Competing Mortality Risks in Radiologically Aggressive Stage IA1–2 Non-Small Cell Lung Cancer

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Background The prognostic implications of the surgical procedure in patients with radiologically aggressive c-stage IA1–2 non-small cell lung cancer (NSCLC) remain unclear. We aimed to identify prognostic factors, distinguish patient-related risk from oncological risk, and explore postoperative outcomes according to the extent of resection within these risk strata. Methods This retrospective study included patients who underwent curative surgery for c-stage IA1–2 NSCLC. Radiologically aggressive tumors were defined as pure-solid tumors on computed tomography with a maximum standardized uptake value (SUVmax) ≥3.0 on positron emission tomography/computed tomography. Patients were stratified according to the identified prognostic factors. Results Of 381 patients, 213 (55.9%) underwent lobectomy and 168 (44.1%) underwent sublobar resection. In multivariable analysis, age ≥75 years and SUVmax >5.0 were independently associated with worse overall survival. Patient-related high risk was defined as age ≥75 years, and oncological high risk as SUVmax >5.0. The 5-year cumulative incidence of lung cancer death was higher in the oncological high-risk group than in the low-risk group (13.8% vs. 6.4%; P = 0.042), whereas the 5-year cumulative incidence of non-lung cancer death was higher in the patient-related high-risk group than in the low-risk group (21.5% vs. 7.9%; P < 0.001). In an exploratory, unadjusted analysis, 5-year overall survival was lower after sublobar resection than after lobectomy only in patients with low patient-related risk and high oncological risk (54.6% vs. 80.1%; P < 0.001). Conclusion Prognosis was influenced by distinct patient-related and oncological risk domains. Separating these risks may support individualized surgical decision-making.