Lung cancer surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammad Braizat, M.S. [2]
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Surgery / procedural therapy
Overview
Surgical resection is the main curative local therapy for early-stage lung cancer. Determining resectability, surgical staging, and the resection itself should be performed by dedicated thoracic surgeons for whom lung cancer surgery is a major part of practice, and they should participate in multidisciplinary tumor boards.[1]
Modern lung cancer surgery has five components:
- Physiologic operability assessment
- Choice of resection extent: wedge, segmentectomy, lobectomy, sleeve resection, or pneumonectomy
- Approach: minimally invasive whenever oncologically sound
- Mandatory nodal staging
- Integration with systemic therapy: increasingly, neoadjuvant or perioperative chemoimmunotherapy for stage II–III disease, with biomarker-directed pathways for EGFR/ALK-positive tumors[1]
Surgery also has a narrow role in small cell lung cancer (SCLC), limited to clinical T1–2N0M0 disease.[2]
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General principles
(NCCN categories are 2A unless otherwise stated.)
- Resection is preferred for medically operable disease. SABR is the preferred definitive radiation alternative; thermal ablation may be an option for selected high-risk patients.[1]
- SABR discussion: Patients with node-negative cancer may be informed about SABR as an option through shared decision-making. SABR is not proven equivalent to lobectomy.[1]
- Thoracic surgical consultation should be part of evaluating any patient considered for curative local therapy. Borderline or high-risk patients being considered for SABR need multidisciplinary review that includes radiation oncology.[1]
- Staging imaging: CT and FDG-PET/CT used for staging should be performed within 60 days before surgical evaluation.[1]
- Treatment plan: The overall plan should be established before any non-emergency treatment begins.[1]
- Smoking: Active smoking slightly increases pulmonary complications. It should not by itself be a reason to deny surgery. Cessation support should be provided.[1]
- Resectability in T3/T4-invasive and N2 disease should be determined by thoracic surgery before any therapy begins.[1]
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Physiologic operability
Cardiac risk is assessed first, following ACC/AHA perioperative guidance. Pulmonary assessment follows, provided cardiac risk is low or has been addressed.[3][4]
The ACCP algorithm (2013) remains the main evidence-graded pulmonary pathway. Thresholds are percent predicted.
| Finding | Interpretation / next step | Strength |
|---|---|---|
| Measure FEV1 and DLCO in all candidates; calculate ppo values | DLCO is often reduced even when FEV1 is normal | Recommended |
| ppoFEV1 and ppoDLCO both >60% | Low risk (including pneumonectomy); no further tests | Grade 1C |
| Either ppo value 30–60% (both >30%) | Low-technology exercise test (stair climb or shuttle walk) | Grade 1C |
| Stair climb <22 m or shuttle walk <400 m | Proceed to formal CPET | Recommended |
| Either ppo value <30% | Formal CPET with VO2max | Grade 1B |
| VO2peak <10 mL/kg/min or <35% predicted | High risk for major anatomic resection; counsel on sublobar or nonsurgical options | Recommended |
| VO2peak >20 mL/kg/min or >75% predicted | Low risk | Recommended |
How societies' high-risk definitions differ:
- ERS/ESTS: Prohibitive risk if FEV1 or DLCO is below 80% and VO2max is below 10 mL/kg/min or below 35% predicted. Also high risk: baseline VO2max 10–20 mL/kg/min with ppoFEV1 or ppoDLCO below 30% and ppoVO2max below 10 mL/kg/min.[4]
- ACCP/STS consensus: High risk if ppoFEV1 or ppoDLCO is below 40% with VO2max below 10 mL/kg/min.[4]
Low lung function is not an automatic contraindication.
- In one series, patients with ppo function below 40% were operated on if predicted postoperative VO2 exceeded 10 mL/kg/min.
- Operative mortality was 6%.
- 2-year survival was 66% after resection versus 19% in patients who refused or were deemed unfit for surgery.[3]
COPD (GOLD 2026):
- Testing should include spirometry with bronchodilator response, lung volumes, DLCO, and resting arterial blood gas.
- High-risk patients need perfusion and exercise testing.
- Surgery should be postponed during an exacerbation.[5]
After induction therapy: DLCO can fall by about 21%, and ppoDLCO independently predicts pulmonary morbidity. Repeating DLCO after induction can be considered.[4]
CPET variables (2026 GRADE meta-analysis):
- High-certainty predictors of perioperative complications: peak VO2 with a 15 mL/kg/min cutoff, peak VO2 as percent predicted, and VE/VCO2 slope with a cutoff of 35.
- No CPET variable reached even moderate certainty for predicting long-term mortality.[6]
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Surgical role by clinical stage (TNM 9th edition)
| Clinical scenario | Role of surgery |
|---|---|
| Stage IA, peripheral T1N0 | Resection with nodal dissection or systematic sampling. Invasive mediastinal staging is optional when nodes are CT- and PET-negative in peripheral tumors ≤3 cm |
| Central T1–T2a N0, T2b N0, T1–2 N1, T3N0, T3N1 | Resection after biomarker testing (EGFR, ALK, RET, PD-L1), pathologic nodal staging, and evaluation for perioperative therapy. Brain MRI for stage II–IIIA |
| T1–3 N1, operable | Neoadjuvant systemic therapy (preferred) then resection, or upfront resection |
| T1–3 N2 (including T1N2a) | Definitive concurrent chemoradiation (category 1), or systemic therapy ± RT then surgery in selected patients (fit, single-station, non-bulky N2, needing only lobectomy) |
| Superior sulcus (Pancoast) tumors, resectable | Neoadjuvant concurrent chemoradiation followed by surgery and adjuvant systemic therapy. MRI of chest/spine for lesions abutting spine, subclavian vessels, or brachial plexus. N2/N3 disease and extensive brachial plexus involvement argue against surgery |
| T3–T4 invasion (chest wall, mediastinum, diaphragm, trachea/carina), N0–1, resectable | Surgery, systemic therapy, or concurrent chemoradiation first. En bloc resection with negative margins. Seek a high-volume center opinion if complete resection is uncertain |
| N3 or unresectable stage IIIB–IIIC | Not surgical; managed under the stage IIIB/IIIC algorithm |
| Oligometastatic, thoracic T1–3 N0 | Resection or SABR of the primary, plus definitive local therapy to the metastatic site |
| Oligometastatic, thoracic N1 | Chemoradiation preferred; resection or definitive RT are alternatives |
| Oligometastatic, thoracic T4 or N2 | Definitive chemoradiation |
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Extent of resection
NCCN principles:[1]
- Anatomic resection is preferred for most patients.
- Segmentectomy and wedge resection should be strongly considered for peripheral T1a–b N0 tumors.
- Sublobar resection should achieve a parenchymal margin ≥2 cm or at least the size of the nodule. It should also sample N1 and N2 stations unless that would substantially increase surgical risk.
- Segmentectomy (preferred) or wedge resection is appropriate when poor pulmonary reserve or major comorbidity rules out lobectomy.
- Sleeve lobectomy is preferred over pneumonectomy when anatomically feasible with negative margins.
| Trial | Population | Key results |
|---|---|---|
| JCOG0802/WJOG4607L (Lancet 2022), n=1106 | cIA, ≤2 cm, consolidation-to-tumor ratio >0.5; segmentectomy vs lobectomy | 5-year OS 94.3% vs 91.1% (HR 0.663; non-inferior and superior). RFS 88.0% vs 87.9%. Local relapse 10.5% vs 5.4%. FEV1 difference 3.5% at 1 year. No 30- or 90-day deaths |
| CALGB 140503 (NEJM 2023) | Peripheral ≤2 cm, N0 confirmed intraoperatively before randomization; sublobar (59% wedge) vs lobectomy | 5-year DFS 63.6% vs 64.1% (non-inferior). OS 80.3% vs 78.9%. Locoregional recurrence 13.4% vs 10.0% (P=.20) |
| JCOG0802 post hoc, pathologic invasive features (2026), n=298 | Lymphatic, vascular or pleural invasion, or nodal metastasis | OS HR 0.657 (not significant). Locoregional relapse HR 2.234 with segmentectomy |
| NCDB cT1c (2–3 cm), comorbidity-free (2025) | Retrospective | No OS difference (aHR 1.13; matched 5-year OS 70.1% vs 72.0%) |
In JCOG0802, the survival difference came from fewer deaths from other diseases and second cancers after segmentectomy, not from better lung cancer control.[7]
Guideline positions:
- ACCP 2025: Sublobar resection and lobectomy are treated as equivalent for peripheral tumors ≤2 cm. This requires a margin ≥2 cm (or margin-to-tumor ratio ≥1), confirmed negative nodes, and location in the outer third of the lung. Lobectomy is strongly recommended over sublobar resection for central tumors, tumors >2 cm, and stage II disease.[11]
- AATS 2023 (early-stage NSCLC): Lobectomy remains standard. Anatomic sublobar resection is acceptable for tumors at low risk of nodal involvement or for patients at high risk with lobectomy (COR 1, LOE B-R).[12]
- AATS (subsolid nodules): Sublobar resection may be considered for peripheral subsolid lesions <2 cm (COR IIa, LOE B-R).[13]
Multiple primary lung cancers: NCCN prefers parenchymal-sparing resection for a growing dominant nodule; radiation or IGTA are alternatives. Stable or slow-growing lesions can be observed.[1]
After neoadjuvant therapy in node-positive disease, retrospective data support keeping lobectomy as the standard. The sublobar trials excluded nodal disease.[14]
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Surgical approach
- NCCN: VATS or robotic-assisted resection should be strongly considered when there is no anatomic or surgical contraindication, provided oncologic principles are maintained and the surgeon is proficient.[1]
- VIOLET RCT (n=503): VATS gave better physical function at 5 weeks, lower day-2 pain, shorter stay (4 vs 5 days), fewer in-hospital complications (RR 0.74), and less prolonged pain. Nodal upstaging and 1-year survival were similar.[15]
- Individual-patient-data meta-analysis of 3 RCTs (Lancet 2026, n=1185): Overall survival favored VATS (HR 0.79, 95% CI 0.65–0.96). Disease-free survival was similar (HR 0.91).[16]
- Robotic versus VATS: RCT meta-analysis (5 RCTs, n=712) found less blood loss (−62 mL), more nodes retrieved (+2.6), and slightly lower pain scores with robotic surgery. Costs were higher. Complications, conversion, and 3-year overall survival did not differ.[17] In a high-volume sleeve lobectomy series, RATS was associated with more dissected lymph nodes and a lower conversion rate than VATS, with similar long-term survival.[18] After neoadjuvant therapy, observational data suggest VATS has higher odds of conversion to open surgery (aOR 1.98).[19]
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Intraoperative lymph node evaluation
- NCCN: Nodal resection and mapping are routine, with at least 1 N1 and 3 N2 stations sampled, or complete dissection. Stations sampled preoperatively by EBUS or mediastinoscopy count toward the total. Formal ipsilateral dissection is indicated when resecting N2 disease.[1]
- ACCP 2025: Systematic hilar and mediastinal sampling or dissection rather than selective or no sampling (strong recommendation, low certainty). At least 3 mediastinal and 1 hilar station (conditional, low certainty).[11]
- ACOSOG Z0030 (n=1023): When thorough systematic sampling was negative, complete mediastinal dissection found occult N2 in 21 patients but did not improve survival (median 8.1 vs 8.5 years).[20]
- Real-world shortfall: In a population-based U.S. cohort, 75% of resections met neither the dissection nor the systematic sampling standard.[21]
- Occult N2 found at surgery: Continue the planned resection with formal dissection. During VATS or robotic surgery, stopping to give induction therapy is an option.[1]
Complete resection (R0): Requires free margins, systematic nodal dissection or sampling, and a negative highest mediastinal node. R1 is microscopic positive margins; R2 is gross residual tumor. Patients with clinical stage IB or higher, or other high-risk features, should be referred to medical oncology.[1]
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Perioperative systemic therapy: surgical implications
Biomarker testing before pathway selection is mandatory. EGFR/ALK status determines whether chemoimmunotherapy or a targeted pathway is appropriate.
For EGFR/ALK-negative tumors ≥4 cm or node-positive:
- NCCN category 1 regimens:[1]
- Neoadjuvant nivolumab plus chemotherapy, with optional adjuvant nivolumab. No known EGFR/ALK.
- Perioperative pembrolizumab with cisplatin-based chemotherapy.
- Perioperative durvalumab. No known EGFR/ALK.
- ASCO: Neoadjuvant chemoimmunotherapy, chemotherapy, or concurrent chemoradiation for stage III NSCLC planned for resection (evidence high; recommendation strong).[22]
- AATS: Platinum doublet plus immunotherapy is the preferred neoadjuvant regimen for resectable stage II–III disease without EGFR/ALK alterations (COR 1, LOE B-R).[12]
For EGFR-mutant tumors (exon 19 deletion or L858R):
- Neoadjuvant osimertinib ± chemotherapy is an option for stage II–IIIB, followed by adjuvant osimertinib.[1]
- NeoADAURA: major pathologic response 26% with osimertinib plus chemotherapy; EFS immature.[23]
- Adjuvant osimertinib is category 1 and improved overall survival in ADAURA.[24]
- Adjuvant pembrolizumab is not recommended for resected EGFR-mutant disease.[11]
For ALK-positive tumors: Adjuvant alectinib is category 1.[1]
| Trial | Proportion reaching surgery (IO vs control) | pCR | EFS / OS |
|---|---|---|---|
| CheckMate 816 (neoadjuvant) | 83% vs 75% | 24% vs 2% | EFS HR 0.63 |
| KEYNOTE-671 (perioperative), 5-year update | 82% vs 79% | 18% vs 4% | 5-year EFS 49.9% vs 26.5% (HR 0.58). 5-year OS 64.6% vs 53.6% (HR 0.74) |
| CheckMate 77T | 77.7% vs 76.7% | 25.3% vs 4.7% | EFS HR 0.58 |
| AEGEAN | 77.6% vs 76.7% | 17.2% vs 4.3% | EFS HR 0.68 |
Surgical relevance: Roughly 1 in 5 patients in both arms did not reach surgery. Resectability and operability should be reassessed after induction. Restaging CT ± PET is used to exclude progression.[1]
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N2 disease
The role of surgery remains controversial. Two randomized trials showed no overall survival benefit from adding surgery, although NCCN considers N2 disease too heterogeneous for those trials to settle the question.[1]
NCCN principles:[1]
- The decision should be made before any therapy, by a multidisciplinary team that includes a thoracic surgeon and a radiation oncologist.
- There should be a high probability of complete resection before neoadjuvant therapy starts.
- Mediastinal evaluation must include the subcarinal station and contralateral nodes.
- One strategy: EBUS ± EUS at initial staging, with mediastinoscopy kept for restaging.
- A cooperative-group trial found unacceptable morbidity and mortality with pneumonectomy after neoadjuvant chemoradiation.
ASCO: Induction therapy followed by surgery may be offered for stage IIIA (N2) only if R0 resection is judged possible, N3 is excluded by multidisciplinary consensus, and expected 90-day mortality is ≤5% (evidence moderate; recommendation weak).[22]
In a matched analysis of Intergroup 0139, perioperative mortality was 26% after pneumonectomy versus 1% after lobectomy.[22]
STS 2025 consensus:
- Single-station non-bulky N2: Surgery is generally appropriate, with neoadjuvant chemoimmunotherapy preferred over adjuvant therapy.[28]
- Bulky N2: Defined as ≥2.5 cm short axis, extranodal involvement, or matted nodes.[28]
- Multistation N2: Generally not a surgical candidate. Selected non-bulky cases with 2–3 involved stations, especially where lobectomy is likely, can be considered after multidisciplinary review.[28]
NCCN 2024 institutional survey (practice patterns): All member institutions consider surgery after neoadjuvant therapy for single-station non-bulky N2. None consider upfront surgery for multistation or bulky (≥3 cm) N2. 85% require at least stable disease after induction before surgery.[1]
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Perioperative mortality benchmarks
- NCDB 30-day mortality: 2.6% lobectomy or bilobectomy, 4.2% wedge, 8.5% pneumonectomy.[29]
- Propensity-matched 90-day mortality: 6.9% after pneumonectomy vs 1.9% after lobectomy. 90-day mortality runs 1.5–2 times the in-hospital rate.[30]
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Surgery versus SBRT in operable stage I
- ACCP 2025: Resection is suggested over SBRT, and over ablation, for operable clinical stage I disease (conditional, low certainty).[11]
- NCCN: SABR is not proven equivalent to lobectomy.[1]
- Revised STARS: A single-arm prospective trial with a prespecified VATS lobectomy and mediastinal dissection comparator found SABR non-inferior for operable stage IA. The authors state it does not replace phase 3 trials.[31]
- Ongoing trials: VALOR (NCT02984761) and STABLE-MATES (NCT02468024) are in progress.[31]
- NCCN high-risk examples for SABR: age ≥75 years, poor lung or cardiac function.[1]
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Small cell lung cancer
(NCCN SCLC v1.2027)
- Eligibility: Stage I–IIA disease makes up <5% of SCLC. Candidates have clinical T1–2N0M0 after full staging, including brain imaging and FDG-PET/CT. T3 (size) N0 may be considered if invasive mediastinal staging is negative.[2]
- Mediastinal staging: Mediastinoscopy or other surgical mediastinal staging is required before resection; EBUS is listed as preferred when expertise exists.[2]
- Operation: Lobectomy (preferred) with mediastinal dissection or systematic sampling of ≥3 N2 and ≥1 N1 stations. SABR, or systemic therapy with concurrent RT, is the alternative.[2]
- Small presumed-SCLC lesions in never-smokers should be resected, because they are likely misdiagnosed carcinoids.[2]
- Unexpected intraoperative SCLC diagnosis: Frozen-section nodal assessment; anatomic resection, preferably lobectomy. Pneumonectomy should not be done to encompass nodal disease.[2]
- After resection: Systemic therapy for all patients. R0, N0: systemic therapy alone. N2/N3: systemic therapy plus mediastinal RT. N1: mediastinal RT may be considered. R1/R2: systemic therapy with concurrent RT.[2]
- Evidence base: The comparative evidence is retrospective. A propensity-matched analysis of >2000 patients favored surgery (HR 0.62), but the only prospective comparisons date from the 1970s–1990s.[32]
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Image-guided thermal ablation
Image-guided thermal ablation (radiofrequency ablation, microwave ablation, cryoablation) may be an option for selected high-risk patients with early-stage NSCLC who are medically inoperable. It is used mainly for lesions <3 cm; larger lesions have more local recurrence and complications. NCCN default for inoperable disease is definitive RT, preferably SABR.[1]
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Enhanced recovery after surgery (ERAS)
Guideline-based thoracic ERAS cut length of stay by 1.2 days and morbidity by 12% (32% to 20%) in a propensity-matched study, with unchanged readmissions. It also reduced pneumonia and arrhythmia across a multi-hospital system.[33]
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Clinically actionable recommendations
(NCCN items are category 2A unless marked. ACCP uses GRADE, ASCO uses evidence strength, and AATS uses COR/LOE.)
- Refer every potential curative-intent patient to a thoracic surgeon. Decide resectability for T3/T4-invasive and N2 disease before starting any therapy (NCCN).[1]
- Cardiac assessment first, then FEV1 and DLCO with ppo values in every candidate. Use stair climb or shuttle walk if either ppo value is 30–60% (Grade 1C), and CPET if either is below 30% (Grade 1B) (ACCP).[3]
- Do not deny surgery for smoking status alone, and provide cessation support (NCCN).[1]
- For peripheral cT1a–b N0 tumors, consider segmentectomy or wedge resection. Requirements: margin ≥2 cm or at least the tumor size, and intraoperatively confirmed node-negative disease (NCCN; ACCP equivalence).[1][11]
- Use lobectomy for central tumors, tumors >2 cm, and stage II disease (ACCP strong recommendation).[11]
- Prefer sleeve resection to pneumonectomy when anatomically feasible and margin-negative (NCCN).[1]
- Use a minimally invasive approach in the absence of contraindications (NCCN; VIOLET RCT).[1][15]
- Evaluate at least 1 N1 and 3 N2 stations, or do a complete dissection (NCCN; ACCP strong for systematic evaluation).[1][11]
- For tumors ≥4 cm or node-positive disease, complete biomarker testing (EGFR, ALK, RET, PD-L1) before surgery. For EGFR/ALK-negative tumors, neoadjuvant or perioperative chemoimmunotherapy is the default. For EGFR-mutant tumors, neoadjuvant osimertinib ± chemotherapy followed by adjuvant osimertinib is an option. For ALK-positive tumors, adjuvant alectinib is category 1.[1][22]
- For N2 disease, operate only if R0 is achievable, N3 has been excluded, and expected 90-day mortality is ≤5% (ASCO weak recommendation). Favor single-station, non-bulky disease that needs only lobectomy.[22][1]
- For superior sulcus tumors, use neoadjuvant concurrent chemoradiation followed by surgery and adjuvant systemic therapy (ASCO strong recommendation). Obtain MRI of chest/spine for lesions abutting spine, subclavian vessels, or brachial plexus.[22][1]
- For limited-stage SCLC, resect pathologically node-negative cT1–2N0 (and selected T3N0 after negative invasive staging) by lobectomy with nodal dissection, and always give adjuvant systemic therapy (NCCN).[2]
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Important updates compared with older teaching
- Lobectomy is no longer universal. Segmentectomy is non-inferior, and in JCOG0802 superior for overall survival, in peripheral ≤2 cm tumors.[7][8]
- Minimally invasive surgery improves recovery. RCT-level pooled data now suggest an overall survival benefit (HR 0.79).[15][16]
- Nodal evaluation is station-based ("3+1"), not a node count.[1]
- Perioperative chemoimmunotherapy is standard for resectable stage II–III disease without EGFR/ALK alterations. For EGFR-mutant disease, neoadjuvant/adjuvant osimertinib is the preferred targeted pathway.[25][24]
- N2 is split into N2a/N2b in TNM 9th edition. Surgery is most accepted for single-station, non-bulky disease.[28][1]
- Surgery in SCLC is guideline-endorsed for pathologically node-negative T1–2 disease.[2]
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Areas of uncertainty, controversy, or guideline disagreement
- Wedge versus segmentectomy: CALGB 140503 used 59% wedges; JCOG0802 used only segmentectomy. The higher locoregional relapse after segmentectomy in JCOG0802, including in tumors with invasive features, remains a concern.[8][9]
- Sublobar resection for T1c (2–3 cm): ACCP strongly recommends lobectomy. Retrospective NCDB data show no difference. JCOG trials of tumors >2 cm are ongoing.[11][10]
- Neoadjuvant-only versus perioperative immunotherapy: No head-to-head trial exists. An indirect meta-analysis found no additional event-free survival gain from the adjuvant phase (HR 0.90).[27]
- Multistation or bulky N2: Surgery remains contentious. Definitions of bulky differ: NCCN's survey uses ≥3 cm; STS uses ≥2.5 cm short axis.[1][28]
- Pneumonectomy after induction: Cooperative-group data show excess mortality, while single-institution series report acceptable safety. 76% of NCCN institutions would consider it after neoadjuvant chemotherapy.[1]
- High-risk physiologic thresholds: ppo below 30% (ACCP; ERS/ESTS) versus below 40% (ACCP/STS), with different exercise criteria.[4]
- Surgery versus SBRT in operable patients: No completed phase 3 RCT; revised STARS suggests non-inferiority but authors state it does not replace phase 3 trials. Observational data favor surgery but are confounded.[11][31]
- Mediastinal dissection versus systematic or lobe-specific sampling: Whether full dissection adds benefit beyond rigorous sampling is unresolved.[11][12]
- SCLC beyond stage I: Surgery after neoadjuvant chemoimmunotherapy in stage II–III disease is investigational.[32]
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High-yield clinical pearls
- JCOG0802's survival advantage came from fewer non-cancer deaths and second cancers. Preserving lung matters in patients at risk of second primaries.[7]
- CALGB 140503 randomized only after intraoperative confirmation of N0. Sublobar equivalence assumes rigorous nodal assessment.[8]
- DLCO can be low with a normal FEV1. Always measure both, and repeat DLCO after induction therapy.[4]
- A ppo value near 30% does not preclude surgery if exercise capacity is adequate.[3]
- A small "SCLC" in a never-smoker is likely a carcinoid. Resect it.[2]
- Every patient with clinical stage IB or higher should see medical oncology.[1]
- Biomarker results must be available before choosing the neoadjuvant pathway. EGFR/ALK-positive tumors do not receive chemoimmunotherapy as default.[1]
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Common pitfalls
- Starting neoadjuvant therapy before a thoracic surgeon has confirmed resectability.[1]
- Giving chemoimmunotherapy to an EGFR/ALK-positive tumor without considering the targeted pathway.[1]
- Assuming PET-negative central tumors need no invasive mediastinal staging.[1]
- Doing a sublobar resection without N1/N2 sampling, or with margins below 2 cm or the tumor size.[1]
- Applying sublobar trial data to node-positive disease or post-neoadjuvant resections.[14]
- Excluding patients on spirometry alone, without ppo calculation and exercise testing.[3]
- Planning pneumonectomy-level multimodality treatment when expected 90-day mortality exceeds 5%.[22]
- Resecting SCLC without invasive mediastinal staging, or omitting adjuvant systemic therapy.[2]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 1.37 1.38 1.39 1.40 1.41 1.42 1.43 1.44 Non-Small Cell Lung Cancer. National Comprehensive Cancer Network. Version 9.2026.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Small Cell Lung Cancer. National Comprehensive Cancer Network. Version 1.2027.
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e166S-e190S.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Pennathur A, Brunelli A, Criner GJ, et al. Definition and assessment of high risk in patients considered for lobectomy for stage I non-small cell lung cancer: The American Association for Thoracic Surgery expert panel consensus document. J Thorac Cardiovasc Surg. 2021;162(6):1605-1618.e6.
- ↑ Global Initiative for Chronic Obstructive Lung Disease. 2026 GOLD Report and Pocket Guide.
- ↑ Dun Y, Yu J, Gao Y, et al. Grading the evidence for CPET variables in predicting perioperative morbidity and long-term mortality in lung cancer surgery: a systematic review and meta-analysis. Syst Rev. 2026. doi:10.1186/s13643-026-03258-y.
- ↑ 7.0 7.1 7.2 7.3 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.
- ↑ 8.0 8.1 8.2 8.3 Altorki N, Wang X, Kozono D, et al. Lobar or sublobar resection for peripheral stage IA non-small-cell lung cancer. N Engl J Med. 2023;388(6):489-498.
- ↑ 9.0 9.1 Katsumata S, Kamigaichi A, Akamine T, et al. Segmentectomy versus lobectomy in NSCLC with pathologically invasive features: a post hoc supplementary analysis of multicenter, phase 3 trial JCOG0802/WJOG4607L. J Thorac Oncol. 2026;21(10):103916.
- ↑ 10.0 10.1 Mathey-Andrews CA, Potter AL, Srinivasan D, et al. Segmentectomy versus lobectomy for patients with 2-3cm non-small-cell lung cancer. Chest. 2025.
- ↑ 11.00 11.01 11.02 11.03 11.04 11.05 11.06 11.07 11.08 11.09 Howington J, Souter LH, Arenberg D, et al. Management of patients with early-stage non-small cell lung cancer: An American College of Chest Physicians clinical practice guideline. Chest. 2025;168(3):810-827.
- ↑ 12.0 12.1 12.2 Expert Consensus Panel, Kidane B, Bott M, et al. The American Association for Thoracic Surgery (AATS) 2023 expert consensus document: Staging and multidisciplinary management of patients with early-stage non-small cell lung cancer. J Thorac Cardiovasc Surg. 2023;166(3):637-654.
- ↑ Chen H, Kim AW, Hsin M, et al. The 2023 American Association for Thoracic Surgery (AATS) expert consensus document: Management of subsolid lung nodules. J Thorac Cardiovasc Surg. 2024;168(3):631-647.e11.
- ↑ 14.0 14.1 Reddington H, Emmerick I, Diaz Collante J, et al. Survival following sublobar resection after neoadjuvant therapy for T1N1-2M0 lung cancer. PLoS One. 2026;21(6):e0349231.
- ↑ 15.0 15.1 15.2 Lim E, Harris RA, McKeon HE, et al. Impact of video-assisted thoracoscopic lobectomy versus open lobectomy for lung cancer on recovery assessed using self-reported physical function: VIOLET RCT. Health Technol Assess. 2022;26(48):1-162.
- ↑ 16.0 16.1 Harris RA, Law JJ, Hao L, et al. Survival outcome of VATS compared with open lobectomy for lung cancer: an individual patient data meta-analysis of randomised trials. Lancet. 2026;407(10534):1182-1190.
- ↑ Arora N, et al. Robotic vs. video-assisted thoracoscopic surgery: a retrospective analysis of safety and length of stay during initial implementation of a robotic program. J Thorac Dis. 2026;18(4):324.
- ↑ Hu S, et al. Comparison of robot-assisted and video-assisted thoracic sleeve lobectomy in non-small cell lung cancer: insights from a high-volume center. J Thorac Dis. 2025;17(4):2174-2185.
- ↑ Shahoud J, et al. Uniportal video-assisted lung resection versus robotic-assisted lung resection, is there a difference? J Thorac Dis. 2024;16(11):7539-7545.
- ↑ Darling GE, Allen MS, Decker PA, et al. Randomized trial of mediastinal lymph node sampling versus complete lymphadenectomy during pulmonary resection in the patient with N0 or N1 (less than hilar) non-small cell carcinoma: results of the American College of Surgery Oncology Group Z0030 trial. J Thorac Cardiovasc Surg. 2011;141(3):662-70.
- ↑ Ray MA, Smeltzer MP, Faris NR, Osarogiagbon RU. Survival after mediastinal node dissection, systematic sampling, or neither for early stage NSCLC. J Thorac Oncol. 2020;15(10):1670-1681.
- ↑ 22.0 22.1 22.2 22.3 22.4 22.5 22.6 Daly ME, Singh N, Ismaila N, Management of Stage III NSCLC Guideline Expert Panel. Management of stage III non–small cell lung cancer: ASCO guideline rapid recommendation update. J Clin Oncol. 2024;42(25):3058-3060.
- ↑ He J, Tsuboi M, Weder W, et al. Neoadjuvant Osimertinib for Resectable EGFR-Mutated Non-Small Cell Lung Cancer. J Clin Oncol. 2025;43(26):2875-2887.
- ↑ 24.0 24.1 Tsuboi M, Herbst RS, John T, et al. Overall Survival with Osimertinib in Resected EGFR-Mutated NSCLC. N Engl J Med. 2023;389(2):137-147.
- ↑ 25.0 25.1 Forde PM, Spicer J, Lu S, et al. Neoadjuvant Nivolumab plus Chemotherapy in Resectable Lung Cancer. N Engl J Med. 2022;386(21):1973-1985.
- ↑ Wakelee H, Spicer JD, Gao S, et al. Five-year outcomes of perioperative pembrolizumab for early-stage non-small-cell lung cancer from the randomized KEYNOTE-671 study. Ann Oncol. 2026.
- ↑ 27.0 27.1 Johnson DB, Nassar AH, Aijaz A, et al. Reconsidering adjuvant and perioperative immune-checkpoint inhibition: de-escalation, expansion and personalization. Nat Rev Clin Oncol. 2026;23(5):341-355.
- ↑ 28.0 28.1 28.2 28.3 28.4 Kim SS, Cooke DT, Kidane B, et al. The Society of Thoracic Surgeons expert consensus on the multidisciplinary management and resectability of locally advanced non-small cell lung cancer. Ann Thorac Surg. 2025;119(1):16-33.
- ↑ Ray MA, Smeltzer MP, Faris NR, Osarogiagbon RU. Survival after mediastinal node dissection, systematic sampling, or neither for early stage NSCLC. J Thorac Oncol. 2020;15(10):1670-1681.
- ↑ Kim SS, Cooke DT, Kidane B, et al. The Society of Thoracic Surgeons expert consensus on the multidisciplinary management and resectability of locally advanced non-small cell lung cancer. Ann Thorac Surg. 2025;119(1):16-33.
- ↑ 31.0 31.1 31.2 Chang JY, et al. Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: a pooled analysis of two randomised trials. Lancet Oncol. 2015;16(6):630-637.
- ↑ 32.0 32.1 Zou R, Zhu Z, Teng X, Yu S, Lyu X. Surgery Versus Radiotherapy After Neoadjuvant Immunochemotherapy in Limited-Stage Small Cell Lung Cancer. J Thorac Dis. 2026;18(5):528.
- ↑ Batchelor TJP, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019;55(1):91-115.