Evaluation of surgical approaches to segmentectomy in lung cancer: A survey study

In early-stage non-small cell lung cancer (NSCLC), segmentectomy has been shown to provide oncologic outcomes comparable to lobectomy and superior functional results, particularly for peripheral solid and subsolid nodules measuring ≤2 cm, as demonstrated by the JCOG0802 and CALGB/Alliance 140503 trials. However, translating these findings into routine clinical practice is constrained by the surgeon's experience, knowledge base, and available technological resources. This study aimed to examine thoracic surgeons' perspectives on segmentectomy, their surgical preferences, and the factors influencing their decision-making processes.

The study was conducted using an anonymous, multiple-choice, scenario-based online survey administered to thoracic surgeons actively practicing in Türkiye who had participated in at least one segmentectomy. The survey comprised five sections: (1) Participant profile, (2) perception of surgical risk, (3) preferences based on clinical scenarios, (4) lymph node dissection practices, and (5) the impact of technological resources. All survey responses were analyzed using descriptive statistical methods. Continuous variables were presented as mean or median (range), while categorical variables were expressed as frequencies and percentages. Cross-tabulations and trend analyses were performed to explore associations between clinical scenarios and surgical preferences. Statistical analyses were conducted using SPSS software (IBM Corp., Armonk, NY, USA).

A total of 118 surgeons participated. The mean duration of surgical experience was 15.8 years. The average annual number of lung resections was 137.6 (median 80; range 30-4000), and the mean annual number of segmentectomies was 24.4 (range 5-350). Of all resections, 65% were performed using video-assisted thoracoscopic surgery. Among participants, 94.8% reported using intraoperative frozen-section analysis, 33.9% used three-dimensional modeling, and 19.1% used indocyanine green technology. Technical infrastructure was reported to influence decision-making by 36.8% of surgeons directly. The most influential decision-making factors were tumor size (73.7%), lymph node status (69.8%), tumor location (57.6%), and functional capacity (53.4%). In clinical scenarios, segmentectomy was preferred in 68.6% of cases with ground-glass opacity-dominant nodules. In patients with solid nodules and low functional reserve, segmentectomy was selected in 47.0% of participants, while lobectomy was chosen in 45%. In semisolid nodules, the size of the solid component was the determining factor in 65.3% of responses. When spread through air spaces (STAS) was detected with negative margins and N0 disease, 46.6% recommended surveillance, whereas 93.2% recommended completion lobectomy when surgical margins were suspicious with tumor contact at the stapler line. The absence of systematic lymph node dissection was considered contrary to oncologic principles by 80.34% of participants. 36.4% of participants reported that decisions were frequently made in multidisciplinary tumor boards, and 22.0% reported that this was always the case.

This study indicates that thoracic surgeons regard segmentectomy as an oncologically comparable alternative to lobectomy with functional advantages in early-stage NSCLC. However, lobectomy remains the predominant approach in daily practice. Variations in surgical preference are associated with technical challenges, determination of segmental borders, lymph node dissection practices, and concerns about surgical margin safety. Tumor size and lymph node status are the most critical factors in decision-making. The safe and oncologically standard implementation of segmentectomy depends on appropriate patient selection, surgical experience, systematic lymph node dissection, intraoperative margin assessment, and enhanced technological support. In addition, structured training programs and interinstitutional exchange of experience may facilitate the safer and more standardized integration of segmentectomy into routine clinical practice.