Article Summary:
- Lobectomy remains the standard operation for many people with early-stage lung cancer.
- New international clinical trials show that selected patients with small Stage I NSCLC may achieve similar survival with a segmentectomy, which removes less healthy lung.
- Segmentectomy preserves more lung tissue but carries a slightly higher risk of local recurrence, making careful patient selection essential.
- Wedge resection is appropriate in selected situations but generally has higher recurrence rates than segmentectomy.
- Australia’s National Lung Cancer Screening Program is expected to identify more patients who may benefit from lung-sparing surgery.
- The most appropriate operation depends on the size and location of the tumour, your overall health and discussion within an experienced multidisciplinary team.
The question is no longer simply ‘Can we remove the cancer?’
Increasingly, it’s ‘How much healthy lung can we safely preserve?’
Types of Lung Cancer Surgery
Several different operations can be used to treat lung cancer. The right choice depends on the size and location of the tumour and your overall health.
Lobectomy
A lobectomy removes an entire lobe of the lung. The lungs are divided into sections called lobes, three on the right and two on the left. During a lobectomy, the surgeon removes the lobe containing the cancer while preserving the remaining lung. For many patients, this remains the recommended operation.
Segmentectomy
A segmentectomy removes one or more anatomical segments within a lobe rather than the whole lobe. Each segment has its own airway and blood supply, allowing surgeons to remove only the affected portion while preserving healthy lung tissue.
Wedge resection
A wedge resection removes the tumour with a margin of surrounding lung tissue. Unlike a segmentectomy, it does not follow the lung’s natural anatomy and is generally reserved for carefully selected situations.
Why Has Lobectomy Been the Standard Lung Cancer Surgery?
For almost 30 years, lobectomy has been considered the gold standard for early-stage NSCLC. That recommendation came from a landmark study published in 1995 (known as The Ginsberg Study or LCSG 821), which showed lower rates of local recurrence than more limited surgery. However, lung cancer diagnosis has changed dramatically since then.
Today’s patients benefit from:
- Low-dose CT lung cancer screening
- PET scanning
- Robotic bronchoscopy
- Endobronchial ultrasound (EBUS)
- Minimally invasive surgery
These advances mean many lung cancers are now diagnosed earlier, often when they measure less than 2 cm and before they have spread to lymph nodes. That prompted researchers to ask an important question: do these smaller cancer still require an entire lobe to be removed?
Can Removing Less Lung Be Just as Effective?
Two landmark international studies have transformed the way surgeons answer this question.
JCOG0802
This Japanese study compared segmentectomy with lobectomy in patients with small peripheral lung cancers. Although local recurrence occurred slightly more often after segmentectomy, patients actually experienced better overall survival.
CALGB 140503
This international trial, which included Australian hospitals, compared lobectomy with sublobar resection. After seven years of follow-up, patients who underwent sublobar surgery had disease-free survival and overall survival that were equivalent to those who underwent lobectomy.
Together, these studies showed that for carefully selected patients, removing more lung does not necessarily improve long-term outcomes.
Who Can Have Lung-Sparing Surgery?
Lung-sparing surgery is not suitable for everyone.
The strongest evidence applies to patients with:
- Stage IA non-small cell lung cancer
- Tumours smaller than 2 cm
- Cancers located in the outer third of the lung
- No evidence of lymph node involvement.
Your thoracic surgeon will also consider your lung function, general health and the position of the tumour before recommending the most appropriate operation.
Does Segmentectomy Increase the Risk of Cancer Returning?
Yes, but only slightly. Across modern studies, segmentectomy is associated with approximately a 4% higher risk of local recurrence than lobectomy.
However:
- Overall survival remains equivalent
- Many local recurrences can be treated successfully
- Modern surgical planning has reduced recurrence rates
Today’s surgeons routinely use:
- Detailed CT planning
- 3D surgical reconstruction
- Careful surgical margins
- Systematic lymph node assessment
Why Preserving Lung Tissue Matters
Many people diagnosed with lung cancer also have emphysema, COPD or reduced lung function.
Preserving healthy lung tissue may help maintain:
- Breathing capacity
- Physical activity
- Quality of life
- Options for future treatment if another lung cancer develops
Emerging research also suggests that patients with less decline in lung function after surgery may experience better long-term survival.
"Conserve lung like their life depends on it, because it just might."
Robotic and Minimally Invasive Lung Cancer Surgery
How much lung is removed is only part of modern lung cancer surgery. Today, many operations are performed using:
- Video-assisted thoracoscopic surgery (VATS)
- Robotic-assisted thoracic surgery (RATS)
Compared with traditional open surgery, these approaches generally result in:
- Less pain
- Shorter hospital stays
- Faster recovery
Current evidence supports minimally invasive surgery over open surgery where appropriate, although research is continuing to determine whether robotic surgery offers additional advantages over VATS.
How Australia’s Lung Cancer Screening Program Is Changing Surgery
Australia’s National Lung Cancer Screening Program is expected to identify many more Stage I lung cancers. That means more patients will be diagnosed while surgery is still likely to cure their cancer. Rather than asking whether surgery is possible, surgeons are increasingly considering which operation provides the best balance between curing the cancer and preserving healthy lung tissue.
Frequently Asked Questions
Not necessarily. For carefully selected patients with small Stage I lung cancers, segmentectomy can provide similar survival while preserving more lung tissue. For many other patients, lobectomy remains the recommended operation.
Yes. Depending on the size and location of the tumour, some patients may be suitable for segmentectomy or wedge resection rather than removal of an entire lobe.
Robotic surgery and VATS are both minimally invasive approaches that generally result in less pain and faster recovery than traditional open surgery. Studies are still determining whether robotic surgery provides additional benefits over VATS.
Yes. Lung cancer screening is expected to detect many more small, early-stage lung cancers, increasing the number of patients who may be suitable for lung-sparing surgery.
Further Reading
- Altorki, N et al (2023) Lobar or Sublobar Resection for Peripheral Stage IA Non–Small-Cell Lung Cancer. N Engl J Med 2023;388:489-498 DOI: 10.1056/NEJMoa2212083
- Ginsberg RJ, Rubinstein LV. (1995) Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 60:615-22; discussion 622-3. doi: 10.1016/0003-4975(95)00537-u
- Saji H et al. (2022) Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. The Lancet, 399, 1607-1617 DOI: 10.1016/S0140-6736(21)02333-3
