title: Could less be more?-A systematic review and meta-analysis of sublobar resections versus lobectomy for non-small cell lung cancer according to patient selection.
abstract: OBJECTIVE
  There is renewed interest in performing segmentectomies and wedge resections for selected patients with early-stage non-small cell lung cancer. However, comparative data on sublobar resections versus lobectomies include 'intentionally selected' patients who could tolerate either procedure, or 'compromised' patients who could only undergo sublobar resections due to significant comorbidities or insufficient cardiopulmonary reserve. To address this important point, the present meta-analysis aimed to compare the survival outcomes of sublobar resections and segmentectomies versus lobectomies based on patient selection and surgical intent.
  
  
  METHODS
  A systematic review was performed using 6 online databases to identify all comparative studies that presented survival data on sublobar resections versus lobectomy procedures. These studies were then categorized according to the patient selection process for those who underwent sublobar resections. Patients were considered 'intentionally selected' if they could have tolerated either procedure, 'compromised' if they underwent a sublobar resection due to ineligibility for a lobectomy, or 'non-specified'.
  
  
  RESULTS
  Fifty-four studies, including a single randomized controlled trial, involving 38,959 patients were found to meet the predefined selection criteria. For sublobar resections, comparative data demonstrated no significant difference in overall survival in the 'intentionally selected' group, but a significantly worse outcome for sublobar resections in the 'compromised group'. Similarly, for the comparison of segmentectomies versus lobectomies, available data demonstrated no significant difference in overall survival in the 'intentionally selected' group, but a significantly worse outcome for segmentectomy in the 'compromised group'.
  
  
  CONCLUSIONS
  The present meta-analysis was the first to emphasize the patient selection process to compare 'intentionally selected' and 'compromised' patients who underwent sublobar resections versus lobectomies. Our results suggested that segmentectomies may be a feasible alternative for selected patients who could tolerate either procedure. These patients generally had tumours that were <2cm, located peripherally with favourable histopathology, and with ground-glass opacity on imaging.
authors.affiliation: The Systematic Reviews Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; Department of Cardiothoracic Surgery, Prince of Wales Hospital, Sydney, Australia. Electronic address: drchriscao@gmail.com.
authors.forename: Christopher
authors.initials: C
authors.lastname: Cao
authors.affiliation: The Systematic Reviews Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Chandrakumar
authors.affiliation: The Systematic Reviews Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.
authors.forename: Sunil
authors.initials: S
authors.lastname: Gupta
authors.affiliation: The Systematic Reviews Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia; Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
authors.forename: Tristan D
authors.initials: TD
authors.lastname: Yan
authors.affiliation: The Systematic Reviews Unit, The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia.
authors.forename: David H
authors.initials: DH
authors.lastname: Tian
mesh_terms: D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D009367:Neoplasm Staging; D018579:Patient Selection; D011013:Pneumonectomy / Q000379:methods*; D017594:Publication Bias; D016896:Treatment Outcome
keywords: Meta-analysis; Non-small cell lung cancer; Segmentectomy; Sublobar resection; Systematic review; Wedge resection