Postoperative anti-tuberculosis therapy after complete resection of asymptomatic pulmonary tuberculous nodules: a multicenter retrospective cohort study

Anti-tuberculosis (anti-TB) therapy is generally recommended for established pulmonary tuberculosis. However, the incremental benefit of postoperative anti-TB therapy after complete resection of asymptomatic pulmonary tuberculous nodules remains uncertain in this specific population. Given the potential treatment-related burden, clarifying the need for postoperative therapy is clinically relevant. We evaluated postoperative recurrence, treatment burden, and factors associated with treatment use to inform postoperative management in this population. In this multicenter retrospective cohort study, patients with computed tomography (CT)-detected asymptomatic pulmonary nodules pathologically confirmed as tuberculosis (TB) after surgical resection at two Chinese centers between 2013 and 2024 were screened. The primary outcome was postoperative TB recurrence. The secondary outcome was treatment burden among treated patients, including medical adverse events and medication-related anxiety. Postoperative treatment regimens were summarized, and factors associated with treatment use were assessed using multivariable logistic regression. Recurrence-free survival was analyzed with Kaplan-Meier curves, log-rank tests, and Firth-penalized Cox models. Of 306 screened patients, 273 were included; 228 received postoperative anti-TB therapy and 45 did not. During a median follow-up of 54.9 months, four recurrences occurred, all in treated patients. Recurrence-free survival did not differ significantly by treatment status (log-rank p = 0.326). In the adjusted Firth model, postoperative treatment was not significantly associated with recurrence-free survival (HR 2.84, 95% CI 0.10–78.56; p = 0.437), but the small number of events and wide confidence interval left the direction and magnitude of the association uncertain. Larger lesion size (OR 1.10 per mm, 95% CI 1.03–1.16; p = 0.003) and positive acid-fast staining result (OR 3.23, 95% CI 1.50–6.96; p = 0.003) were independently associated with treatment use. Among treated patients, 43.9% experienced treatment burden. Routine postoperative anti-TB therapy after complete resection of asymptomatic pulmonary tuberculous nodules was not significantly associated with improved recurrence-free survival in this cohort, whereas treatment-related burden was common among treated patients. However, given the limited number of recurrence events and baseline differences between treatment groups, these findings suggest that postoperative observation should be considered only in carefully selected patients.