Evolving surgical standards in early-stage non-small cell lung cancer: A review of sublobar resections and future perspectives

Lung cancer remains the leading cause of cancer-related mortality globally, with surgical resection representing the cornerstone of curative treatment for early-stage NSCLC. Historically, lobectomy has been the gold standard, according to perceptions of oncologic efficacy. However, concerns regarding pulmonary preservation and perioperative morbidity have catalyzed renewed interest in sublobar resections, including wedge resection and segmentectomy. Early randomized trials, notably the Lung Cancer Study Group (LCSG) trial of 1995, demonstrated higher recurrence rates with sublobar resections, establishing lobectomy as the preferred approach. Nevertheless, advances in preoperative imaging, staging accuracy, and minimally invasive techniques—specifically video-assisted thoracoscopic surgery (VATS)—have prompted reconsideration of this standard. Recent landmark randomized trials, notably JCOG 0802 and CALGB 140503, provided pivotal evidence supporting sublobar resection as oncologically comparable with lobectomy for small (≤2 cm), peripheral tumors, with the added benefits of reduced morbidity and better preservation of pulmonary function. However, these studies also identified increased locoregional recurrence rates associated with sublobar resections. Current guidelines, including the NCCN recommendations, now support sublobar resections as a viable alternative in carefully selected patients. Despite these advancements, ongoing debates persist regarding the optimal patient selection criteria, appropriate application in central tumors, management of tumors larger than 2 cm, and the significance of tumor features such as tumor spread through airspaces (STAS) and the consolidation-to-tumor ratio (CTR). Further investigation is required to refine patient selection and surgical techniques, particularly to clarify whether segmentectomy confers advantages over wedge resection and to determine the necessity and extent of mediastinal lymph node staging. This review critically examines historical and contemporary evidence informing the role of sublobar resections and highlights areas needing further research to optimize outcomes for early-stage NSCLC patients.