The evolving role of wedge resection in early-stage non-small cell lung cancer: a literature review

Introduction

Lung cancer remains the leading cause of cancer-related mortality worldwide, accounting for approximately 1.8 million deaths annually, with non-small cell lung cancer (NSCLC) comprising around 85% of cases (1).

Historically, lobectomy has been the standard surgical treatment for early-stage NSCLC based on the landmark Lung Cancer Study Group trial in 1995. However, advances in lung cancer screening, increased patient life expectancy and the development of high-resolution, low-radiation computed tomography (CT) scans have led to increased detection of sub centimetric, non-solid and often metachronous lung lesions. These technological and demographic changes have led to a paradigm shift in thoracic surgery as smaller, indolent tumors are increasingly diagnosed at earlier stages. These technological and demographic changes have led to a paradigm shift in thoracic surgery as smaller, indolent tumors are increasingly diagnosed at earlier stages. In parallel, the accuracy of preoperative staging has markedly improved. Modern tools such as positron emission tomography-computed tomography (PET-CT), endobronchial ultrasound (EBUS), and brain magnetic resonance imaging (MRI) allow for a more precise assessment of tumor extension and nodal status. Although not systematically used in earlier trials, these modalities enable clinicians today to confidently identify truly localized stage I tumors. This enhanced diagnostic precision opens the door to considering limited resections in carefully selected patients, where the oncologic benefit of lobectomy over smaller resections may be marginal, and organ-preserving strategies can be applied without compromising oncologic safety (2,3).

The scientific community is now questioning whether lobectomy should remain the standard of care in all cases, particularly in selected patient populations. Current research is focused on evaluating the surgical management of lung cancer in patients with multiple comorbidities, those with pure ground-glass opacity (GGO) lesions, and those diagnosed at an early stage. This change in perspective has led to a renewed interest in defining the appropriate indications for sub-lobar resections and in trying to evaluate their possible oncological efficacy compared to lobectomy in certain particular subgroups of patients. We present this article in accordance with the Narrative Review reporting checklist (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-562/rc).

Methods

A narrative review was conducted using literature retrieved from PubMed, Scopus, and Google Scholar, covering the period from January 2000 to March/April 2024. The search strategy included the following terms and their combinations using Boolean operators: (“wedge resection” OR “segmentectomy” OR “sublobar resection” OR “partial lung resection”) AND (“non-small cell lung cancer” OR “NSCLC”) AND (“early-stage” OR “stage I”) AND (“oncologic resection” OR “surgical margins” OR “lymph node dissection” OR “STAS” OR “solid nodules” OR “ground-glass opacity” OR “learning curve” OR “expertise” OR “SBRT” OR “artificial intelligence”).

The search was limited to studies published between January 2000 and March 2024, in English, and involving human subjects. Eligible publications included randomized controlled trials, retrospective cohort studies, meta-analyses, and clinical guidelines. When available, studies differentiating between wedge resection and segmentectomy were analyzed separately. In cases where outcomes were reported for “sublobar resection” as a combined group, this was explicitly acknowledged and discussed in the analysis. Additionally, key insights were extracted from visual content in the presentation developed by Dr. Ilaria Ceccarelli and Dr. Agathe Seguin-Givelet. The search strategy is summarized in Table 1.

Historical evolution of surgical standards in early-stage NSCLC

The surgical management of early-stage NSCLC has undergone significant transformation over the past three decades. Prior to the 1990s, various surgical approaches, including limited resections like wedge, were employed without standardized protocols. The landscape shifted dramatically in 1995 with the publication of the Lung Cancer Study Group (LCSG) trial, which compared lobectomy to sublobar resections (segmentectomy and wedge resection) and concluded that lobectomy offered superior overall survival (OS) and lower recurrence rates. This pivotal study established lobectomy as the gold standard for operable stage I NSCLC and relegated wedge resection to a role primarily reserved for high-risk surgical candidates as a compromise operation (4). However, the LCSG trial had significant limitations: it grouped wedge and segmentectomy together, lacked PET imaging or systematic nodal staging as brain MRI evaluation, and showed higher perioperative mortality than seen today.

Despite this consensus, scepticism around the rigid application of lobectomy began to grow in the early 2000s, particularly as more early-stage tumors were being detected incidentally or through the expansion of low dose CT screening programs. These screenings, implemented widely in the 2010s, facilitated the diagnosis of smaller, peripheral tumors often less than 2 cm in size, raising questions about the necessity of full lobar resections in every case.

In response, two major randomized controlled trials, the Japanese Clinical Oncology Group (JCOG0802) and the Cancer and Leukemia Group B (CALGB 140503), have provided crucial data regarding the oncologic outcomes of sublobar resections.

The JCOG0802/WJOG4607L trial was a phase III, multicenter, randomized study that included 1,100 patients with clinical stage IA NSCLC (tumors ≤2 cm in size). It demonstrated that segmentectomy could achieve better OS than lobectomy for tumors ≤2 cm, although with a modest increase in local recurrence. The trial compared lobectomy with segmentectomy, explicitly excluding wedge resections. No 30-day or 90-day mortality was observed in the study and the morbidity rate was low and overlapping in the two groups (5).

Meanwhile, the CALGB/Alliance 140503 trial, another phase III, noninferiority study that enrolled 697 patients with clinical T1aN0 NSCLC, showed that sublobar resection (including wedge and segmentectomy) was non-inferior to lobectomy in terms of disease-free survival (DFS) but noted that wedge resections had a higher incidence of locoregional recurrence (LRR).

Among the results of this study, an important element is the morbidity factor, which appears to be burdensome not only for lobectomies but also for wedge resections. This result may open a new discussion about the feasibility of the procedure in frail patients (6).

It is important to underline that both the CALGB 140503 and JCOG0802/WJOG4607L trials focused on a highly selected subset of patients with early-stage NSCLC. Specifically, inclusion criteria were limited to patients with clinical stage IA (cT1aN0) tumors measuring ≤2 cm and located strictly in the peripheral regions of the lung. In CALGB 140503, extensive preoperative and intraoperative staging was mandated, including PET-CT and invasive mediastinal nodal assessment to ensure pN0 status, with frozen section analysis and margin verification required. Similarly, JCOG0802 included only peripheral solid-dominant tumors, but with less systematic mediastinal staging. These trials therefore reflect oncologic outcomes in a strictly defined population, under highly controlled surgical conditions.

This historical evolution, in this restricted group of patients with NSCLC, reflects a broader shift toward individualized, biology-driven surgical strategies, emphasizing not just tumor size but its radiological and molecular features.

Principles of oncologic lung surgery

The foundation of effective lung cancer surgery is rooted in achieving oncological completeness while minimizing patient morbidity. Traditionally, this has translated into some essential pillars: complete resection (R0), appropriate anatomical extent of surgery and a systematic lymph node evaluation.

Margins and resection quality in wedge resection for NSCLC

The oncologic adequacy of wedge resection for early-stage NSCLC, particularly in peripheral stage IA tumors, remains a subject of ongoing debate. While less invasive than anatomical resections, wedge resections are frequently scrutinized for their potential to compromise long-term cancer control, largely due to concerns regarding resection margins and the quality of surgical execution.

A cornerstone in defining oncologic completeness comes from the seminal work of Rami-Porta et al., who proposed a comprehensive framework for categorizing lung cancer resections into three groups: complete, uncertain, and incomplete. According to this IASLC-endorsed classification, a complete resection (R0) requires microscopically negative margins, systematic nodal dissection, no extracapsular nodal extension, and negative highest mediastinal nodes (7).

When any of these elements are missing, the resection is classified as “uncertain” (R(un)), a status that has been consistently associated with worse survival outcomes compared to complete resections. Gagliasso et al. proceeded to provide further validation of the prognostic value of the R classification. In a series of 1,277 NSCLC patients, OS declined significantly from complete to uncertain to incomplete resections. Patients in the uncertain category had a median survival of just 39.9 months, compared to 80.1 months for those with complete resections. It should be noted that these findings apply to a heterogeneous NSCLC population, of which only 38.8% were stage I at the time of surgery.

The authors reported that patients who had sublobar resection were significantly more likely to undergo an incomplete resection, as compared with patients who had major anatomic resection (14.0% and 6.3%, respectively, P=0.002) (8).

Several studies have specifically addressed the issue of margin adequacy in wedge resections. Mohiuddin et al. conducted a retrospective analysis of 479 patients undergoing wedge resection for tumors ≤2 cm, finding that a margin distance ≥15 mm significantly decreased the risk of local recurrence. They reported that patients with a 10-mm margin had a 45% lower local recurrence risk compared to those with a 5-mm margin, with no additional benefit observed beyond 15 mm. This study underscores the importance of achieving an optimal margin width to ensure oncologic safety. However, it should be noted that while intraoperative margin evaluation was strongly recommended in the study by Mohiuddin et al., the methodology did not explicitly report whether resection was extended intraoperatively in cases where the margin was found to be close but negative. Furthermore, patients with positive margins or margin distances of less than 1 mm were excluded from the analysis, to avoid the potential introduction of a selection bias that would favourably impact oncological outcomes. Therefore, while the study supports the importance of achieving adequate margins, it does not clarify whether surgical strategies were adapted in real-time when margins were judged insufficient during the procedure (9).

Similarly, El-Sherif et al. evaluated local recurrence after sublobar resection, stratifying patients based on margin distance. In their cohort, those with margins <1 cm experienced a significantly higher rate of local recurrence (14.6%) compared to those with ≥1 cm margins (7.5%). Importantly, wedge resections were disproportionately associated with suboptimal margins. Indeed, of the 41 patients with margins of less than 1 cm, wedge resection was employed in 34 cases (82.9%), while segmentectomy was utilised in 7 cases (17.1%) (P=0.003) (10).

The issue of surgical quality in wedge resections was also investigated in a large population-based study by Ajmani et al. who analysed over 10,000 patients from the National Cancer Database. The results of the study were highly significant: only 16.7% of wedge resections met criteria for high-quality surgery (negative margins and ≥5 lymph nodes sampled), and only these high-quality resections were associated with a survival advantage over stereotactic body radiation therapy (SBRT) In contrast, wedge resections with positive margins provided no survival benefit over SBRT, emphasizing the critical importance of both margin status and nodal evaluation (11).

Achieving adequate oncologic margins is not always technically feasible, particularly in the presence of small but deeply located lesions or when parenchymal sparing is critical due to reduced functional reserve. However, several intraoperative tools may assist the surgeon in maintaining oncologic standards in such challenging scenarios. In addition to frozen section analysis, which remains the most widely adopted method for intraoperative margin assessment, Miyoshi et al. have proposed the use of cytological lavage of stapling cartridges as an innovative approach to evaluate margin status in real time. This technique may offer additional reassurance when wider margins cannot be safely achieved, particularly during wedge resections for small peripheral malignant tumors (12).

And what is shown about margins and the value of resection in wedge procedures in the CALGB 140503 trial? Although not randomized between wedge and segmentectomy, the trial provided insights into technical standards and outcomes. A margin of at least 2 cm or a margin equal to the tumor diameter was recommended for wedge resections, though this was arbitrarily defined by trial designers. The median margin length achieved in wedge resections was 1.6 cm, lower than the 2.0 cm median in segmentectomies. Notably, intraoperative frozen section assessment of the margin was performed in 87% of wedge resections, and when positive, surgeons often converted to larger resections (6).

Despite this variability, the post hoc analysis of CALGB 140503 showed that wedge resection achieved comparable outcomes to segmentectomy in terms of 5-year DFS (62.5% vs. 63.8%), OS, and lung cancer-specific survival. However, LRR was slightly more frequent after wedge resection (14.4%) compared to segmentectomy (12.3%), although this difference was not statistically significant. Patients undergoing wedge resection were also more likely to have a margin-to-tumor ratio below 1, suggesting a higher frequency of technically suboptimal resections. This may in part be related to the predominance of minimally invasive approaches in the trial, where manual palpation of the lung was not routinely performed. The lack of tactile feedback may have limited the surgeon’s ability to secure optimal margins, particularly in wedge resections (13).

A final consideration must be given to current international guidelines. The National Comprehensive Cancer Network (NCCN) recommends that wedge resection should achieve a parenchymal margin of at least 2 cm or a margin equal to the diameter of the tumor, whichever is greater, to minimize the risk of local recurrence (14).

According to the current position of the European Society of Medical Oncology (ESMO), wedge resection is only considered to be a valid procedure in cases where alternative treatment options are ineffective. The ESMO’s current guidelines do not provide comprehensive details regarding margins (15).

Lymph node dissection (LND) and wedge resection

LND is a critical component of oncologic surgery in NSCLC, playing a dual role in accurate pathological staging and potential therapeutic benefit. While lobectomy routinely includes systematic hilar and mediastinal nodal clearance, wedge resections frequently omit this step, often leaving the nodal status indeterminate (pNX) and exposing patients to the risks of understating, suboptimal adjuvant planning, and worse long-term outcomes (16).

A large retrospective SEER analysis by Yendamuri et al. demonstrated that the number of lymph nodes examined (LNE) was the strongest independent predictor of survival, regardless of the type of resection performed. Patients with no nodes sampled had significantly lower survival than those with increasing node counts: hazard ratios for OS were 0.79 (1–3 nodes), 0.77 (4–6 nodes), 0.68 (7–9 nodes), and 0.45 (>9 nodes) compared to zero nodes examined (17).

This supports the assertion that nodal evaluation may be more prognostically significant than the choice between wedge and segmentectomy.

Wei et al. and Huang et al. reinforced these findings by showing that patients with fewer than six nodes examined had survival rates indistinguishable from those with confirmed nodal metastases, even when classified as pN0 (18,19).

Beyond quantity, nodal station location is equally crucial. Xiao et al. showed that up to 40% of patients with adjacent (aLN) node involvement had concurrent metastasis in intrapulmonary (iLN) nodes, which are often omitted in wedge resections (20).

Failure to target these areas contributes to false-negative staging and possible omission of adjuvant therapy.

From a practical perspective, frozen section analysis of nodal tissue plays a central role in intraoperative staging. In the CALGB 140503 trial, frozen section was used in 87% of wedge resections, allowing surgeons to immediately convert to a more extensive resection in the case of nodal positivity (6).

Gossot et al. reported that frozen section (performed during segmentectomy) enabled conversion in 5–7% of cases, often changing the entire surgical strategy and reducing the risk of R(un) resections (21).

Despite its value, LND is frequently underperformed in wedge resection. The reasons are multifactorial: perceived technical difficulty, especially in minimally invasive settings, time pressure in high-volume centers, and the erroneous belief that small or peripheral tumors pose minimal nodal risk (22).

Gossot et al. identified some common failures in wedge resections that compromise oncologic integrity: mislabeling the procedure as anatomical, inadequate parenchymal margins, lack of iLN or aLN sampling, omission of frozen section, and failure to dissect mediastinal nodes (21).

Zhang et al. and Mynard et al. have shown that wedge resections performed without lymphadenectomy in such patients still resulted in occult nodal upstaging in a non-trivial proportion of cases (23,24).

The European Society of Thoracic Surgeons (ESTS) consensus states that any sublobar resection, including wedge, must include at least one hilar node and at least three mediastinal stations, including station 7, for oncologic validity. Frozen section of segmental or hilar nodes is strongly encouraged (25).

The NCCN similarly mandates ≥3 mediastinal stations plus hilar nodes for all resections with curative intent (26).

The ACCP emphasizes that frozen section should be employed when feasible in all sublobar resections and that the absence of nodal staging renders the operation oncologically incomplete (27).

An important consideration in the context of sublobar resections, particularly wedge resections, is the systematic dissection of station 11 lymph nodes, located at the intersegmental level. These nodes lie at the interface of segmental bronchi and vessels and are frequently involved in early nodal spread. However, their exposure requires opening the fissures and anatomically isolating the bronchovascular structures of the pulmonary segment, a step that is rarely performed during wedge resections. The omission of station 11 evaluation may therefore represent a significant oncologic limitation of the wedge technique. Huang et al. demonstrated that station 11 involvement is a common reason for intraoperative conversion from segmentectomy to lobectomy, as its positivity on frozen section often indicates more extensive disease than initially expected (28). In a similar vein, Stasiak et al. demonstrated that station 11 contained metastatic cells in approximately 20% of patients with a positive sentinel node, underscoring its pivotal function in precise nodal staging and surgical decision-making (29). These findings reinforce the necessity of station 11 assessment to ensure oncologic completeness, particularly in sublobar procedures where its omission is both common and consequential.

In conclusion, thorough lymph node evaluation remains a critical component of oncologic lung surgery, particularly in the context of limited resections. For wedge resections to meet oncologic standards, they must include systematic hilar and mediastinal nodal assessment, ideally supported by intraoperative frozen section. The evidence is unequivocal: omission of lymph node evaluation compromises staging, diminishes survival, and invalidates what may otherwise appear to be a curative resection.

Spread through air spaces (STAS) and wedge resection

STAS is an increasingly recognized form of tumor invasion in NSCLC, particularly in lung adenocarcinomas. First defined by Kadota et al. in 2017 as the presence of micropapillary clusters, solid nests, or isolated tumor cells within the alveolar spaces beyond the edge of the primary tumor, STAS has since been associated with higher rates of recurrence and poorer prognosis in several histological subtypes and surgical contexts (30).

The application of wedge resection in STAS-positive NSCLC is a contentious issue due to the inherent limitations of this non-anatomic technique. Wedge resections do not follow bronchovascular planes and are often unable to achieve the wide parenchymal margins necessary to capture STAS tumor cells, which may extend several millimetres beyond the gross tumor edge. Shiono et al. demonstrated that STAS was a significant prognostic factor for recurrence and OS in patients who underwent wedge resection, but not in those who underwent anatomical segmentectomy. This suggests that the impact of STAS may be partially mitigated by anatomical resections, which include wider margins and nodal evaluation (31).

Similarly, Masai et al. found that both STAS and margin distance <1.0 cm were independent risk factors for local recurrence in limited resections, with STAS showing a hazard ratio of 12.24 for local recurrence (32).

These findings were supported by Ren et al. who showed that STAS-positive patients undergoing sublobar resection had significantly worse recurrence-free survival (RFS) and OS compared to those without STAS. Notably, they also detected STAS within residual lung segments in simulated sublobar resections, reinforcing concerns about inadequate margins (33).

Kadota et al. also showed that in patients treated with limited resection, the presence of STAS led to significantly increased risks of both local and distant recurrence, with a 5-year cumulative recurrence rate of 42.6% in STAS-positive tumors compared to 10.9% in STAS-negative ones Conversely, STAS was not significantly associated with recurrence in patients who underwent lobectomy, emphasizing the protective role of anatomical completeness and nodal clearance (30).

Jia et al. reviewed the broad implications of STAS in lung cancer and highlighted that the presence of STAS is associated with several high-risk pathological features, including solid/micropapillary histology, lymph vascular invasion, and higher tumor stage. Their review further emphasized that current evidence supports the consideration of STAS as a formal histologic criterion of invasion (34).

From a clinical perspective, Toyokawa et al. found that STAS-positive patients were more likely to experience margin recurrences after limited resection, including wedge. Importantly, all patients with margin recurrences in their study were STAS-positive, underlining the inadequacy of narrow resections in this population (35).

The practical implication of these findings is that wedge resection may be oncologically insufficient for patients with STAS-positive tumors. In centres where intraoperative frozen section analysis can identify STAS or high-risk histologies, conversion to segmentectomy or lobectomy may improve outcomes. However, routine detection of STAS intraoperatively remains technically challenging and is not widely practiced. A recent meta-analysis by Yang et al. confirmed that STAS is an independent negative prognostic factor in stage I lung adenocarcinoma, significantly affecting both RFS and OS. Importantly, the study showed that patients undergoing sublobectomy had a markedly higher risk of recurrence when STAS was present [5-year RFS: hazard ratio (HR) =6.92], compared to those treated with lobectomy. These results suggest that in cases where STAS is identified postoperatively on a wedge resection specimen, a reoperation to complete anatomical resection may be considered, especially in patients fit for surgery. Nevertheless, in frail or elderly patients, or when a completion lobectomy poses high risk, alternative strategies such as close radiologic follow-up or adjuvant therapy may be appropriate. Given the lack of prospective trials, such decisions must currently be individualized (36).

Although the CALGB 140503 trial represents a landmark study in comparing sublobar and lobar resections for early-stage NSCLC, it is important to note that STAS was not included as a stratification factor in its original design. Furthermore, STAS was not evaluated in the subsequent post-hoc analyses. Given the increasing recognition of STAS as a prognostically relevant variable, particularly in determining the risk of local recurrence after sublobar resection, its omission from the study limits a more effective interpretation of oncological outcomes between segmentectomy and wedge resection (6).

Patient selection criteria

Is wedge resection a valid option in elderly patients with early-stage NSCLC?

The choice of surgical strategy in elderly patients with early-stage NSCLC is uniquely challenging. While lobectomy remains the gold standard for operable stage I NSCLC, this approach may not be feasible for older patients with diminished cardiopulmonary reserve or significant comorbidities. In this context, wedge resection, despite its oncologic limitations, has been increasingly considered as a potentially valid compromise between efficacy and safety.

Several studies have investigated the role of wedge resection in patients over the age of 75 or 80 years. In a large population-based analysis using the Surveillance, Epidemiology, and End Results (SEER) database, Mery et al. evaluated outcomes in elderly patients undergoing surgery for early-stage NSCLC. They found that while lobectomy was associated with superior long-term survival in younger populations, in patients aged ≥80 years, wedge resection provided similar cancer-specific survival with lower perioperative mortality (37).

Berry et al. examined postoperative mortality and long-term outcomes in patients aged ≥80 years. Their study demonstrated that sublobar resections, particularly wedge, were associated with lower complication rates and shorter hospital stays, with comparable OS to lobectomy in patients with significant frailty. Importantly, for carefully selected elderly individuals, wedge resection did not appear to compromise cancer control. In the study by Berry et al., patient selection was based on several indicators of physiological frailty and operative risk. Specifically, impaired pulmonary function, quantified by lower predicted FEV1, was the only independent preoperative variable associated with increased risk of complications. Other characteristics frequently observed in this cohort included multiple comorbidities, such as coronary artery disease (24%), chronic obstructive pulmonary disease (23%), and previous thoracic surgery (18%), as well as functional limitations measured by the Zubrod performance status. The study’s multivariable model further demonstrated that resections more extensive than wedge and the use of thoracotomy were both independently associated with significantly higher morbidity, thus justifying the use of limited resections in selected high-risk octogenarians (38).

More recently, the JCOG0802 trial raised important questions about the generalizability of its findings to older populations. While segmentectomy was shown to have superior OS compared to lobectomy in tumors ≤2 cm, the mean age of enrolled patients was approximately 67 years, and only a small subset were octogenarians (5).

The ongoing JCOG2109 (AWESOME trial) specifically targets patients aged ≥80 to address whether wedge resection is an acceptable oncologic approach in this population, comparing it to segmentectomy. Preliminary observational data suggest that wedge resection may offer acceptable oncologic outcomes with significantly fewer respiratory complications (39).

Wang et al. conducted a meta-analysis focusing on surgical outcomes in elderly NSCLC patients. They found no significant difference in cancer-specific survival between wedge and segmentectomy in the ≥80 population. However, wedge resection was associated with significantly fewer postoperative complications, including atrial fibrillation and prolonged air leak (40).

Errett et al. had already pointed out decades ago that in elderly patients with limited life expectancy, the priority should be balancing oncologic radicality with surgical risk. Their work remains relevant, as it highlighted the paradox that maximizing oncologic control in a frail population may lead to overtreatment and functional decline (41).

The role of wedge resection in this context is not only technical but also philosophical. It raises the question of whether it is more beneficial to provide a potentially curative yet less aggressive operation that preserves lung function and quality of life, even at the cost of slightly increased recurrence risk. In patients with limited physiological reserve or competing risks of mortality, the oncologic inferiority of wedge resection may be clinically irrelevant.

As for the CALGB 140503 trial, although not focused exclusively on the elderly, subgroup analyses did not show a significant interaction between age and outcomes after wedge or segmentectomy. However, the strict inclusion criteria of the trial may have excluded the frailest elderly patients, limiting its applicability to this population (6).

This discussion naturally raises the broader question of whether, in elderly and physiologically limited patients, less invasive and lower-morbidity approaches, such as SBRT or other non-surgical alternatives, may offer a more balanced strategy that better aligns with patient-centred priorities. In clinical scenarios where the balance between oncologic radicality and preservation of quality of life is critical, these modalities may serve as reasonable alternatives to surgery. These approaches will be further discussed in the following sections of this review.

Wedge resection in frail and functionally impaired NSCLC patients

In patients with early-stage NSCLC, the presence of impaired pulmonary function or significant comorbidities often limits the feasibility of lobectomy or even segmentectomy. In this high-risk population, wedge resection may represent a pragmatic alternative that balances oncologic control with procedural safety. Obviously, however, this indication is technically feasible only if the lesion is peripherally located, since achieving an adequate parenchymal margin, typically at least 2 cm. It is not possible for deep-seated tumors without compromising an excessive amount of lung parenchyma or failing to meet oncologic standards.

This approach is less invasive and has been shown to be better tolerated in patients with marginal pulmonary reserve. The landmark study by Errett et al. remains a cornerstone in this context. Comparing wedge resection and lobectomy in patients with peripheral stage I NSCLC, they found that wedge resection was associated with similar 2- and 6-year survival despite being performed in an older and more functionally impaired cohort. Pulmonary function was significantly worse in the wedge group preoperatively [forced expiratory volume in 1 second (FEV1) 1.56 vs. 1.94 L, P<0.001], yet operative mortality and morbidity were similar, supporting its use in poor-risk patients (41).

In 2006, a prospective analysis by Griffin and colleagues examined a prospective analysis comparing 10-year survival of patients with poor pulmonary reserve undergoing wedge resection versus lobectomy. The study specifically analysed OS, not DFS. The primary endpoint was all-cause mortality, calculated from the date of surgery until death. This includes both cancer-related and non-cancer-related causes. Notably, in the wedge resection group, 29% of patients were reported to be clinically free of lung cancer at the time of death, confirming that many patients in this physiologically compromised cohort died from competing causes rather than tumor recurrence. This finding underscores the relevance of wedge resection as a pragmatic compromise in patients with severe pulmonary limitations: although less extensive than lobectomy, it may still offer a survival benefit in a population unlikely to tolerate more radical interventions and whose life expectancy is often shaped more by comorbidities than by oncologic progression (42).

A few years later, in 2011, Nakamura et al. analysed outcomes in a video-assisted thoracoscopic surgery (VATS) cohort, showing that wedge resections performed for high-risk patients due to comorbidities had a significantly lower 5-year survival (41.1%) compared to intentional wedge resections for small GGO tumors (83.3%). The significant difference in 5-year OS between high-risk and intentional wedge resection groups was closely linked to the radiological appearance of the tumors. Patients in the high-risk group underwent wedge resection primarily due to comorbidities, and most of these lesions were solid-dominant tumors, rather than pure ground-glass opacities (GGOs). In contrast, the intentional wedge group included patients with radiologically favourable lesions, particularly small, non-invasive GGOs, which are known to carry a more indolent biological behaviour. Therefore, the poorer survival observed in high-risk patients is not attributable to GGO morphology, but rather to underlying comorbidities and the more aggressive radiologic and histologic profile of their tumors. The survival benefit seen in the GGO group reflects the favourable oncologic nature of such lesions and supports limited resection in highly selected cases.

While the survival difference highlights the prognostic impact of patient selection, the results also underscore that in physiologically limited patients, wedge resection can still offer a meaningful survival benefit compared to non-surgical options (43).

In 2014, the Society of Thoracic Surgeons (STS) database analysis conducted by Linden et al. offered high-level evidence on perioperative outcomes. In a propensity-matched cohort, wedge resection was associated with a 37% lower mortality and 50% lower major morbidity compared to anatomic resections, especially among patients with FEV1 <85% predicted. Importantly, the reduction in morbidity was consistent across all age groups and comorbidity profiles (44).

Subsequently, in 2018, Gu et al. compared pulmonary function loss after VATS lobectomy, segmentectomy, and wedge resection. They observed significantly less loss of forced vital capacity (FVC) and FEV1 in the wedge resection group, with changes comparable to mediastinal procedures without lung resection. This finding strongly supports the functional advantage of wedge resection in patients with impaired reserve, as it preserved lung function more effectively than anatomical resections, reinforcing its role as a preferable option in selected cases (45).

In a follow-up study conducted in 2019, Mori et al. evaluated pulmonary function following wedge resection in a cohort of patients and found that postoperative vital capacity (VC) and FEV1 declined at 3 months but largely recovered to near preoperative levels by 12 months, indicating that lung function loss was minimal in the long term (46).

The existing literature clearly supports wedge resection as a reasonable and frequently utilized option in patients with poor pulmonary function or high surgical risk. This is reflected in clinical practice, where surgeons often select wedge resection for frail individuals to minimize surgical trauma and preserve lung function. However, a critical evaluation of the CALGB 140503 trial, provides essential insights that challenge this widespread assumption.

The trial and its post-hoc analyses addressed the perioperative outcomes and functional results of wedge versus segmentectomy. In terms of morbidity, wedge resection did show a slightly lower rate of certain complications, such as prolonged air leak (0.6% vs. 2.5%). However, there were no statistically significant differences in 30- or 90-day mortality between wedge and segmentectomy groups, nor was overall morbidity meaningfully different.

More importantly, functional outcomes were closely evaluated. In the 2024 post-hoc analysis, changes in FEV1 at 6 months postoperatively were minimal and not significantly different between wedge and segmentectomy (5% vs. 3%, P=0.930). (6,47).

This undermines the long-held perception that wedge resection offers a clear pulmonary advantage in frail patients.

This finding challenges the assumption that wedge should be favoured solely for its presumed respiratory benefit. If segmentectomy, an anatomical and oncologically sound procedure, achieves similar functional preservation with potentially superior oncologic reliability, then it could become the preferred option when feasible, even in patients with limited reserve. In this light, wedge resection might not necessarily be the optimal choice based purely on assumptions of functional protection and should instead be considered only after a careful evaluation of the patient’s overall clinical profile and surgical candidacy.

Surgeon’s choice and the role of expertise

While clinical indications and patient factors should ideally guide the choice between wedge resection and segmentectomy for early-stage NSCLC, in real-world practice, surgeon expertise and institutional resources can significantly influence surgical decision-making.

A 2024 European survey published by Brunelli et al. offers compelling insights into this issue. The study explored what thoracic surgeons would choose for themselves if diagnosed with early-stage lung cancer. While most favoured segmentectomy over lobectomy in appropriate cases, their willingness to undergo a segmentectomy was strongly influenced by the surgeon’s experience and the availability of advanced tools such as 3-dimensional (3D) CT reconstruction. Only 6% of respondents were willing to undergo a segmentectomy at a centre with low procedural experience; 50% would request referral to a more experienced centre, and 39% would prefer a lobectomy instead. This data underscores how confidence in surgical expertise can override theoretical procedural preference (48).

The learning curve associated with segmentectomy further complicates its widespread adoption. Segmentectomy, especially when performed via minimally invasive approaches, is significantly more technically demanding than wedge resection. A study by Zhang et al. on robotic segmentectomy identified three distinct phases in the learning curve: initial learning (first 21 cases), consolidation (up to 46 cases), and proficiency (after 47+ cases). Technical competency, including reductions in operative time and blood loss, was only consistently achieved after approximately 40 operations (49).

Similarly, Hamada et al. reported that proficiency in VATS segmentectomy was reached after 84 cases, highlighting that even experienced thoracic surgeons need extended exposure to achieve optimal outcomes (50).

However, it is essential to interpret learning curve data with caution. Several experts in the field, including Gossot and Seguin (51), have emphasized that surgical proficiency in segmentectomy is not defined solely by the number of cases performed. Mastery requires repeated experience with anatomically distinct procedures, as each segmentectomy presents unique technical challenges. For instance, completing forty S6 or lingulectomies may not equip a surgeon with the skills necessary to perform a complex S9+10 resection. In this sense, the learning curve in segmentectomy is never truly complete, but rather an ongoing process of refinement and adaptation. This perspective highlights the importance of both procedural volume and anatomical variability in developing true expertise in sublobar surgery.

Le Gac et al. analysed the economic impact of the learning curve in robotic segmentectomy and confirmed that early-phase procedures are associated with longer operative times and increased costs due to equipment use and operative inefficiencies. These logistical and economic challenges may drive less experienced surgeons or institutions to favour wedge resection, even when segmentectomy might be oncologically more appropriate (52).

Beyond the surgeon’s personal experience, hospital procedural volume also impacts surgical quality. A 2022 analysis by Mack et al. found that high-volume centres performing segmentectomies had significantly lower 90-day mortality (1.2% vs. 2.6%, P=0.03), fewer positive margins (1.3% vs. 2.7%, P=0.03), and greater adherence to lymph node sampling protocols (88.5% vs. 80.7%, P<0.01) compared to low-volume centres (53).

These findings suggest that centralization of care or referral to experienced centres may be warranted, especially for complex anatomical resections.

A systematic review and meta-analysis by von Meyenfeldt et al. confirmed that high-volume hospitals were associated with reduced postoperative mortality in lung cancer surgery [odds ratio (OR) 0.71, 95% CI: 0.62–0.81], while surgeon specialty also played a role: general thoracic surgeons achieved better outcomes than general surgeons (54).

Finally, the need for advanced imaging tools such as three-dimensional reconstructions further illustrate the disparity in procedural adoption. As Brunelli et al. reported, 25% of surgeons would be reluctant to undergo segmentectomy without 3D imaging. However, not all centres have access to such technology, which may limit the safe implementation of anatomical segmentectomy in those settings and perhaps drive the surgeons for an easier operation like wedge (48).

Ultimately, while technical skill, surgical volume, and institutional resources remain central to the quality of lung cancer surgery, outcomes are also shaped by patient-specific and human factors that extend beyond pure procedural metrics. Notably, a recent review by Zirafa et al. highlighted that women consistently demonstrate better perioperative and long-term outcomes after lung resection, irrespective of the surgical approach. Even more intriguing, the authors discuss preliminary evidence suggesting that sex concordance between patient and surgeon (particularly female-female pairs) may be associated with improved results (55).

These findings suggest that, alongside ongoing efforts to refine surgical technique and standardize learning curves, attention should also be given to more nuanced elements of the care relationship. In a field traditionally dominated by male expertise, this offers a timely reminder that excellence in surgery is multidimensional and sometimes, the best outcomes are achieved when technical mastery meets human alignment.

Alternative sublobar strategies

Wedge resection has long represented the least invasive surgical approach for stage I NSCLC, particularly in high-risk or physiologically fragile patients. However, in recent years, non-surgical sublobar alternatives, most notably SBRT and image-guided thermal ablation, have increasingly gained prominence. For many early-stage NSCLC patients deemed unfit for lobectomy, these modalities are now routinely favoured. In practice, this has led to the paradoxical exclusion of wedge resection from multidisciplinary discussions, where surgery is often dismissed outright in favour of SBRT, even when a minimal surgical intervention could be technically feasible and oncologically sound. This trend highlights the need to re-examine current clinical decision-making frameworks and ensure that all therapeutic options, including conservative surgery, are considered in a balanced and individualized manner.

SBRT has gained traction as a curative-intent option for patients with medically inoperable stage I NSCLC. In 2010, Grills et al. conducted a prospective comparison of SBRT and wedge resection in 124 medically inoperable patients, finding no significant difference in regional or distant recurrence, though SBRT demonstrated a trend toward reduced local recurrence (4% vs. 20%, P=0.07). OS was higher in the surgical group, yet cause-specific survival was equivalent (56).

Conversely, a 2014 study by Port et al. using a propensity-matched cohort showed that SBRT was associated with a higher rate of recurrence than wedge resection (30% vs. 9%, P=0.016), but no statistically significant difference in DFS (57).

More recently, Yerokun et al. utilized the National Cancer Database to compare wedge resection and SBRT in 6,295 patients with cT1N0 tumors measuring less than 2 cm. Wedge resection was associated with significantly better 5-year OS (49.9% vs. 31.0%, P<0.001), even after rigorous propensity score matching. Moreover, a higher institutional rate of SBRT use for stage I NSCLC was correlated with an increased observed-to-expected mortality ratio at 3 years (58).

This finding suggests that greater reliance on SBRT in clinical practice, potentially at the expense of surgical options, may negatively impact long-term outcomes. These data underscore the need to reintroduce wedge resection as a legitimate therapeutic option during multidisciplinary tumor board discussions, particularly for patients in whom more extensive surgery is contraindicated. Despite being technically feasible and oncologically meaningful in selected cases, wedge resection is often excluded from deliberations, and its role may need to be reassessed in the current era of personalized oncologic care These results were further corroborated by a comprehensive review by Park et al. in 2022, which found that while SBRT is associated with better short-term morbidity and quality-of-life outcomes, long-term survival remains inferior to surgery, even non anatomical resections. Importantly, this detriment persists even in adjusted comparisons and among matched cohorts (59).

Radiofrequency ablation (RFA) and microwave ablation (MWA) represent alternative non-surgical strategies particularly relevant for patients unfit for any form of resection. In a preliminary study, Ranieri et al. reported high technical success and a 94.4% rate of local control using RFA, with only minor complications (60).

Ambrogi et al. in a 2006 pilot study confirmed the feasibility and safety of RFA in a surgical setting, achieving complete tumor necrosis in 6 of 9 resected specimens post-ablation (61).

Subsequently, in a comparative study of 121 marginal surgical candidates, Ambrogi et al. compared wedge resection (n=59) to RFA (n=62). At a median follow-up of 36 and 42 months, local recurrence was 2% in the wedge group and 23% in the RFA group (P=0.002), with superior 5-year OS in the wedge group (52% vs. 35%, P=0.044) (62).

The 2022 review by Detterbeck et al. emphasized that while ablation is associated with low morbidity and preservation of pulmonary function, its long-term oncologic outcomes are significantly inferior to both SBRT and surgery. However, differences between ablation and SBRT were less pronounced than those between ablation and surgery (63).

MWA, a newer form of image-guided thermal therapy, is rapidly gaining attention as a potentially superior alternative to RFA and a competitor to SBRT. In a large real-world analysis of over 42,000 patients, Laeseke et al. demonstrated that MWA was associated with significantly higher 3-year OS (69%) compared to RFA (50%) and SBRT (57%) in early-stage NSCLC (64).

These findings were reinforced by Laeseke et al., who showed that MWA yielded the highest disease-free survival among all ablative modalities, while maintaining comparable local tumor progression rates to SBRT (65).

In addition to oncologic efficacy, MWA offers practical procedural advantages: it is performed in a single session, allows for real-time histologic confirmation, and facilitates mediastinal staging during the same intervention, capabilities not achievable with SBRT (66,67). Moreover, the immunologic response induced by thermal injury may enhance systemic antitumor effects, particularly when combined with immune checkpoint inhibitors (68). These benefits make MWA a cost-effective and clinically versatile tool for non-surgical candidates and suggest its increasing relevance in future treatment algorithms.

When comparing wedge resection, SBRT, and ablation, both oncologic and functional outcomes should be carefully evaluated. According to the guideline framework proposed by Detterbeck et al., wedge resection remains preferable in operable patients due to superior local control and survival. SBRT is a compelling option for patients with borderline operability or those declining surgery, while ablation is generally reserved for patients with no surgical or radiotherapeutic options (63).

Shirvani et al. also emphasized that among elderly patients, SBRT offers a survival benefit in the first 6 months post-treatment compared to surgery, though this reverses beyond that point. This result must be taken into account during the decision-making process for the treatment of the frail patient and would seem not to exclude surgery (69).

While wedge resection remains a standard approach for sublobar treatment in high-risk patients, non-surgical alternatives like SBRT and thermal ablation, particularly MWA, have demonstrated meaningful clinical roles. SBRT remains the preferred radiotherapeutic option, while MWA is emerging as a powerful, single-session treatment with both diagnostic and therapeutic capabilities. These developments reinforce the importance of individualized care and multidisciplinary evaluation in the management of early-stage NSCLC.

Future prospective

In the era of digital surgery, it is increasingly important to consider how novel technologies may redefine surgical standards, leading toward a more tailored approach to oncologic treatment. Emerging tools, particularly artificial intelligence (AI), radiomics, and molecular genomics—are poised to enhance the precision of surgical decision-making, potentially supporting a personalized paradigm for sublobar resections, including wedge procedures.

One of the most transformative opportunities lies in the application of radiomics and AI to preoperative imaging. By extracting high-dimensional quantitative features from CT scans, radiomics can characterize the tumor’s spatial and textural attributes beyond what is perceptible to the human eye. These data can inform predictions about tumor invasiveness, the likelihood of STAS, and even genetic mutations such as epidermal growth factor receptor (EGFR) status.

For example, machine learning models trained on perinodular and intranodular features have shown potential in distinguishing adenocarcinomas from benign granulomas and in predicting aggressive histological behaviours (70).

The integration of radiogenomics further augments this approach. By combining imaging data with molecular profiles, clinicians may be able to predict the biological behaviour of tumors without invasive biopsies. In one study, CT-derived radiomic features coupled with clinical variables enabled non-invasive prediction of EGFR mutations with an Area under the receiver operating characteristic curve (AUC) of 0.828 (71).

In clinical practice, this could guide the selection of candidates for less extensive resections like wedge resection when a tumor displays features associated with low aggressiveness.

In parallel, genomic profiling is revolutionizing thoracic oncology by offering insights into tumor heterogeneity, progression, and therapeutic response. As emphasized by Cannone et al., the concept of precision surgery parallels that of precision medicine: surgical decisions are increasingly tailored based not only on clinical stage but also on genomic alterations, such as EGFR, Anaplastic Lymphoma Kinase (ALK), or Kirsten Rat Sarcoma viral oncogene homolog (KRAS) mutations. This paradigm could justify the use of wedge resection in molecularly indolent tumors, especially when margins are precisely calculated through radiologic modelling (72).

AI, particularly when integrated with real-time electronic health records and imaging data, may further enhance intraoperative guidance and risk stratification. As described by Loftus et al. AI-driven decision support systems can synthesize complex datasets to predict postoperative complications, guide margin adequacy, and identify suspicious lymph nodes intraoperatively (73).

In thoracic surgery, this technology is evolving to assist with intraoperative navigation, possibly enabling real-time assessments of resection completeness, thus reinforcing the oncological validity of wedge resections in selected patients (74).

Moreover, in the near future, AI may help identify patients who can safely undergo wedge resection by modeling individualized risk based on comorbidities, tumor biology, and radiologic features. This data-driven personalization may allow surgeons to select patients for wedge resection who would traditionally be excluded due to its perceived limitations.

As Bertolaccini et al. highlight, this evolution is not purely technological but philosophical, representing a shift toward a biology-driven definition of oncological adequacy. The future of wedge resection may no longer hinge solely on anatomical extent but rather on biologic behaviour, imaging phenotype, and risk modeling (75).

Looking ahead, current guidelines and trials like CALGB 140503 have set rigid boundaries between wedge and segmentectomy based on size and location, emerging tools may blur these distinctions. The convergence of radiomics, genomics, and AI could enable thoracic surgeons to perform wedge resections with greater confidence, selecting the right operation for the right patient, and thus restoring a meaningful oncological role to this minimal intervention in the era of personalized lung cancer therapy.

Conclusions

Wedge resection, traditionally viewed as a compromise for frail or inoperable patients, is increasingly recognized as a potential option within a more personalized surgical strategy. While it remains inferior to segmentectomy in terms of local control and oncologic thoroughness, especially in tumors with aggressive features, it may offer acceptable outcomes when performed with strict adherence to oncologic principles, especially adequate margins and lymph node evaluation.

Segmentectomy should still be considered the preferred sublobar approach when technically feasible, given its superior balance between radicality and functional preservation. However, wedge resection has a role in selected patients, particularly when guided by careful preoperative assessment.

The evolution of thoracic surgery, with the integration of radiomics, molecular profiling, and AI may further refine patient selection and surgical planning. At the same time, emerging non-surgical techniques such as bronchoscopic ablation are reshaping the landscape of early-stage NSCLC treatment.

In this rapidly changing scenario, the role of wedge resection must be critically reassessed, not dismissed but refined. Its future relevance will depend on the ability to incorporate precision tools and surgical rigor into an individualized, biology-driven treatment approach.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Erik R. de Loos, Aimée J. P. M. Franssen and Peter B. Licht) for the series “Current Advances and Innovations in Surgical Lung Cancer Treatment” published in Translational Lung Cancer Research. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-562/rc

Peer Review File: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-562/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-562/coif). The series “Current Advances and Innovations in Surgical Lung Cancer Treatment” was commissioned by the editorial office without any funding or sponsorship. M.D. reports serving as Thoracic Domain Member (2022-2025) and Thoracic Robotic Surgery Task Force Chair (2021-2025) of EACTS. A.S.G. reports serving as the President of the International Sublobar Conference (Paris, France). The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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