEASE
unsuspected nodal disease. J Thorac Cardiovasc Surg. 2020;159:2469-
2483.
11. Omasa M, Date H, Takamochi K, Suzuki K, Miyata Y, Okada M.
Completion lobectomy after radical segmentectomy for pulmonary malig-
nancies. Asian Cardiovasc Thorac Ann. 2016;24:450-454.
12. Kneuertz PJ, Singer E, D’Souza DM, Abdel-Rasoul M, Moffatt-Bruce SD,
Merritt RE. Hospital cost and clinical effectiveness of robotic-assisted vs.
video-assisted thoracoscopic and open lobectomy: a propensity score
weighted comparison. J Thorac Cardiovasc Surg. 2019;157:2018-2026.
13. Naruke T, Suemasu K, Ishikawa S. Lymph node mapping and curability
at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc
Surg. 1978;76:832-839.
14. Speicher PJ, Gu L, Gulack BC, et al. Sublobar resection for clinical
stage IA non-small-cell lung cancer in the United States. Clin Lung Cancer.
2016;17:47-55.
15. Cao J, Xu J, He Z, et al. Prognostic impact of lymphadenectomy on
outcomes of sublobar resection for stage IA non-small cell lung cancer </[2
cm. J Thorac Cardiovasc Surg. 2018;156:796-805.
16. Darling GE, Allen MS, Decker PA, et al. Randomized trial of mediastinal
lymph node sampling versus complete lymphadenectomy during pulmonary
resection in the patient with N0 or N1 (less than hilar) non-small cell carci-
noma: results of the American College of Surgery Oncology Group Z0030
Trial. J Thorac Cardiovasc Surg. 2011;141:662-670.
17. Li W, Yang XN, Liao RQ, et al. Intraoperative frozen sections of the
regional lymph nodes contribute to surgical decision-making in non-small
cell lung cancer patients. J Thorac Dis. 2016;8:1974-1980.
18. Handa Y, Tsutani Y, Mimae T, Miyata Y, Okada M. Complex segmen-
tectomy in the treatment of stage IA non-small-cell lung cancer. Eur J
Cardiothorac Surg. 2020;57:114-121.
19. Gossot D, Lutz JA, Grigoroiu M, Brian E, Seguin-Givelet A. Unplanned
procedures during thoracoscopic segmentectomies. Ann Thorac Surg.
2017;104:1710-1717.
0003-4975/$36.00
https://doi.org/10.1016/j.athoracsur.2023.04.017
For pN1, the prognosis of the wedge group was
significantly worse than that of the lobectomy group, but
no significant difference was found for pN2. In addition
to survival, there are some interesting secondary results
that are worth discussing. First, there was a significant
difference in the distribution of stages pN1 and pN2 be-
tween the wedge and lobectomy groups. The percentage
of pN1 cases was clearly higher in the lobectomy group
compared with the wedge group. What does this mean?
Essentially, there may be a certain number of cases in
which hilar nodal involvement was missed among those
diagnosed as pN0 by wedge resection. It is possible that
the prognosis of wedge resection is worse than that of
lobectomy for stage IA and pN0, especially in cases with
a tumor diameter >2 cm.
Second, the results of this study are convincing
because they suggest that the N1 node was not
completely resected in patients in the wedge group
diagnosed as pN1. This is comparable to the results of
the American College of Surgeons Oncology Group
(ACOSOG) SZ0030 study on cN0-pN2, which suggest that
metastases beyond the N2 node have already developed