Optimizing wedge resection for peripheral clinical stage IA1-2 non-small cell lung cancer with tumor spread through air spaces.

Abstract

Wedge resection (WR) is widely used as a lung parenchyma-sparing option for peripheral clinical stage IA1-2 (cIA1-2) non-small cell lung cancer (NSCLC) but is considered inferior to lobar resection (LR) in patients with spread through air spaces (STAS). This study aimed to identify acceptable candidates and surgical quality thresholds under which WR may achieve outcomes comparable with LR in cIA1-2 STAS-positive NSCLC. Consecutive patients with peripheral cIA1-2 STAS-positive NSCLC who underwent WR or LR between 2014 and 2020 at 6 high-volume institutions were retrospectively reviewed. Propensity score matching (PSM) was applied to mitigate selection bias. The primary end point was recurrence-free survival (RFS). Among 4831 patients (4177 LR and 654 WR), PSM yielded 2528 LR and 632 WR cases. WR was associated with better perioperative outcomes but worse RFS and a greater recurrence rate than LR. Interaction and stratified analyses indicated that WR achieved comparable RFS with LR in patients aged ≥75 years or with cIA1 disease, whereas WR was associated with poorer RFS in patients aged <75 years or with cIA2 disease. Cox regression revealed that greater resection margin length and greater margin-to-tumor ratio (MTR), but not increased lymph node dissection or R0 resection, were independently associated with improved RFS following WR. Cut-off analyses showed that WR with a resection margin ≥2.6 cm or MTR ≥1.7 achieved survival outcomes comparable with LR. WR may achieve survival outcomes comparable with LR in selected patients with peripheral cIA1-2 STAS-positive NSCLC, particularly in those aged ≥75 years, those with cIA1 disease, or when surgical margin thresholds (≥2.6 cm or MTR ≥1.7) are met.