Does segmentectomy offer similar outcome to lobectomy in patients with clinical stage IA1-2 NSCLC and pathologic upstaging due to visceral pleura infiltration?

Background Segmentectomy has become the standard of care in selected patients with stage IA1 and IA2 NSCLC. Lobectomy remains the treatment of choice for stage IB NSCLC. However, it is unclear how patients with clinical stage IA1-2 NSCLC should be managed if upstaging occurs due to visceral pleura infiltration on final pathology (stage IB). We aimed to compare the outcomes of patients who underwent lobectomy or segmentectomy for clinical stages IA1-2 NSCLC and had visceral pleura infiltration on final pathology.

Methods & Materials We retrospectively analyzed all patients with clinical stage IA1-2 NSCLC and postoperative upstaging due to visceral pleura infiltration who underwent surgery at our center between 2013 and 2024. Disease-free (DFS) and overall (OS) survivals were calculated from the date of surgery until recurrence or death, respectively. Univariate analysis was performed to study the impact of clinical variables on DFS and OS.

Results We identified 46 patients in clinical stage IA1-2 NSCLC who underwent lobectomy (n=18) or segmentectomy (n=28) and had upstaging to stage IB due to visceral pleura infiltration on final pathology report. There was no difference in patient demographics or clinical characteristics between the groups. Most of the resections (89%) were performed by VATS. None of the patients from the segmentectomy group had completion lobectomy due to visceral pleura infiltration on final pathology report. One death occurred within the first 90-days following surgery due to pneumonia in the lobectomy group. Median tumor size was 1.7cm (range 1-2cm). Number of removed lymph nodes was significantly lower in the segmentectomy group (15.5 vs. 22.5 p=0.031). Resection margin was significantly smaller in the segmentectomy group (median 2.15cm vs. 3.4cm p=0.028). 5-year DFS (62% vs. 83%, p=0.393) and OS (49% vs. 63%, p=0.213) were not statistically significantly different between the segmentectomy and lobectomy groups. Patients with a margin to tumor ratio MTR≥ 1 had significantly better DFS (87% vs. 39%, p=0.019) than those with a MTR<1. In patients with less comorbidities (Charlson Deyo comorbidity score< 5), lobectomy offered significantly better survival (100% vs. 44%, p=0.031).

Conclusion 5-years OS and DFS were not different in our cohort of patients with stage IA1-2 NSCLC who underwent lobectomy or segmentectomy and had upstaging due to visceral pleura infiltration. Therefore, upstaging may not necessitate completion lobectomy. Further studies are still required to confirm our findings.