Anatomical Segmentectomy versus Lobectomy for cT1N0M0 NSCLC Upstaged to pT2aN0M0 by Occult Visceral Pleural Invasion: a multicenter cohort study

OBJECTIVES: Occult visceral pleural invasion (VPI) may upstage cT1N0M0 non-small cell lung cancer (NSCLC) to pT2aN0M0. We compared perioperative and oncological outcomes after segmentectomy and lobectomy in this setting. METHODS: This multicenter retrospective study included cT1N0M0 NSCLC patients treated with minimally invasive segmentectomy or lobectomy who were subsequently upstaged to pT2aN0M0 because of VPI. Propensity score matching (PSM) (1:1) was performed. Perioperative and oncological outcomes were compared. Exploratory and sensitivity analyses evaluated tumors ≤20 mm and patients who did not receive adjuvant therapy. RESULTS: Among 448 patients, 104 underwent segmentectomy and 344 lobectomy. After PSM, 87 matched pairs were analyzed. Segmentectomy was associated with shorter operative time, lower postoperative morbidity, and shorter hospital stay. No significant differences were observed in DFS (p = 0.387), OS (p = 0.075), or CSS (p = 0.388). Multivariable analysis identified adjuvant therapy and age as independent predictors of DFS and OS, respectively, whereas the extent of resection was not independently associated with survival. In patients with a preoperative CT total tumor diameter ≤20 mm, segmentectomy was associated with a higher rate of local recurrence (13.8vs2.0%, p = 0.037) and worse adjusted DFS and OS, despite no significant differences in Kaplan-Meier survival. CONCLUSIONS: In patients with cT1N0M0 NSCLC upstaged to pT2aN0M0 because of occult VPI, segmentectomy was associated with lower postoperative morbidity, with no significant differences in oncological outcomes in the overall matched cohort. Exploratory findings in patients with a preoperative CT total tumor diameter ≤20 mm suggest a higher risk of local recurrence and worse adjusted DFS and OS after segmentectomy, warranting further validation.