David Spigel, MD: Recently I saw a woman with—very much like this case—a stage IA cancer that was resected. It was [performed by a] surgeon in town I don’t work with that much. I noticed the patient had a wedge resection. The patient came to see me and said, “What else do I need to do?” As we’ll talk about in that case, there was no indication for PD-L1, EGFR, or chemotherapy. But I couldn’t shake it, part of me was thinking, “You didn’t really have the ideal surgery.” What are your thoughts about, maybe not that case, but am I wrong [that] we’re still aiming for lobectomies? I guess the better way to ask this question is, when is a wedge good enough?

David H. Harpole Jr, MD: There have been 2 really important studies that came out in the last 12 months. One was the JCOG0802 study, which randomized 1100 patients to lobectomy or segmentectomy. Those were 2-cm or smaller adenocarcinomas. That revealed a slight improvement, interestingly, in overall survival for the segmentectomy, but a higher local recurrence rate. Then [there was] the CALGB 140503/Alliance trial, [Nasser] Altorki’s, [MD,] trial, which was segmentectomy or wedge vs lobectomy on around 900 patients, which showed equivalency.

I always bring out the key point that in the Altorki trial, which we put a number of patients on, the patient had to have a diagnosis of cancer, but more importantly had to have all nodal stations sampled in the operating room and found to be negative prior to randomization, which was not the case for the Japanese trial, where they had some node-positive patients. It makes it confusing, but right now, we don’t ever believe a wedge should be primary therapy in a good-risk patient. If one is going to entertain that idea, they certainly need to do a full nodal staging with that to get the answer.

David Spigel, MD: I apologize, I’ve not always equated wedge with segmentectomy. I thought segmentectomy was even a little more, am I right?

David H. Harpole Jr, MD: The segmentectomy is what we and thoracic surgical oncologists prefer because when you do the segment, you dissect down into the segmental bronchi. So by definition you get the 11, 12, and 13 nodes, but more importantly, it’s an anatomic resection where you take the artery, vein, and bronchus together, whereas a wedge is just basically taking a chunk out. So we really do favor segments.

David Spigel, MD: Yes. It’s frustrating when you’re seeing somebody with such good outcomes. You don’t want to disparage your colleagues in the community, but it struck me that that wasn’t the appropriate surgery for that patient.

David H. Harpole Jr, MD: There’s that very depressing SEER [Surveillance, Epidemiology, and End Results] data set, which looked at patients who had either lobectomy or wedge, and then just stratified by number of nodes taken, and there was a dramatic difference in 5-year survival. It’s clearly stage migration. In other words, the ones who were really staged with nodes did much better than those who weren’t. When you have someone with a wedge with no nodes, you really don’t know what stage they are, and it makes it more difficult for you to figure out therapy.

David Spigel, MD: Yes. Fortunately, she had all the nodes sampled that we needed.

Transcript edited for clarity.