Treatment of non-small cell lung cancer ≤2 cm in size: less may not be more

As the timely detection of earlier stage non-small cell lung cancer (NSCLC) improves with the heightened adoption of lung cancer screening, it becomes imperative to establish clear surgical treatment guidelines for smaller, early stage tumors, with a goal of obtaining superior oncologic outcomes and improved patient survival. Much controversy has existed in the past regarding the optimal surgical approach to stage 1 NSCLCs (1). The Lung Cancer Study Group’s prospective multi center randomized clinical trial of lobectomy versus limited resection, reported over two decades ago, led to recommendations of restricting sublobar surgical resections to higher-risk stage 1 NSCLC patients with poor pulmonary reserve. This was due to the finding of inferior outcomes with the sublobar approach (2), and was related to increased local tumor recurrence and decreased survival in these patients, when compared with lobectomy. Other studies have also shown worse long-term outcomes of patients treated with limited resections for early stage NSCLC when compared with lobectomy (3-5), while a 13-year analysis of sublobar resection versus lobectomy for stage 1 non-small cell lung cancer, published in 2006 by El-Sherif et al. found no difference in disease-free survival between these two types of resection (6). More recently, mounting evidence suggests that sublobar resection may be an acceptable surgical treatment in certain patients with smaller early stage NSCLC (7), with equivocal survival noted with wedge resection when compared with segmentectomy (8,9)