For small cancers, the picture changed in 2022. The Japanese JCOG0802 trial randomized 1,106 patients with a peripheral lung cancer up to 2 cm to segmentectomy or lobectomy, and five-year survival came out higher after segmentectomy, 94.3 against 91.1 percent, though local recurrence ran twice as high, 10.5 against 5.4 percent. Wedge resection formed no part of that trial.
The operation
Wedge or segment for a small cancer
How we choose
A small ground-glass tumor at the outer third of the lung suits a wedge with a wide margin. A solid tumor, a tumor deeper in the lung, or one close to a segment border goes to a segmentectomy or lobectomy, since a wedge cannot reach a safe margin there. Breathing tests and age weigh in for every decision.
Segment against lobe in numbers
JCOG0802 enrolled solid-looking cancers up to 2 cm at the outer third of the lung, followed for a median of 7.3 years.
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JCOG0802, segmentectomy against lobectomy, 1,106 patients, cancers up to 2 cm
| Outcome |
Segmentectomy |
Lobectomy |
| Survival at five years |
94.3 percent |
91.1 percent |
| Free of relapse at five years |
88.0 percent |
87.9 percent |
| Local relapse |
10.5 percent |
5.4 percent |
| Complications grade 2 or worse |
27 percent |
26 percent |
Why survival favored the segment
More lung, fewer other deaths
More patients died of other illnesses after lobectomy, and keeping more lung leaves room to treat a second lung cancer later. The loss of breathing capacity at one year differed by only 3.5 percent between the two groups, smaller than the trial's own threshold for a meaningful difference.
How we perform a wedge resection
Finding a small nodule
A nodule under 1 cm or lying deeper than 1 cm from the surface escapes the surgeon's finger and camera. A CT-guided marker placed beforehand, a dye or a fine wire, or ultrasound on the lung during surgery finds it.
1
Anesthesia
General anesthesia with a tube that lets one lung rest while we operate on it.
2
Placing the ports
Two or three incisions of 1 to 3 cm between the ribs.
3
Removing the wedge
Staplers take the wedge with a margin at least as wide as the nodule, and the specimen comes out in a bag.
4
Checks and closure
The lung goes back up under water to check for air leaks, and one chest drain stays in place.
Lymph nodes
For a lung cancer treated by wedge, we sample the lymph nodes in the middle of the chest during the same operation, since cancer found there changes the treatment that follows.
The findings suggest that segmentectomy should be the standard surgical procedure for this population of patients.
JCOG0802 trial, Lancet, 2022
- Air leak from the staple line, the commonest problem, which closes on its own in most patients within days.
- Bleeding.
- Chest infection.
- Pain and numbness along the incisions.
- Cancer returning at the staple line.
Recovery
One to three nights in hospital, the drain out once the air leak stops, walking the same evening and desk work within a week or two. Lifting heavy weights waits four weeks.
The PulMiCC trial
Patients in the control group (who did not undergo lung metastasectomy) have better survival than is assumed.
PulMiCC trial of 93 patients, Colorectal Disease, 2020
What the trial found
The PulMiCC trial randomized 93 patients with lung metastases from bowel cancer to wedge removal or active monitoring. Median survival came out at 3.5 years after surgery and 3.8 years without it, with no significant difference. The trial stopped short of its planned size, so it cannot rule out a smaller benefit.
- One or a few metastases.
- A long gap since the original cancer.
- The original cancer controlled.
- Doubt whether the nodule holds a metastasis or a new lung cancer.
What decides the result
For lung cancer, the margin decides. Mohiuddin and colleagues in Boston followed 479 patients after wedge resection of a cancer up to 2 cm, and local recurrence reached 11.0 percent at two years. A 10 mm margin cut the risk by 45 percent against a 5 mm margin, and margins beyond 15 mm added nothing.
Increasing the margin distance ≤15 mm significantly decreased the local recurrence risk, with no evidence of additional benefit beyond 15 mm.
Boston study of 479 patients, Journal of Thoracic and Cardiovascular Surgery, 2014
The stay in Istanbul
Plan five to seven days in Istanbul, with the wound check and the pathology report before you leave. Our surgeon confirms fitness to fly once the drain has been out for 48 hours and a chest X-ray shows no air around the lung. A companion can sleep in your room. Our coordinators speak English, Arabic, French, Russian, Serbian, Romanian and Spanish, and follow-up after you return home runs through them, with CT reports reviewed by our surgeon. The cost depends on keyhole or open surgery, nodule marking and any further resection, and the estimate after the free review lists each.
Follow-up
Scans after surgery
For lung cancer, a chest CT every six months for two years, then every year, read by our team or by your doctor at home.
Lung wedge resection FAQ
Is a wedge resection enough for lung cancer?
Not for a fit patient with a solid cancer, where a segment or a lobe has given better cancer control in every trial so far. A wedge suits small ground-glass tumors and patients whose lungs cannot spare more.
How long does a wedge resection take?
Under an hour of operating time for a single nodule by keyhole surgery.
How much lung function do I lose?
Little, since a wedge removes the smallest amount of lung of any resection.
Can several nodules come out at once?
Yes. Separate wedges remove nodules in different parts of the same lung.
What if the nodule turns out to be cancer during surgery?
We agree beforehand whether to continue to a segment or lobe under the same anesthesia.
References
- Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Annals of Thoracic Surgery. 1995;60(3):615-622.
- Landreneau RJ, Sugarbaker DJ, Mack MJ, et al. Wedge resection versus lobectomy for stage I (T1 N0 M0) non-small-cell lung cancer. Journal of Thoracic and Cardiovascular Surgery. 1997;113(4):691-698.
- Mohiuddin K, Haneuse S, Sofer T, et al. Relationship between margin distance and local recurrence among patients undergoing wedge resection for small (2 cm or less) non-small cell lung cancer. Journal of Thoracic and Cardiovascular Surgery. 2014;147(4):1169-1175.
- Saji H, Okada M, Tsuboi M, 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(10335):1607-1617.
- Milosevic M, Edwards J, Tsang D, et al. Pulmonary metastasectomy in colorectal cancer: updated analysis of 93 randomized patients, control survival is much better than previously assumed. Colorectal Disease. 2020;22(10):1314-1324.
