13 Lesser Resection Versus Lobectomy for Stage I Lung Cancer in Patients with Good Pulmonary Function

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13

Lesser Resection Versus Lobectomy for Stage I Lung Cancer in Patients with Good Pulmonary Function

Anthony W. Kim and William H. Warren

These fi ndings were essentially the same as those reached by Warren and colleagues, who re- assessed a series of patients having undergone lobectomy or segmental resection for stage I lung cancer.

Of note, those patients had been reported previously in papers advocating limited resec- tions. Interestingly, some of these patients were used as the case material of reports about second and third primary tumors,

suggesting that an unfavorable outcome after limited resection might have been related to a prior lung cancer.

A number of other papers have emerged sup- porting the conclusion that limited resection should be reserved for poor pulmonary risk patients.

To a lesser degree, papers have also emerged arguing for wider adoption of limited pulmonary resections, even in good-risk patients, particularly for small peripheral adenocarcino- mas with bronchoalveolar features. In this chapter, we will review data published since the LCSG fi ndings were released. In particular, we will attempt to reassess the value of limited pulmo- nary resections in patients considered to be able to tolerate a lobectomy (i.e., good-risk patient).

13.1. Nomenclature and Definitions

A segmentectomy is an anatomical resection whereby one or more segments are resected by dissecting out, ligating, and dividing the segmen- tal arteries and veins and dividing the segmental bronchus or bronchi. A wedge resection is a non- anatomical resection of lung without hilar dis- Historically, the surgical procedure of choice for

curative resection of lung cancer, even in its early stages, has been a lobectomy or pneumonectomy.

The role of a more conservative resection, such as a segmentectomy or wedge resection, has been explored by many, paralleling the interest in con- servative resection of breast cancer, where studies determined that clinical results of lumpectomy compared favorably with modifi ed radical mastectomy.

Although segmentectomy was fi rst described as a surgical procedure for bronchiectasis, the role of segmental resections in the management of lung cancer dates back more than 30 years.

Since the original description, many authors have examined the role of lobectomy over a more limited resection.

These were often retrospec- tive studies, examining the outcomes of patients who underwent a limited resection having been determined to be a poor surgical risk for lobectomy.

In 1995, Ginsberg and Rubinstein published

the results of a Lung Cancer Study Group (LCSG)

randomized, controlled trial evaluating the role

of limited pulmonary resection versus lobectomy

in the surgical management of early-stage lung

cancer.

All patients entered in this trial were

good-risk patients and were able to undergo

either a lobectomy or limited resection. This sen-

tinel report concluded that, based on the higher

incidence of local recurrence and decreased 5-

year survival in patients undergoing a limited

pulmonary resection, lobectomy remained the

procedure of choice for patients with T1N0 non-

small cell lung carcinoma.

section and therefore, does not identify pulmonary vessels or segmental bronchi. “Limited” or “lesser resections” have been defi ned in the literature as anything less than a standard lobectomy. As such, an anatomical segmentectomy (involving one or more segments) and a wedge resection have both fallen into this umbrella term of

“limited pulmonary resection.” Whenever possi- ble, we will attempt to distinguish between these two procedures. A lobar and mediastinal lymph node dissection is an integral part of the proce- dure whenever a carcinoma is resected, even when the pulmonary resection is limited. Early- stage lung cancer is defi ned as tumor limited to the lung parenchyma (i.e., not invading sur- rounding structures and the absence of nodal or systemic metastatic disease).

According to the most recent TNM classifi ca- tion, T1 disease is defi ned as carcinoma that is 3 cm or less is maximal diameter, not invading visceral pleura and more than 2 cm from the carina. T2 disease is defi ned as primary lung car- cinoma either measuring greater than 3 cm in maximal diameter, or invading the visceral pleura (but not the parietal pleura), or involving a lobar bronchus (with/without lobar obstructive pneumonia or atelectasis) but more than 2 cm from the carina. Stage I is comprised of T1N0M0 (stage IA) or T2N0M0 (stage IB) carcinoma. The publications from North America and Europe western concentrate on the role of limited resec- tions for stage IA disease.

There is no universally accepted defi nition of what comprises poor pulmonary function, espe- cially as it pertains to selection of patients for lobectomy versus lesser pulmonary resections. A patient is deemed at high operative risk for com- plications after lobectomy if he/she: presents with a Pco

greater than 45 mm Hg, Po

less than 50 mm Hg (without supplimental O

), has a pre- dicted postoperative forced expiratory volume in 1 s (FEV

) less than 0.8 L or less than 40% pre- dicted, or has poor exercise performance status (unable to climb a fl ight of stairs without resting).

In addition, cardiac function must be considered.

An ejection fraction of under 15%, and Pa pres- sure of over 45 mm Hg and angina or systemic hypertension refractory to medical management would also qualify a patient to be a high surgical risk. Inevitably, patient compliance and overall

state of health must also be considered. Although most thoracic surgeons can agree that a given patient is at high risk for complications after lobec- tomy (and therefore more likely to be considered for a limited resection), the designation of a patient as high risk must remain, for the time being, to a large degree, a matter of clinical judgment.

Upon reviewing the literature, one must attempt to distinguish the experience of those patients deemed by the surgeon to have been able to tolerate a lobectomy from those who could not on the basis of the above-stated criteria. A sur- rogate indicator of good pulmonary function, other than the obvious declaration of such in the literature, has been the description of intentional limited resection in patients who would other- wise tolerate a more extensive formal resection.

Of the many outcomes reported in the literature on the role of limited pulmonary resection, sur- vival and local recurrence are the most objective and common to virtually all the recent publica- tions. Typically, survival has been reported as 5- year Kaplan Meier survival curves, although 2-year and 3-year survival is also occasionally reported. This study has proposed local recur- rence to be defi ned as the presence of lung cancer in the ipsilateral hemithorax (including medias- tinum) following resection. This study and others have adopted this defi nition to avoid potential confusion distinguishing recurrence from incom- plete resections versus a second primary tumors.

As such, for the purposes of this analysis, the development of carcinoma in the ipsilateral lung after a resection is reported as a local/regional recurrence regardless of the exact location within the hemithorax, histology, or time interval since the resection. According to this defi nition, there is no exception or allowance for a second primary tumor. While the foregoing defi nition may be overly broad from a tumor biology point of view, if adopted, it is unambiguous and therefore serves as a statistic by which diverse clinical series can be compared.

13.2. Evidence-Based Medicine

In keeping with the theme of this book, this

chapter will attempt to focus on a review of papers

fi lling the following criteria: (1) patients with

stage I lung carcinoma, (2) patients undergoing a limited but complete pulmonary resection, (3) at a minimum, survival data is reported, (4) the series was comprised of at least 40 patients. As is expected with any controversial topic, signifi cant clinical data exist that refute or support the advantages of limited resections over lobectomy.

13.2.1. Literature Critical of the Use of Limited Pulmonary Resection

After an extensive review of the literature, the publication by the LCSG

is the only report that can be categorized as level 1 evidence reporting the role of limited resection versus lobectomy for stage IA non-small cell lung cancer (NSCLC) in good-risk patients. In their report of this pro- spective and randomized trial, there was a statis- tically signifi cant increase in the incidence of local recurrence in the limited resection group

(even after the authors attempted to exclude second primary lesions). Among patients under- going a segmentectomy, there was a 2.0-fold increase, and among those undergoing a wedge resection, there was a 3.9-fold increase over the incidence after lobectomy (Table 13.1). Further- more, the 5-year survival of patients undergoing a limited resection was worse than those who undergoing a lobectomy, a difference that reached statistical signifi cance (Table 13.2). The only ben- efi cial effect noted was in pulmonary function tests at 6-month follow-up, where virtually every parameter was observed to be better preserved in the limited resection compared to the lobectomy group. However, this benefi t was not sustained when patients were studied 12 or 18 months post- operatively. Ginsberg and Rubinstein concluded that there were no statistically signifi cant differ- ences in the perioperative morbidity and mortal- ity.

On the basis of the increased incidence of

Limited resections

Reference Year Lobectomy Combined Segment Wedge p Value Warren⁷ 1994 4.9% 22.7% 0.004 Ginsberg⁸ 1995 6.4% 17.2% 0.008 Landreneau¹³ 1997 7.7% Open 57.1% 0.07

VATS 26.7%

Miller¹⁵ 2002 13.32% 8.3% 30.8% ns Koike²¹ 2003 0.6% 2.7% ns Campione¹¹ 2004 2.0% 19% Significant Abbreviation: ns, not significant.

TABLE 13.2. Overall 5-year survival after lobectomy, segmentectomy, and wedge resection for stage 1 NSCLC.

Limited resections

Reference Year Lobectomy Combined Segment Wedge p Value Warren⁷ 1994 68% 44% 0.035 Ginsberg⁸ 1995 68% 48% 0.088 Kodama¹⁷ 1997 88% 93% good risk ns

48% poor risk 0.003 Landreneau¹³ 1997 70% Open = 58% ns

VATS = 65%

Sugarbaker¹⁴ 2000 74% 48% 0.0014 Okada²⁰ 2001 88% 87% ns Koike²¹ 2003 90% 89% ns Keenan^22a 2004 67% 62% ns Abbreviation: ns, not significant.

aFour-year survival data.

local/regional recurrence and 5-year survival, they concluded that limited resections should not be considered the oncological equivalent of a lobectomy, discouraging the use of a limited resection when the patient is deemed to be able to tolerate either resection.

Landreneau and colleagues published their multi-institutional retrospective review of wedge resections, either by VATS (60 patients) or open (42 patients) versus lobectomy (117 patients) for the surgical management of stage IA lung cancer.

They observed that, although postoperative mor- bidity was signifi cantly less after wedge resection than after lobectomy, local recurrence following wedge resection was higher than lobectomy.

Their analysis, however, showed that although this incidence approached, it did not reach statis- tical signifi cance (p = 0.07). Of concern was the fact that local recurrence seemed to occur earlier after wedge resection (median time to recurrence of 10 months) than in the lobectomy group (median time to recurrence of 19 months). Based on their fi ndings, the authors concluded that, in the face of the increased risk of local recurrence and poorer survival, lobectomy was the proce- dure of choice for the good-risk pulmonary patient. They agreed that wedge resections should be reserved for those patients deemed to be poor- risk patients.

In another retrospective study, Sugarbaker and Strauss compared the clinical courses of 58 patients undergoing a limited resection and 186 patients undergoing lobectomy or pneumonec- tomy for clinical stage I lung cancer.

They observed that patients undergoing a limited resection (90% of whom had T1N0 tumors) had a worse survival than patients undergoing lobec- tomy/pneumonectomy (57% of whom had T1N0 tumors). Thus, patients undergoing a limited pulmonary resection had with a worse 5-year survival than patients undergoing a lobectomy/

pneumonectomy despite the earlier stage in the limited resection group. On the basis of these fi ndings, Sugarbaker and Strauss also endorsed the concept that a lobectomy is the operation of choice for stage I lung cancer.

Miller and associates analyzed a subset of patients with NSCLC less than 1.0 cm in diame- ter.

In their retrospective analysis of 100 patients (stage I, 93; stage II, 6; stage IIIA, 2), the incidence

of local recurrence (wedge resection, 30.8%;

segmentectomy, 8.3%; lobectomy, 13.3%), approached, but did not reach, statistical signi- fi cance (probably due to the low number of patients). There was, however, a decreased 5-year overall and lung cancer–free survival in patients undergoing a limited resection (33% and 47%, respectively) when compared to lobectomy (71%

and 92%, respectively). In addition, as Ginsberg and Rubinstein had observed, upon further sub- dividing limited resection into wedge resection and segmentectomy, patients undergoing seg- mentectomy had a statistically signifi cant better 5-year survival (57%) than those undergoing wedge resection (27%). Based on their results, the authors concluded that a lobectomy is the resec- tion of choice, even for tumors 1.0 cm or less in diameter.

In 1999, Takizawa and colleagues published their results comparing the pulmonary function of 40 patients before and after undergoing a seg- mental resection versus 40 patients undergoing a lobar resection for T1 peripheral lung carcino- mas.

All patients undergoing segmentectomy were deemed able to tolerate either a limited resection or a lobectomy. Patients were studied 2 weeks and again at 12 months after surgery.

Despite the tendency toward improved pulmo- nary function in the patients undergoing the more conservative resections, analysis showed that this difference was not statistically signifi - cant. The authors concluded that suspected improvement in performance status did not merit advocating limited pulmonary resections in good-risk patients after considering adequacy of lymph node dissection, higher incidence of local recurrence, and decreased 5-year survival.

13.2.2. Literature Supporting the Use of Limited Pulmonary Resection

Despite the studies that have concluded that

limited pulmonary resections are not the onco-

logical equivalent of lobectomy, numerous studies

have been supportive of the use of limited pulmo-

nary resection, even in patients judged to be able

to tolerate a lobectomy. Shortly after the LCSG

publication, literature from Japan emerged advo-

cating limited pulmonary resections. Kodama

and associates evaluated their clinical experience

with limited resections in 63 good-risk and 17 poor-risk patients with stage IA NSCLC, compar- ing the results with 77 patients undergoing a lobectomy.

The average diameter for pulmonary lesions in the limited resection group was 1.67 cm versus 2.29 cm in the lobectomy group. The authors did not observe a signifi cant difference in rates of local recurrence comparing the good- risk patients undergoing a limited resection versus lobectomy. However, there was a statisti- cally signifi cant higher incidence in local/regional recurrence in poor-risk patients undergoing limited resection compared to lobectomy patients.

This was thought to be due, at least in part, to two factors. Patients with larger tumors tended to undergo a lobectomy if they were good risk, but underwent a limited resection if they were deemed poor risk. Good-risk patients tended to undergo a limited resection only if their tumors were small. Furthermore, none of the 17 poor-risk (and only 13 of the 46 good-risk) patients under- going a limited resection underwent a complete lobar and mediastinal node dissection. Six patients having undergone a limited pulmonary resection had recurrence in the mediastinum.

There was no statistically signifi cant difference in 5-year survival comparing good-risk segmen- tectomy patients with lobectomy patients (88%

vs. 93%). The authors concluded that a complete mediastinal lymph node dissection was indicated in patients undergoing a limited pulmonary resection, even in poor-risk patients. Based on their fi ndings, however, citing the fact that there was no difference in survival in good-risk patients, the authors concluded that segmentec- tomy combined with mediastinal lymph node dissection could be adequate therapy for stage IA disease.

Several reports have appeared from the Study Group of Extended Segmentectomy for Small Lung Tumors. The authors defi ne extended seg- mentectomy as segmentectomy and complete lobar/mediastinal lymph node dissection. This study group has examined the role of such resec- tions on patients with tumors less than 2 cm in diameter and have produced several reports.

In this prospective multi-institutional trial, they reported on 70 patients undergoing a segmentec- tomy with mediastinal lymph node dissection and 107 patients undergoing lobectomy for path-

ological stage IA carcinoma. The 5-year survival rates were 87.3% for patients undergoing segmen- tectomy versus 72.7% for patients undergoing lobectomy for stage IA disease. In patients with T1 (T less than 2.0 cm) tumors, the 5-year sur- vival rate was 87.1% for segmentectomy versus 87.8% for the lobectomy population. This differ- ence was not statistically signifi cant. The authors emphasized the value of frozen section to help stage the patient intra-operatively when consid- ering limited resection. As long as preoperative selection criteria were stringently adhered to, and a concerted effort was made to eliminate patients with more advanced stage, the authors advocated segmentectomy with good pulmonary margins and mediastinal node dissection as a good alter- native to lobectomy. The major disadvantage of the work of this group, however, is that the seg- mentectomy patients were studied prospectively and compared retrospectively with patients having undergone a lobectomy at the same insti- tutions. Nevertheless, Okada and colleagues

have achieved enviable 5-year survival in this subset of patients. Not surprisingly, they advo- cate segmentectomy with mediastinal node dis- section in the management of stage IA lesions (especially when the tumor is less than 2 cm in diameter), even in patients considered to be a good risk for lobectomy.

In 2003, Koike and colleagues reported retro- spectively on results of limited resection for good-risk patents with tumors less than 2 cm,

and compared them to patients undergoing a standard lobectomy for T1N0M0 (T less than 2 cm) disease. Of this group, 74 patients had a limited resection (segmentectomy in 60 patients, wedge resection in 14 patients). Only 48 patients underwent a complete hilar and mediastinal node dissection. Segmentectomy was only per- formed if the surgeon felt that a 2-cm surgical margin could be obtained. Lobectomy was per- formed in 159 patients meeting the same criteria.

There was no signifi cant difference in the periop- erative morbidity and mortality. Nor was there any signifi cant difference in local recurrence.

Both the 3-year and 5-year survival data showed no important difference between patients under- going lobectomy versus limited resection (97.0%

vs. 94.0%, and 90.1% vs. 89.1%, respectively).

The authors concluded that patients with tumors

less than 2 cm in diameter may be candidates for a limited resection, but admitted that more con- trolled studies exploring this option are warranted.

In the United States, Keenan and colleagues retrospectively analyzed 201 patients with T1N0 NSCLC who underwent surgical resections over a 5-year period.

In addition to studying local recurrence and survival, the authors used preop- erative and 12-month postoperative pulmonary function tests to determine if there was any func- tional advantage of a segmentectomy (54 patients) versus a lobectomy (147 patients). Mediastinal lymph node dissection was performed routinely in the lobectomy patients, but not in the segmen- tectomy patients. There was no observed statis- tically signifi cant difference in local/regional recurrence (but the trend was in favor of lobec- tomy). Likewise, there was no statistically signifi - cant difference in the 1-year and 4-year survival between the two groups (but once again, the trend was in favor of lobectomy). Preoperatively, the patients undergoing segmentectomies had signifi cantly greater pulmonary compromise when compared those undergoing lobectomy.

These differences in forced vital capacity (FVC), FEV

, maximum voluntary ventilation (MVV), and diffusing capacity for carbon monoxide (DCCO), were all signifi cant. When compared to the preoperative status, the segmentectomy patients experienced a postoperative decrease in FVC, FEV

, MCC, and DLCO at 12 months, but only the DLCO change was statistically signifi - cant. On the other hand, patients undergoing lobectomy demonstrated statistically signifi cant decreases in all these same parameters. Based on their fi ndings, the authors supported the notion that segmental resection be performed in periph- eral carcinomas less than 3.0 cm when completely within anatomical boundaries of the segment, and in all lesions 2.0 cm or less.

13.3. Impact of Evidence

13.3.1. Age

In 2005, Mery and coworkers published their fi ndings on the role of limited resection in the elderly.

Patient information was accessed through SEER (Surveillance, Epidemiology, and End Results) database from 1992 to 1997. Patients

were divided into three groups based upon their age: group 1, ≤65 years; group 2, from 65 and 74 years; and group 3, ≥75 years of age. Stages I and II disease were included in this analysis (stage I, 83%; stage II, 17%). Limited resections were per- formed with increasing frequency among the three groups: group 1 (8.1%), group 2 (12%), and group 3 (17%). The authors assumed the decision to perform limited resections was based on per- ceived greater surgical risk (i.e., comorbidities and poorer pulmonary reserve), although the exact criteria by which selection was made were not stated. Not surprisingly, the authors found that overall survival decreased as a function of age. Furthermore, the overall survival benefi t of lobectomy over limited pulmonary resection proved to be a function of age. A survival benefi t for patients undergoing lobectomy versus limited resection was seen in groups 1 and 2, but was not apparent in group 3 (patients 75 years or older).

By post hoc statistical analysis, it was determined that patients beyond age 71 undergoing lobec- tomy were not likely to see a survival advantage (beyond 25 months) when compared to patients undergoing segmentectomy. The authors con- cluded that limited resections could be a feasible alternative in patients greater than 71 years without impacting long-term survival.

13.3.2. Tumor Size

Although stage IA disease has been described

typically as early-stage disease, several authors

have made attempts to subclassify T1N0 tumors

according to the tumor diameter (such as <1.0 cm

or <2.0 cm.). Tumor size within the T1N0 classi-

fi cation has been shown to correlate with sur-

vival. Several authors have concluded that

patients with tumors ≤2.0 cm. have a statistically

signifi cant 5-year survival advantage over

patients with tumors 2.1 to 3.0 cm, regardless of

the extent of the surgical resection, provided a

complete resection was performed, including a

mediastinal lymph node dissection.

Port and

colleagues reached the same conclusion with

respect to the disease-specifi c 5-year survival.

It is important to take this observation into

account, whenever analyzing these retrospective

papers, many of which reserved limited pulmo-

nary resections to patients with tumors <2.0 cm.

13.3.3. Tumor Biology

In addition to tumor size, histopathology has been the subject of studies to determine when to consider performing a limited pulmonary resec- tion. Yamato and colleagues review their 4-year experience of 42 patients undergoing limited resection for a bronchioloalveolar carcinoma less than 2.0 cm.

Thirty-four of these patients under- went a nonanatomical wedge resection, 2 under- went segmentectomy, and 6 were converted to a lobectomy. All patients underwent a mediastinal lymph node dissection. In addition to using frozen section analysis to evaluate the presence of nodal metastases, frozen section analysis was used to confi rm the absence of active fi broblastic proliferation, which has been shown to portend a worse prognosis.

Patients with nodal metasta- ses or invasion of the pleura or stroma, or who had demonstrable active fi broblastic prolifera- tion, were converted to a lobectomy. During the follow-up period, ranging from 12 to 47 months, all patients were alive without signs of local recurrence. Based on their careful selection cri- teria (including tumor size and histological fea- tures), the authors concluded that a limited pulmonary resection is a viable option for this subgroup of patients with T1N0 bronchioloalveo- lar carcinoma meeting their size and histological criteria. They also rationalized that a wedge resection had an advantage over a segmentec- tomy by alluding to the theoretical advantage of preserving as much pulmonary volume. However, their study was single armed, the clinical follow- up was short, and these tumors are known to be biologically more indolent than other non-small cell carcinomas. In addition, no data was given on the incidence of local/regional recurrence in these notoriously soft and ill-defi ned tumors, making it diffi cult to determine the appropriate resection margin clinically. In addition, bron- chioloalveolar carcinoma is known for its multi- focal nature, which is presumably spread directly through regional airways.

13.3.4. Meta-analysis

Recently, Nakamura and colleagues analyzed 14 articles published in the period 1980 to 2004 con-

taining postoperative survival data on patients undergoing limited pulmonary resections.

Care was taken to select independent authors and study groups, and that patients had early-stage disease. Of the 14 publications cited, in only 4 papers were limited resections performed on patients assessed to be able to tolerate a lobec- tomy. Although the authors performed an exten- sive search of the literature, publication bias may have been a factor because potentially important studies, such as those of Porrello and colleagues and Yamato and colleagues, were not included.

The authors did acknowledge limitations of per- forming meta-analysis on retrospective studies.

Other expressed limitations included heteroge- neity of the patient populations (ability or inabil- ity to tolerate a lobectomy, age differences), heterogeneity in the carcinomas (size, histology, and pathological stage), and variability in surgi- cal technique (wedge vs. segmentectomy, pres- ence or absence of a mediastinal node dissection).

Upon performing a meta-analysis, the authors concluded, once again, that while there was an apparent overall survival advantage at 1-, 3-, and 5-year mark in favor of patients undergoing a lobectomy over patients undergoing a limited pulmonary resection; this advantage did not reach statistical signifi cance.

13.4. Conclusions

Based on an extensive review of the currently

available English language literature, and in

accordance with the Oxford Centre for Evidence-

Based Medicine,

it is our recommendation that

(1) a pulmonary wedge resection not be per-

formed on any patient with stage I NCSLC. This

recommendation is based upon level 1 and 2 evi-

dence. The grade of recommendation for this is

A. (2) In the good-risk pulmonary patient with

T1N0 NSCLC, our recommendation is for a lobec-

tomy and complete nodal dissection to achieve

the maximum survival benefi t. While several

studies failed to demonstrate a statistically sig-

nifi cant survival advantage in small T1N0 tumors,

no study proved that these operations were

equivalents. In fact, in every study, there was a

survival advantage for patients undergoing lobec-

tomy, but in no single study did this reach statis- tical signifi cance. This recommendation is based upon level of evidence that is classifi ed as 2. The grade of recommendation for this is B. In the case of the extremely small stage IA lesions, a segmen- tectomy may be a reasonable option, but should be approached with caution and close follow-up.

There is a need for a more thorough prospective randomized, controlled trial to elucidate the true benefi t of segmentectomy (in contradistinction to a wedge resection), in this subset of patients with T1N0 tumors (T1 < 2.0 cm). (3) Patients with T2N0 tumors should undergo lobectomy. There is an extreme paucity of literature regarding limited resection in this subset of stage I patients.

Furthermore, use of a lesser resection is counter- intuitive, leaving the patient with a narrow margin of resection. Therefore, although level of evidence is at best classifi ed as 2, the grade of recommendation for this is A. (4) Patients T1N0 tumors and deemed to be at high risk for postop- erative morbidity and mortality after lobectomy should be considered for anatomical segmentec- tomy together with hilar and mediastinal node dissection. However, the exact criteria by which patients are deemed to be high-risk remains an open question and worthy of additional studies.

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