Beyond tumour size: Integrating tumour biology and technical quality to select the extent of resection in early-stage NSCLC.

Abstract

Objective: Randomized trials have established anatomical segmentectomy as an acceptable alternative to lobectomy for selected patients with peripheral, node-negative NSCLC ≤2 cm. However, trial populations were highly selected, and tumour diameter alone does not capture the biological heterogeneity of early-stage disease.

Methods: A structured search of Undermind and PubMed identified comparative studies, randomized trials, meta-analyses and consensus evidence available through 10 August 2026. Evidence was critically appraised and synthesized narratively, with emphasis on recurrence, survival, staging and technical quality.

Results: Segmentectomy provides excellent outcomes when adequate margins, anatomical completeness and rigorous nodal assessment are achieved. GGO-dominant tumours, particularly those with low consolidation-to-tumour ratio, represent the strongest candidates for parenchymal preservation. Increasing CTR, pure-solid morphology, larger size, high FDG uptake, micropapillary or solid histology, STAS, VPI and LVI identify progressively higher-risk phenotypes, but none alone consistently proves that lobectomy improves survival. Micropapillary components exceeding approximately 5%, STAS, inadequate margins, incomplete staging and multiple coexisting adverse features strengthen the rationale for lobectomy. Segmentectomy is generally preferable to wedge resection for solid, deeper or biologically aggressive lesions, whereas wedge resection remains reasonable for carefully selected small, peripheral, GGO-dominant tumours. The favourable results of randomized trials depend on accurate preoperative and intraoperative staging and should not be generalized to unselected cT1c or biologically aggressive tumours.

Conclusions: Sublobar resection should be viewed as refined selection rather than replacement of lobectomy. Tumour size defines eligibility, but biology increasingly determines suitability. Precision surgery will require prospective validation of integrated models combining morphology, metabolism, pathology, molecular biomarkers, patient physiology and technical quality.