Current advances in extended resections for non-small cell lung cancer-a narrative review

Locally advanced non-small cell lung cancer (NSCLC) encompasses a biologically and anatomically highly heterogenous spectrum. For tumours with infiltration of the chest wall, thoracic inlet, central airways, great vessels, diaphragm or vertebral column, the goal of surgery remains a complete R0 resection, but the boundary between resectable and unresectable disease is fluid and depends on anatomy, nodal burden, response to induction therapy, functional reserve as well as institutional experience. This review summarizes current concepts in extended resection and proposes a practical framework for patient selection.

We performed a narrative review of literature indexed in PubMed, Embase, Scopus and Google Scholar from January 2000 to January 2026. Priority was given to guidelines, expert consensus statements, prospective studies, systematic reviews/meta-analyses, and recent multicentre or large institutional series. Evidence was synthesized narratively with emphasis on resectability, patient selection, operative strategy and oncologic outcomes.

Extended resection is defined as anatomical pulmonary resection combined with en bloc resection and-if necessary-reconstruction of adjacent structures. Across all T3 and T4 subgroups, nodal status, tumour size, depth of invasion, cardiopulmonary reserve and feasibility of radical resection are key factors for determining operability and prognosis. Perioperative immunotherapy is reshaping the treatment landscape by increasing pathological response rates and creating new possibilities for surgery in borderline resectable cases or in salvage surgery. Definitive chemoradiotherapy followed by consolidation immunotherapy remains the preferred strategy when R0 resection is unlikely, nodal burden is bulky, functional reserve is limited, or major reconstruction would carry a prohibitive risk.

Extended resection for locally advanced NSCLC should be considered a tailored multidisciplinary strategy rather than a purely technical exercise. The best candidates are those in whom multimodal therapy can provide an R0 resection with acceptable perioperative risk. Future work should focus on refining resectability criteria, incorporating biological response markers to immunotherapy into decision-making, and prospectively evaluating salvage strategies.