Beyond Tumour Size: The Impact of Spread Through Air Spaces and Pleural Invasion on Surgical Strategy for Early-Stage...

To review the prognostic impact of spread through air spaces (STAS) and visceral pleural invasion (VPI) in early-stage non-small-cell lung cancer (NSCLC), assess their relevance to the increasing use of sublobar resection, and describe current limitations in their preoperative and intraoperative assessment.

A comprehensive literature review was conducted to summarize key original studies, meta-analyses, and major clinical trials addressing STAS, VPI, diagnostic modalities, and surgical strategies for early-stage NSCLC.

Spread through air spaces is associated with a higher risk of loco-regional recurrence after sublobar resection, and this risk is not adequately reduced by wider surgical margins. Anatomic resection, such as segmentectomy, provides more favourable outcomes than non-anatomic wedge resection in STAS-positive disease. Visceral pleural invasion is associated with an increased risk of distant metastasis, which may contribute to the comparable survival observed between segmentectomy and lobectomy in small VPI-positive tumours. The preoperative and intraoperative identification of both features remains limited due to the low sensitivity of frozen-section analysis for STAS and the modest accuracy of current radiologic predictors.

Tumour size alone is insufficient to guide surgical planning in early-stage NSCLC. Spread through air spaces and VPI have measurable prognostic effects and should be considered when determining the extent of resection. Improved predictive tools and prospective studies incorporating these pathological factors are needed to optimize surgical decision-making and treatment selection.