Sub-superior (S*) segmentectomy of the lung-first case report from India

Oligometastatic lung lesions are often managed with curative-intent surgery, with segmentectomy serving as a parenchyma-sparing procedure that requires precise anatomical knowledge. The sub-superior (S*) segment, first described by Boyden and more recently characterized by Zhou, is an underrecognized lower lobe variant with an incidence of approximately 32%. We report the first case from India of a combined superior (S6) and sub-superior (S*) segmentectomy performed for pulmonary metastasis from a synovial sarcoma. A 38-year-old male with a right thigh synovial sarcoma underwent hip disarticulation, chemotherapy, and subsequent lung metastasectomy. Contrast-enhanced computerized tomography (CECT) with three-dimensional (3D) reconstruction revealed a pleural-based lesion in the lower lobe involving the sub-superior and superior segments, with type 1 sub-superior bronchial anatomy. Surgical resection was planned using the Optimizing the Margins with the Principles of Segmentectomy (OMPS) algorithm, and an extended segmentectomy of S6 and S* was performed via thoracotomy with the modified inflation-deflation method for delineating intersegmental planes. The patient had an uneventful recovery, and final histopathology confirmed negative margins. This case highlights the importance of recognizing the sub-superior segment in surgical planning, particularly in the Indian context where literature remains sparse. Awareness of this variant can aid in achieving oncologic clearance while preserving lung function during complex lower lobe resections.