Marginal benefit of segmentectomy over lobectomy in minimally invasive surgery for stage IA lung cancer

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Background: In the treatment of stage IA lung cancers, segmentectomy has been demonstrated to be oncologically noninferior to lobectomy, but its perioperative benefits remain unclear. This real-world study aimed to evaluate whether reducing resection extent in minimally invasive segmentectomy provides perioperative benefits compared with lobectomy. Methods: Data from consecutive patients undergoing minimally invasive segmentectomy or lobectomy at eight Chinese and Italian hospitals between January 2014 and December 2020 were retrospectively collected. Patients with previous thoracic surgery, disease above clinical stage IA, induction therapy, right-middle-lobe lesions, or extended resection were excluded. The primary endpoint was any postoperative complication of Common Terminology Criteria for Adverse Events (CTCAE) version 3.0 grade ≥3 within 30 days. Perioperative outcomes were compared after propensity score matching (PSM). A nomogram was developed to identify patients at high risk of experiencing grade ≥3 complications after lobectomy. Stratified subgroup and Bayesian analyses were also performed. Results: Among 2,542 patients, 2,500 underwent surgery with curative intent (821 segmentectomies and 1,679 lobectomies), and 801 pairs were matched. Segmentectomy was associated with a numerically lower rate of grade ≥3 complications than lobectomy (4.7% vs. 7.1%; P=0.057), with a similar trend for prolonged air leak (PAL) (2.5% vs. 4.2%; P=0.07). In the nomogram-defined high-risk subgroup, segmentectomy had a 92.1% posterior probability of reducing PAL, with no difference in other complications. Segmentectomy involving <1/2 of the corresponding lobe had a 96.4% posterior probability of reducing PAL. Conclusions: Minimally invasive segmentectomy was associated with some short-term recovery advantages over lobectomy, but no statistically significant reduction in 30-day grade ≥3 complications or PAL was demonstrated. Its perioperative benefit in high-risk patients appeared limited and was mainly related to PAL.

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