Commentary: Calling a spade a spade? What constitutes a segmentectomy.

Central MessageTo better understand the oncologic outcomes of what segmentectomy offers, we must define it and uphold these standards for future studies.See Article page 1919. To better understand the oncologic outcomes of what segmentectomy offers, we must define it and uphold these standards for future studies. See Article page 1919. The Nederlands–Leuvens Longkanker Screenings Onderzoek (NELSON) trial proved that a national program for lung cancer screening improves lung cancer–related mortality largely in part to detecting smaller tumors and earlier stage of disease.1de Koning H.J. van der Aalst C.M. de Jong P.A. Scholten E.T. Nackaerts K. Heuvelmans M.A. et al.Reduced lung-cancer mortality with volume CT screening in a randomized trial.N Engl J Med. 2020; 382: 503-513https://doi.org/10.1056/nejmoa1911793Crossref PubMed Scopus (0) Google Scholar Over the course of the NELSON trial, surgical resection, specifically lobectomy, was the gold standard for treatment of early-stage lung cancer.2Ginsberg R.J. Rubinstein L.V. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer.Ann Thorac Surg. 1995; 60: 615-623https://doi.org/10.1016/0003-4975(95)00537-UAbstract Full Text PDF PubMed Scopus (2408) Google Scholar Lobectomy has been challenged by limited resection over the years through retrospective studies showing conflicting results.3Shi Y. Wu S. Ma S. Lyu Y. Xu H. Deng L. et al.Comparison between wedge resection and lobectomy/segmentectomy for early-stage non–small cell lung cancer: a Bayesian meta-analysis and systematic review.Ann Surg Oncol. 2022; 29: 1868-1879https://doi.org/10.1245/s10434-021-10857-7Crossref PubMed Scopus (10) Google Scholar However the recent multicenter randomized controlled trial, JCOG0802/WJOG4607L, suggests that segmentectomy provides noninferior overall survival in early-stage non–small cell lung cancer (<2 cm) resection compared with lobectomy.4Saji H. Okada M. Tsuboi M. Nakajima R. Suzuki K. Aokage K. et al.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.Lancet. 2022; 399: 1607-1617https://doi.org/10.1016/S0140-6736(21)02333-3Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar This landmark study signals a shift toward parenchyma-sparing oncologic resection. Segmental resections are technically more challenging than lobectomy. Parenchymal dissection, smaller segmental hilar structures, variations in anatomy, and lack of natural occurring fissures are all factors that add to the complexity of a segmentectomy. The oncologic superiority of segmentectomy over wedge resection is rooted in hilar nodal dissection, which allows appropriate pathologic staging. Dissection of segmental vascular and bronchial components allow and enable segmental nodal dissection. It is unclear if one can achieve the same thoroughness of nodal clearance by just dissecting 1 or 2 out of the 3 hilar structures and ligating the rest en masse with the fissure. The effects of nonuniform degree of dissection results in variability in reporting and hence affect the study of dependent outcomes such as pathologic upstaging, disease recurrence, and overall survival. Through diligent review of operative reports, Weiss and colleagues5Weiss K.D. Deeb A.L. Wee J.O. Swanson S.J. Bueno R. Jaklitsch M.T. et al.When a segmentectomy is not a segmentectomy: quality assurance audit and evaluation of required elements for an anatomic segmentectomy.J Thorac Cardiovasc Surg. 2023; 165: 1919-1925Abstract Full Text Full Text PDF Scopus (3) Google Scholar evaluated the quality of segmentectomy resections at their own institution in this edition of The Journal of Thoracic and Cardiovascular Surgery. The authors queried all segmentectomies at their institution over a 3-and-a-half-year period, which yielded 271 operative reports. Anatomic segmentectomies (N = 219, 80.8%) were defined as those that included the segmental bronchus. Of those, 177 (65.3%) explicitly stated that the segmental bronchus, artery, and vein were dissected out. On the opposite end of the spectrum, there were 24 (8.9%) operative reports where no bronchus, artery, or vein dissections were explicitly dictated. Anatomic segmentectomies had more lymph nodes sampled and larger margins compared with the nonanatomic resections. Although not significant, there was a trend toward more anatomic segmentectomies as time progressed. It would have been interesting to determine whether these operative reports correlated with the bottom line (pathologic upstaging, cancer recurrence, and overall survival). This study is a call to arms for our specialty to define what a segmentectomy is, in order to better understand the oncologic outcomes gained or lost from an anatomic segmentectomy. When a segmentectomy is not a segmentectomy: Quality assurance audit and evaluation of required elements for an anatomic segmentectomyThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 6PreviewThe advent of lung cancer screening and detection of smaller nodules amplifies the need to clarify the oncological quality of sublobar resections. Furthermore, studies comparing sublobar resections to lobectomies offer conflicting conclusions. We hypothesize that this is driven, in part, by inconsistency in reporting; that is, variable interpretation of what constitutes an operative segment. Without an established standard, 2 very different operations may be reported as segmental resections, leaving the data on sublobar approaches subject to interpretative variability. Full-Text PDF