Commentary: Sublobar resection for ground-glass opacity: Is less really more?

Central MessageSublobar resection is a sound option to treat peripheral GGOs with a low risk of recurrence. Intraoperative pathologic analysis should drive decisions to perform sublobar resection.See Article page XXX. Sublobar resection is a sound option to treat peripheral GGOs with a low risk of recurrence. Intraoperative pathologic analysis should drive decisions to perform sublobar resection. See Article page XXX. Ground-glass opacities (GGOs) are often discovered on computed tomography performed during the workup for other medical issues or through lung cancer screening programs.1Kobayashi Y. Mitsudomi T. Management of ground-glass opacities: should all pulmonary lesions with ground-glass opacity be surgically resected?.Transl Lung Cancer Res. 2013; 2: 354-363PubMed Google Scholar,2Wood D.E. Kazerooni E.A. Baum S.L. Eapen G.A. Ettinger D.S. Hou L. et al.Lung cancer screening, version 3.2018, NCCN clinical practice guidelines in oncology.J Natl Compr Canc Netw. 2018; 16: 412-441Crossref PubMed Scopus (358) Google Scholar GGOs that persist on interval imaging are concerning for early-stage lung cancer.1Kobayashi Y. Mitsudomi T. Management of ground-glass opacities: should all pulmonary lesions with ground-glass opacity be surgically resected?.Transl Lung Cancer Res. 2013; 2: 354-363PubMed Google Scholar, 2Wood D.E. Kazerooni E.A. Baum S.L. Eapen G.A. Ettinger D.S. Hou L. et al.Lung cancer screening, version 3.2018, NCCN clinical practice guidelines in oncology.J Natl Compr Canc Netw. 2018; 16: 412-441Crossref PubMed Scopus (358) Google Scholar, 3Nakata M. Saeki H. Takata I. Segawa Y. Mogami H. Mandai K. et al.Focal ground-glass opacity detected by low-dose helical CT.Chest. 2002; 121: 1464-1467Abstract Full Text Full Text PDF PubMed Scopus (265) Google Scholar In patients who can tolerate surgery, resection of the GGO can provide both a definitive diagnosis and treatment with an extremely high rate of cure. Currently, there is no consensus on the extent of surgical resection needed to treat this type of lung lesion. Last year, midterm survival outcomes were published from the Japanese Clinical Oncology Group 0804 trial of patients with peripheral GGOs treated with sublobar resection. The GGOs in the study participants were 2 cm or less in size and had a consolidation tumor ratio of 0.25 or less.4Suzuki K. Watanabe S. Wakabayashi M. Saji H. Aokage K. Moriya Y. et al.A single-arm study of sublobar resection for ground-glass opacity dominant peripheral lung cancer.J Thorac Cardiovasc Surg. 2022; 163: 289-301Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar In this prospective, multicenter trial, 314 patients underwent sublobar resection (258 wedge resections [82%] and 56 segmentectomy [18%]). Recurrence-free survival was 99.7% at 5 years, and overall survival was 99.4%. In the current article by Yoshino and colleagues,5Yoshino I. Moriya Y. Suzuki K. Wakabayashi M. Saji H. Aokage K. et al.Long-term outcome of patients with peripheral ground-glass opacity-dominant lung cancer after sublobar resections.J Thorac Cardiovasc Surg. 2023; (XXX:XXX)Abstract Full Text PDF Google Scholar updated survival data, extending to 10 years after surgical resection, are reported from this series. With longer follow-up, the recurrence-free survival was 98.6% and overall survival was 98.5% at 10 years. One patient developed a recurrence at the staple line (0.3%) that was detected 8.3 years after his index segmentectomy. The authors also comment on the prevalence of second lung cancers within the cohort—18 patients (5.8%) were diagnosed with a second lung cancer within 10 years of their initial operation, which was similar to the incidence seen in the Japanese population. Within the surgical community, there is increasing interest in parenchymal-sparing operations, such as segmentectomy or wedge resection, for the treatment of early-stage lung cancer. Although a randomized controlled trial more than 30 years ago found that patients who underwent wedge resection had more loco-regional recurrence than patients who underwent lobectomy, more recent studies suggest that wedge resection yields acceptable outcomes in a clinical climate with detection of smaller tumors, better staging, and an increasingly older patient population with comorbidities.6Kent M. Landreneau R. Mandrekar S. Hillman S. Nichols F. Jones D. et al.Segmentectomy versus wedge resection for non-small cell lung cancer in high-risk operable patients.Ann Thorac Surg. 2013; 96: 1747-1754Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar,7Altorki N.K. Wang X. Wigle D. Gu L. Darling G. Ashrafi A.S. et al.Perioperative mortality and morbidity after sublobar versus lobar resection for early-stage non-small cell lung cancer: post-hoc analysis of an international, randomized, phase 3 trial (CALGB/Alliance 140503).Lancet Respir Med. 2018; 6: 915-924Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar This debate on the optimal approach for treatment of early-stage lung cancer is ongoing with the main criticisms of parenchymal-sparing resections being the potential for inadequate oncologic margins and accompanying risk of cancer recurrence.8Altorki N. Wang X. Kozono D. Watt C. Landreneau R. Wigle D. et al.Lobar or Sublobar Resection for Peripheral Stage IA Non-Small-Cell Lung Cancer.N Engl J Med. 2023; 388: 489-498Crossref PubMed Scopus (64) Google Scholar In the Japanese Clinical Oncology Group 0804 multi-institution trial of sublobar resection with wedge resections, in 82% of the participants, there was only 1 documented recurrence in 10 years, suggesting that nonanatomic sublobar resection is a reasonable treatment option for peripheral GGOs less than 2 cm.5Yoshino I. Moriya Y. Suzuki K. Wakabayashi M. Saji H. Aokage K. et al.Long-term outcome of patients with peripheral ground-glass opacity-dominant lung cancer after sublobar resections.J Thorac Cardiovasc Surg. 2023; (XXX:XXX)Abstract Full Text PDF Google Scholar One rationale for sublobar resection is preservation of lung parenchyma in the event that future operations become necessary. Patients with lung cancer are at higher risk of developing a second malignancy in their lifetime, although this was not reflected in the incidence of a second lung cancer in this study. Although the type of sublobar resection used was not randomized in this trial, the study reflects real-life decisions that surgeons must make regarding the adequacy of the surgical margins and the need for completion segmentectomy or lobectomy based on intraoperative pathologic assessments. The majority of GGOs treated with sublobar resection in this study were adenocarcinoma in situ, minimally invasive adenocarcinoma, or invasive adenocarcinoma with lepidic growth. Because adenocarcinoma in situ and minimally invasive adenocarcinoma have a low potential for nodal or distant metastasis,9Zha J. Xie D. Xie H. Zhang L. Zhou F. Ying P. et al.Recognition of “aggressive” behavior in “indolent” ground glass opacity and mixed density lesions.J Thorac Dis. 2016; 8: 1460-1468Crossref PubMed Google Scholar,10Cheng Z. Zheng D. Li Y. Li H. Sun Y. Xiang J. et al.Tumor histology predicts mediastinal nodal status and may be used to guide limited lymphadenectomy in patients with clinical stage I non-small cell lung cancer.J Thorac Cardiovasc Surg. 2018; 155: 2648-2656Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar treating these “well-behaved” lesions with wedge resection may be appropriate but not generalizable to solid lesions that may harbor cells with a more aggressive tumor biology. Although prospective trials provide a glimpse of anticipated outcomes after sublobar resection, tumor biology ultimately drives survival and is hard to predict preoperatively. As surgeons, we must continue to provide individualized surgical plans based on intraoperative pathologic analysis to provide the best care for our patients. Long-term Outcome of Patients with Peripheral Ground Glass Opacity Dominant Lung Cancer after Sublobar ResectionsThe Journal of Thoracic and Cardiovascular SurgeryPreviewThis study aimed to evaluate the long-term prognosis of patients with peripheral small ground glass opacity (GGO)-dominant lung cancer after sublobar resection. We have already reported the 5-year safety and efficacy of sublobar resection and herein report the long-term outcomes after a 10-year follow-up period. Full-Text PDF Open Access