Oncologic outcomes of sublobar resection in non–small cell lung cancer ≤3 cm with adverse pathologic features

Objectives This study evaluated the association between resection extent and recurrence-free survival in patients with clinically node-negative NSCLC ≤3 cm with adverse pathologic features including visceral pleural invasion, spread through air spaces (STAS), or high-grade histology. Methods We retrospectively reviewed patients who underwent curative-intent resection for cN0M0 NSCLC with pathologic tumor size ≤3 cm between 2017 and 2023. Patients were categorized into sublobar resection and lobectomy groups. Cox proportional hazards models were used to identify factors associated with recurrence-free survival. Propensity-score weighting was used to account for measured differences between the surgical groups, followed by weighted survival analyses within prespecified individual and combined adverse-feature subgroups. Results Among 1,774 patients, 666 underwent sublobar resection and 1,108 underwent lobectomy. Visceral pleural invasion, STAS, and high-grade histology were independently associated with a higher risk of recurrence. Lobectomy was not independently associated with recurrence-free survival in multivariable analysis (HR, 1.17; 95% CI, 0.69–1.98, p = 0.562). In unadjusted subgroup analyses, recurrence-free survival did not significantly differ by resection extent among patients with visceral pleural invasion, STAS, or high-grade histology with similar findings in combined subgroups (p > 0.05). Weighting reduced the baseline imbalances, while the resulting survival curves remained largely overlapping across the individual adverse-feature subgroups. Conclusions Visceral pleural invasion, STAS, and high-grade histology were independently associated with recurrence, whereas resection extent was not. The weighted analysis did not show a clear separation between surgical groups, although the present analysis was not designed to demonstrate comparable efficacy between the two surgical approaches.