Extent of resection for spread-through air spaces-positive stage IA1-2 non-small cell lung cancer

Sublobar resection has demonstrated noninferiority to lobectomy in unselected stage IA non-small cell lung cancer (NSCLC), but the optimal surgical approach in tumors with spread-through air spaces (STAS) remains unclear. This study examines how extent of resection influences clinical outcomes in patients with STAS-positive stage IA1-2 NSCLC.

Patients who underwent lung resection for primary pathologic stage IA1-2 NSCLC between February 2018 and January 2022 at a tertiary academic institution were included. In the STAS-positive cohort, multivariable competing risk models were used to assess cumulative incidence of recurrence and lung cancer-related death after lobectomy versus sublobar resection, and propensity score-matched analysis was performed for overall survival and recurrence-free survival. Exploratory analysis was performed to evaluate outcomes after specific resection type (lobectomy, segmentectomy, wedge) in the STAS-positive cohort.

A total of 445 patients met inclusion criteria, of whom 158 (35.5%) were STAS-positive. Within the STAS-positive cohort, recurrence was significantly more frequent after sublobar resection (subdistribution hazard ratio, 7.60; 95% confidence interval, 1.85-31.33, P = .005), and lung cancer-specific mortality was higher (subdistribution hazard ratio, 5.12; 95% confidence interval, 1.03-25.62; P = .047). Propensity-score matching yielded 40 well-balanced pairs. Overall survival was similar between lobectomy and sublobar resection (5-year overall survival: lobectomy 91.5% vs sublobar 80.3%, P = .18). In contrast, recurrence-free survival was significantly worse after sublobar resection (5-year recurrence-free survival: lobectomy 88.8% vs sublobar 66.1%, P = .042). On exploratory analysis, inferior recurrence-free survival was observed for wedge resection (P = .024) but not for segmentectomy (P = .324) when compared with lobectomy.

Sublobar resection, particularly wedge resection, is associated with worse recurrence-free survival for STAS-positive stage IA1-2 NSCLC.