Management of borderline resectable NSCLC: a narrative review

Borderline resectable NSCLC (BR-NSCLC) represents a complex clinical entity in which surgical resection is technically feasible but oncological benefit and margin negativity are uncertain. Advances in multimodal therapies, particularly the incorporation of neoadjuvant and/or perioperative chemo-immunotherapy (CT-IO), are redefining the management of these patients, as this strategy has significantly increased complete and major pathological response rates, nodal downstaging and survival. However, challenges remain, including standardized criteria for defining resectability, optimal therapeutic strategies, the role of extending lung resection after neoadjuvant CT-IO, therapeutic options in patients who do not undergo resection after neoadjuvant CT-IO, optimal treatment in patients with actionable genomic alterations, and the search for biomarkers to guide decision making. This narrative review summarizes the evolving definitions of resectability, analyses evidence supporting neoadjuvant and perioperative immunotherapy in BR-NSCLC and explores current strategies to convert initially unresectable tumours to resectable, from a multidisciplinary approach, which is crucial in this rapidly changing landscape. Given the lack of universally standardized 'borderline resectable' criteria, we propose a pragmatic operational framework that explicitly separates resectability (probability of achieving an R0 resection with meaningful oncologic benefit) from operability (physiologic ability to tolerate the planned extent of resection). We also provide a multidisciplinary treatment pathway to support consistent decision-making across common clinical scenarios.