Lobectomy, segmentectomy, and wedge resection for elderly patients with solid-predominant stage I NSCLC: survival,...

Lobectomy has long been regarded as the standard surgical treatment for stage I non-small cell lung cancer (NSCLC). However, elderly patients may have limited physiological reserve and may not tolerate the associated loss of pulmonary function. Whether segmentectomy or wedge resection can provide comparable oncologic outcomes and potential functional benefits in elderly patients with solid-predominant stage I NSCLC remains unclear. This study aimed to compare the long-term oncologic outcomes, postoperative safety, and preservation of pulmonary function among lobectomy, segmentectomy, and wedge resection in elderly patients with solid-predominant stage I NSCLC, and to evaluate whether segmentectomy and wedge resection could serve as a feasible alternative to lobectomy in this population.

We conducted a retrospective cohort study using the Western China Lung Cancer Database. Patients aged ≥60 years with pathological stage I solid-predominant NSCLC who underwent lobectomy, segmentectomy, or wedge resection were included. Propensity score-based weighting was performed to reduce baseline imbalance, including inverse probability of treatment weighting based on the average treatment effect (ATE) estimand and overlap weighting as a sensitivity analysis. Overall survival (OS) was the primary endpoint; disease-free survival (DFS) and lung cancer-specific survival (LCSS) were secondary endpoints. Postoperative complications and computed tomography (CT)-estimated postoperative pulmonary function were also evaluated.

A total of 1,402 patients were included, comprising 1,187 lobectomies, 128 segmentectomies, and 87 wedge resections. After weighting adjustment, segmentectomy showed long-term survival outcomes generally comparable to lobectomy, with no significant differences in OS, DFS, or LCSS. In contrast, wedge resection was associated with the poorest survival outcomes. In the ATE-weighted cohort, wedge resection showed lower 10-year OS than lobectomy and segmentectomy (49.2% vs. 69.1% vs. 79.1%), lower 10-year DFS (47.7% vs. 61.1% vs. 58.8%), and lower 10-year LCSS (57.2% vs. 78.7% vs. 82.2%). Segmentectomy numerically achieved the highest CT-derived functional lung volume preservation, whereas wedge resection did not show a clear functional lung preservation advantage. Subgroup analyses and the analysis in patients aged ≥70 years showed broadly consistent findings.

In elderly patients with solid-predominant stage I NSCLC, segmentectomy showed long-term survival outcomes generally comparable to lobectomy and may provide a favorable balance between oncologic outcomes and pulmonary function preservation. Wedge resection was associated with inferior survival and did not demonstrate a clear functional lung preservation advantage. These findings require further validation in prospective studies.