Impact of Spread Through Air Spaces on Outcomes After Uniportal VATS Resection for Lung Adenocarcinoma: A Propensity...

Background: Tumor Spread Through Air Spaces (STAS) is a histopathological pattern of invasion associated with aggressive behavior in lung adenocarcinoma. Its prognostic impact and implications for surgical strategy remain controversial. This study evaluated the impact of STAS on survival and recurrence outcomes in patients undergoing uniportal video-assisted thoracoscopic surgery (U-VATS) for lung adenocarcinoma. Methods: We retrospectively analyzed consecutive patients with histologically confirmed lung adenocarcinoma who underwent U-VATS resection between January 2020 and January 2023 at a single tertiary referral center. Propensity score matching (1:1) was performed to reduce selection bias between STAS-positive and STAS-negative patients. Overall survival (OS) and recurrence-free survival (RFS) were analyzed using Kaplan-Meier estimates and log-rank tests. Multivariable Cox proportional hazards regression models were used to identify independent predictors of survival. Subgroup analyses were performed according to the type of resection. Results: Among 365 included patients, 111 (30.4%) were STAS-positive. After propensity score matching, 222 patients were analyzed (111 STAS-positive and 111 STAS-negative). STAS-positive patients showed a higher overall recurrence rate compared with STAS-negative patients (36.9% vs. 27.9%, p = 0.15), with a significantly increased rate of local parenchymal recurrence (18.9% vs. 9.0%, p = 0.03). No significant differences in OS or RFS were observed between matched groups. Multivariable Cox regression analysis confirmed that STAS was not independently associated with OS (HR 0.88, 95% CI 0.50-1.53, p = 0.643). In STAS-positive patients, sublobar resection was associated with significantly worse survival outcomes compared with lobectomy and emerged as an independent predictor of mortality (HR 2.61, 95% CI 1.14-5.97, p = 0.02). Conclusions: STAS was associated with an increased risk of local recurrence but was not independently associated with overall survival after U-VATS resection for lung adenocarcinoma. However, in STAS-positive patients, sublobar resection was independently associated with worse survival outcomes, suggesting that surgical extent plays a critical role in this subgroup. These findings support consideration of a personalized surgical approach in patients with STAS-positive lung adenocarcinoma.