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The Changing Landscape of Surgical Treatment for Early-stage Non-small Cell Lung Cancer

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Published Online: Dec 12th 2023 touchREVIEWS in Respiratory & Pulmonary Diseases. 2024;9(1):Online ahead of journal publication
Authors: Sylvia S Yong, Christopher M Kapp
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Surgical resection is the cornerstone of management for early-stage non-small cell lung cancer. In this review article, we aim to highlight the evolution of surgical practice, from conventional resection to the now standard video-assisted thoracoscopic surgery, to the rising application of robotic video-assisted thoracic surgery, along with more lung-sparing resections. The increasing role of bronchoscopy in earlier diagnoses and staging in conjunction with less invasive operative management is expected to contribute towards improving morbidity and survival rates of patients with non-small cell lung cancer.


Lung cancerbronchoscopynon-small cell lung cancerperipheral pulmonary nodulesvideo-assisted thoracoscopic surgery


Lung cancer accounts for the highest cancer-related mortality and is the second most common cause of malignancy worldwide.1 Diagnosis at an early stage (ES) has a direct effect on management and survival rates. Overall, the 5-year survival rate from 2013 to 2019 in the US was 62.8% when the cancer was detected at stage I or II compared with the significantly lower rates of 34.8% and 8.2% when detected at stage III and metastatic disease, respectively.2 The primary histological distinction in lung cancer is non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), with the former accounting for 80–85% of cases.3 Surgical resection is the primary standard treatment for stage I and II NSCLC and, along with a growing body of evidence supporting neoadjuvant immunotherapy, is confirmed as an important component in the multimodal management of selected stage IIIA NSCLC.4 With advancements in screening, diagnostic techniques and treatment options (ranging from radiation therapy to targeted immunotherapies), there have been notable improvements in survival rates for patients with lung cancer. Within a span of a decade (2010–2020), death rates in the US decreased from 47.4% to 31.8% overall for all types of lung cancer.2 This article aims to highlight the changing role of surgery and bronchoscopy in the treatment of ES NSCLC.

Treatment strategies for early-stage lung cancer

Currently, surgical resection remains the gold standard for treatment of ES NSCLC. The main alternative treatment modality in selected cases without bronchus or lobar involvement is stereotactic body radiotherapy (SBRT), in which ablative doses of radiation are delivered to the primary tumour. Although SBRT is less invasive than surgical resection, operative management in conjunction with lymph node (LN) excision has been shown to improve survival rates for various subsets of NSCLC.3,5,6 One large cohort study based on the National Cancer Database from 2004–2015 highlighted a 5-year overall survival for patients with ES NSCLC who underwent surgical resection of 48.1% to 64.6%, depending on the type of resection, compared with 30.4% in those who received SBRT.3 Despite these data, SBRT remains an important option for patients who are not suitable for surgery. There are limitations of the interpretation of studies in favour of surgical management, as those who opted for SBRT are often poor surgical candidates whose co-morbidities may have contributed towards inferior survival rates. Some limited retrospective studies with the propensity-score matching of data have suggested the equivalence of SBRT and surgical management.7,8 Randomized prospective data comparing the two treatment strategies have been limited by inadequate enrollment size. However, one post hoc analysis of two small randomized trials suggested the noninferiority of SBRT.9

A major part of definitive surgical therapy is the performance of adequate regional LN sampling, as surgical resection performed with LN dissection is associated with superior long-term survival coupled with minimal additional procedure-associated morbidity.3,6 In addition to achieving histological diagnosis and obtaining adequate tissue for next-generation sequencing, if not previously ascertained, surgical LN dissection assists with appropriate staging to guide postoperative management, as patients with any LN disease warrant adjuvant chemotherapy and, frequently, concomitant immunotherapy.

There has been growing recognition of the role of immunotherapy as a neoadjuvant or perioperative component of surgical management in NSCLC amenable to resection. The CheckMate 816 trial significantly improved survival with neoadjuvant nivolumab plus chemotherapy in resectable NSCLC.4 Subsequent similar trials have validated this finding with various other neoadjuvant immunotherapies, with the general hypothesis that it facilitates T-cell priming that can downstage tumours prior to surgical resection, followed by on-going activity against micrometastatic disease post-resection.10–13

The evolution of surgical management

Conventional open lobectomy has a favourable 5-year disease-free survival rate of 68%.14,15 However, it is associated with a significant postoperative complication rate of up to 37%, including increased frequency of respiratory failure, decreased baseline pulmonary function, and a mortality rate of up to 3%.6,14,15 While video-assisted thoracoscopic surgery (VATS) was first used as early as 1910, it became more widespread in the 1980s, and its use was facilitated by improved video technology and single lung ventilation with double-lumen endotracheal tubes.16 This treatment has since become the standard surgical approach.6,16,17 Early retrospective studies noted noninferiority of survival of patients with ES NSCLC who underwent VATS compared with open thoracotomy, and subsequent meta-analyses confirmed the superior 5-year survival rates in these patients.18–21 Importantly, no difference in the extent and adequacy of mediastinal LN dissection obtained and lower rates of complications and duration of chest tube placement has been attested with VATS.22–24 More recent randomized control trials additionally suggested improved recovery of physical function postoperatively, as well as the overall lower cost of VATS.17,25 Furthermore, patients with high-risk co-morbidities, particularly those with poor baseline pulmonary function, have lower postoperative complication rates.26

With the advent of minimally invasive surgery, robotic video-assisted thoracic surgery (RVATS) became an additional strategy for lung resections in the 2000s. As well as being less invasive than VATS, as it can produce smaller incisions without needing to spread the ribs, RVATS also allows for more precise dissection compared with VATS due to its binocular visualization system and capability to use carbon dioxide insufflation to increase the working area.27 Initial retrospective comparison of patients who underwent RVATS versus VATS or thoracotomy portray comparable types and rates of complications and favourable long-term stage-specific survival.28–30 There is still a relative paucity of data reviewing long-term outcomes, particularly as conflicting reports depict a potentially lower number of LNs examined and lower rates of nodal upstaging. The first prospective randomized control trial described comparable perioperative outcomes between RVATs and VATS.31 Notably, this study used uniportal VATS, yet another extension of techniques in minimally invasive surgery using a single incision, which allows for a sagittal alignment of instruments inside the chest cavity, rather than the traditional multiport method. Uniportal VATS has received some critique, such as that it may be prohibitory for segmentectomies, which require the careful delineation of margins to prevent locoregional recurrence.32 Nonetheless, this technique represents an improvement that may be particularly relevant for application in resource settings where RVATS is not feasible.33

In addition to technical advancements, there have also been progressive efforts towards sub-lobar resections or segmentectomies, with the aim of preserving maximal lung parenchyma. Lobectomy has previously been established as the standard of care for the resection of ES NSCLC due to the findings of a randomized prospective trial by the Lung Cancer Study Group suggesting a threefold increase in the frequency of recurrence and a 50% increase in cancer-specific mortality rate with sub-lobar resections.34 However, with the increased detection of smaller peripheral pulmonary nodules (PPN) since 1995 when the Lung Cancer Study Group study was conducted, there has been on-going debate over revisiting this guideline. To this end, two recent large randomized noninferiority trials proposed sub-lobar resections as the management of choice for small-sized peripheral ES NSCLC. The first was a multicentre study conducted across Japan, which randomized patients to receive either segmentectomy or lobectomy. This study showed segmentectomy to be superior for 5-year overall survival.35 The second was an international multicentre trial published in 2023, which similarly suggested the noninferiority of sub-lobar resection versus lobectomy in both disease-free and overall survival in patients with clinical stage IA NSCLC with a tumour size of 2 cm or smaller.36 Even though locoregional recurrence rates were slightly higher after sub-lobar resection at 13.4% compared with 10.0% with lobectomy, the authors suggest that the difference was not clinically meaningful. There were otherwise no statistically significant differences in regional or distant recurrence rates. Sub-lobar resections are now recognized as the acceptable standard of care for patients with stage IA NSCLC by the American Society of Clinical Oncology.37

The role of bronchoscopy

One of the important roles of bronchoscopy has become not only the evaluation of nodules but also the concurrent evaluation of mediastinal and hilar lymphadenopathy with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). EBUS-TBNA has largely replaced mediastinoscopy for the initial evaluation, as it has higher nodal staging accuracy and safety.38,39 Its high negative predictive value for radiographically N0 disease, sensitivity for detection of occult metastasis allowing for nodal upstaging, and low complication rate make it an ideal staging technique.38,39 A recent long-term analysis confirmed a good correlation for 5-year survival analyses for nodal staging performed by EBUS-TBNA, and notably, patients with false-negative N0 staging via EBUS-TBNA had a comparable survival rate to those with N1 disease.40

While the diagnostic yield of each method remains highly variable with a lack of comparative studies, image-guided bronchoscopy techniques with navigational systems and biopsies localized by radial probe EBUS are used to evaluate PPN for earlier pathologic diagnosis that were previously not able to be endoscopically reached via conventional bronchoscopy.41 Most recently, robotic-assisted bronchoscopy (RB) has emerged as a platform for improving lesion localization and, possibly, diagnostic yield.42 However, more randomized trials are needed to validate the performance of RB.42 Transbronchial cryobiopsy is another means of minimally invasive tissue sampling that allows for larger sample size and superior preservation of tissue for both histopathologic and molecular analysis in comparison with traditional forceps biopsies.43,44 The availability of a smaller 1.1 mm probe has shown promising safety data for the widespread application to even novice bronchoscopists.45 These advances in the technology of bronchoscopy allow for less frequent surgical resection of benign disease and optimization of patient selection.46

In addition to its diagnostic role in pulmonary nodules, bronchoscopy can also be used in therapeutics. Bronchoscopic-guided dye marking for PPN has been shown to be helpful for directing surgical resection, given these small lesions that otherwise often have no visual pleural markers, particularly in the absence of tactile stimulus with the use of VATS and RVATS.47,48 While this technique is still in its infancy, it has thus far been suggested to be feasible, effective and safe. Indeed, a recent international consensus statement supported the use of fluorescence imaging for marking boundaries for sublobar resections and intraoperative lung nodule localization with class IIa recommendations.49 Future studies will evaluate the possibility of bronchoscopic ablation for ES lung cancer; however, these do not appear to be ready for widespread clinical adoption and are still in the early clinical trial phases.50


The evolution of surgical management and the practice of bronchoscopy are complementary in lung cancer management. The trend towards a less invasive surgical approach has implications for not only patient-centred outcomes, but it may also broaden the eligibility of patients with ES NSCLC who may have previously been excluded from consideration for resection. Earlier histopathologic diagnosis and accurate staging with improved bronchoscopic PPN localization and sampling will also expand the patient population considered for resection and, perhaps in the future, even change the current approach to the treatment of SCLC with earlier, more localized detection.

Article Information:

Sylvia S Yong and Christopher M Kapp have no financial or non-financial relationships or activities to declare in relation to this article.

Compliance With Ethics

This article involves a review of the literature and did not involve any studies with human or animal subjects performed by any of the authors.

Review Process

Double-blind peer review.


The named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published.


Sylvia S YongUniversity of Illinois Chicago, Division of Pulmonary, Critical Care, Sleep and Allergy, 840 S. Wood Street MC 719, Room 920NChicago, IL


No funding was received in the publication of this article.


This article is freely accessible at © Touch Medical Media 2023.

Data Availability

Data sharing is not applicable to this article as no datasets were generated or analysed during the writing of this article.




1. Sung HFerlay JSiegel RLet alGlobal cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countriesCA Cancer J Clin2021;71:20949DOI10.3322/caac.21660.

2. The Surveillance, Epidemiology, and End Results ProgramCancer Stat Facts: Lung and Bronchus Cancer2023Available at (Date last accessed24 June 2023).

3. Chi AFang WSun YWen SComparison of long-term survival of patients with early-stage non-small cell lung cancer after surgery vs stereotactic body radiotherapyJAMA Netw Open. 2019;2:e1915724. DOI10.1001/jamanetworkopen.2019.15724.

4. Forde PMSpicer JGirard NNeoadjuvant nivolumab plus chemotherapy in resectable lung cancerN Engl J Med2022;387:5723DOI10.1056/NEJMc2208133.

5. Lo HAbel SFinley Get alSurgical resection versus stereotactic body radiation therapy in early stage bronchopulmonary large cell neuroendocrine carcinomaThorac Cancer2020;11:30510DOI10.1111/1759-7714.13260.

6. Allen MSDarling GEPechet TTVet alMorbidity and mortality of major pulmonary Resections in patients with early-stage lung cancer: initial results of the randomized, prospective ACOSOG Z0030 trialAnn Thorac Surg2006;81:10139DOI10.1016/j.athoracsur.2005.06.066.

7. Verstegen NEOosterhuis JWAPalma DAet alStage I–II non-small-cell lung cancer treated using either stereotactic ablative radiotherapy (SABR) or lobectomy by video-assisted thoracoscopic surgery (VATS): Outcomes of a propensity score-matched analysisAnn Oncol2013;24:15438DOI10.1093/annonc/mdt026.

8. Shirvani SMJiang JChang JYet alSublobar resection, and stereotactic ablative radiotherapy for early-stage non-small cell lung cancers in the elderlyJAMA Surg2014;149:124453DOI10.1001/jamasurg.2014.556.

9. Chang JYSenan SPaul MAet alStereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: A pooled analysis of two randomised trialsLancet Oncol2015;16:6307DOI10.1016/S1470-2045(15)70168-3.

10. Chaft JEOezkan FKris MGet alNeoadjuvant atezolizumab for resectable non-small cell lung cancer: An open-label, single-arm phase II trialNat Med2022;28:215561DOI10.1038/s41591-022-01962-5.

11. Wislez MMazieres JLavole Aet alNeoadjuvant durvalumab for resectable non-small-cell lung cancer (NSCLC): Results from a multicenter study (IFCT-1601 IONESCO)J Immunother Cancer2022;10:10DOI10.1136/jitc-2022-005636.

12. Cascone TWilliam WN JrWeissferdt Aet alNeoadjuvant nivolumab or nivolumab plus Ipilimumab in operable non-small cell lung cancer: The phase 2 randomized NEOSTAR trialNat Med2021;27:50414DOI10.1038/s41591-020-01224-2.

13. Parekh JParikh KReuss JEet alCurrent approaches to neoadjuvant immunotherapy in resectable non-small cell lung cancerCurr Oncol Rep2023;25:91322DOI10.1007/s11912-023-01430-4.

14. Lackey ADonington JSSurgical management of lung cancerSemin intervent Radiol2013;30:13340. DOI10.1055/s-0033-1342954.

15. Harpole DH JrDeCamp MM JrDaley Jet alPrognostic models of thirty-day mortality and morbidity after major pulmonary resectionJ Thorac Cardiovasc Surg1999;117:96979DOI10.1016/S0022-5223(99)70378-8.

16. Klapper JD’Amico TAVATS versus open surgery for lung cancer resection: Moving toward a minimally invasive approachJ Natl Compr Canc Netw2015;13:1624DOI10.6004/jnccn.2015.0023.

17. Lim EBatchelor TJPDunning Jet alVideo-assisted thoracoscopic or open lobectomy in early-stage lung cancerNEJM Evid2022;1DOI10.1056/EVIDoa2100016.

18. Shiraishi TShirakusa THiratsuka Met alVideo-assisted thoracoscopic surgery lobectomy for C-T1N0M0 primary lung cancer: Its impact on locoregional controlAnn Thorac Surg2006;82:10216DOI10.1016/j.athoracsur.2006.04.031.

19. Sugi KKaneda YEsato KVideo-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancerWorld J Surg2000;24:2730DOI10.1007/s002689910006.

20. Taioli ELee DSLesser MFlores RLong-term survival in video-assisted thoracoscopic lobectomy vs open lobectomy in lung-cancer patients: A meta-analysisEur J Cardiothorac Surg2013;44:5917DOI10.1093/ejcts/ezt051.

21. Yan TDBlack DBannon PGMcCaughan BCSystematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancerJ Clin Oncol2009;27:255362DOI10.1200/JCO.2008.18.2733.

22. Watanabe AKoyanagi TOhsawa Het alSystematic node dissection by VATS is not inferior to that through an open thoracotomy: A comparative clinicopathologic retrospective studySurgery2005;138:5107. DOI10.1016/j.surg.2005.04.005.

23. D’Amico TANiland JMamet Ret alEfficacy of mediastinal lymph node dissection during lobectomy for lung cancer by thoracoscopy and thoracotomyAnn Thorac Surg2011;92:22631DOI10.1016/j.athoracsur.2011.03.134.

24. Villamizar NRDarrabie MDBurfeind WRet alThoracoscopic lobectomy is associated with lower morbidity compared with thoracotomyJ Thorac Cardiovasc Surg2009;138:41925DOI10.1016/j.jtcvs.2009.04.026.

25. Bendixen MKronborg CJørgensen ODet alCost-utility analysis of minimally invasive surgery for lung cancer: A randomized controlled trialEur J Cardiothorac Surg2019;56:75461DOI10.1093/ejcts/ezz064.

26. Ceppa DPKosinski ASBerry MFet alThoracoscopic lobectomy has increasing benefit in patients with poor pulmonary functionAnn Surg2012;256:48793DOI10.1097/SLA.0b013e318265819c.

27. Cao CManganas CAng SCYan TDA systematic review and meta-analysis on pulmonary resections by robotic video-assisted thoracic surgeryAnn Cardiothorac Surg2012;1:310DOI10.3978/j.issn.2225-319X.2012.04.03.

28. Cerfolio RJGhanim AFDylewski Met alThe long-term survival of robotic lobectomy for non–small cell lung cancer: A multi-institutional studyJ Thorac Cardiovasc Surg2018;155:77886DOI10.1016/j.jtcvs.2017.09.016.

29. Gallina FTTajè RForcella Det alOncological outcomes of robotic lobectomy and radical lymphadenectomy for early-stage non-small cell lung cancerJ Clin Med2022;11:2173DOI10.3390/jcm11082173.

30. Rajaram RMohanty SBentrem DJet alNationwide assessment of robotic lobectomy for non-small cell lung cancerAnn Thorac Surg2017;103:1092100DOI10.1016/j.athoracsur.2016.09.108.

31. Jin RZheng YYuan Yet alRobotic-assisted versus video-assisted thoracoscopic lobectomy: Short-term results of a randomized clinical trial (RVlob trial)Ann Surg2022;275:295302DOI10.1097/SLA.0000000000004922.

32. Sato MThe pros and cons of Uniportal VATS segmentectomy in the treatment of early-stage lung cancer: should the procedure be prioritized? J Thorac Dis2023;15:23841DOI10.21037/jtd-22-1864.

33. Rocco GOne-port (uniportal) video-assisted thoracic surgical resections—A clear advanceJ Thorac Cardiovasc Surg2012;144:S2731DOI10.1016/j.jtcvs.2012.06.006.

34. Ginsberg RJRubinstein LVRandomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancerAnn Thorac Surg1995;60:61522DOI10.1016/0003-4975(95)00537-u.

35. Saji HOkada MTsuboi Met alSegmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): A multicentre, open-label, phase 3, randomised, controlled, non-inferiority trialThe Lancet2022;399:160717DOI10.1016/S0140-6736(21)02333-3.

36. Altorki NWang XKozono Det alLobar or sublobar resection for peripheral stage IA non-small-cell lung cancerN Engl J Med2023;388:48998DOI10.1056/NEJMoa2212083.

37. O’Reilly DBotticella ABarry Set alTreatment decisions for resectable non–small-cell lung cancer: Balancing less with more?Am Soc Clin Oncol Educ Book2023;43:e389950DOI10.1200/EDBK_389950.

38. Agrawal AMurgu SEBUS vs. mediastinoscopy for initial pathologic mediastinal staging in NSCLCInFerguson MK, (ed). Difficult Decisions in Thoracic Surgery: An Evidence-Based Approach. Difficult Decisions in Surgery: An Evidence-Based ApproachSpringer International Publishing2020;6781.

39. Ong PGrosu HEapen GAet alEndobronchial ultrasound-guided transbronchial needle aspiration for systematic nodal staging of lung cancer in patients with N0 disease by computed tomography and integrated positron emission tomography-computed tomographyAnn Am Thorac Soc2015;12:4159. DOI10.1513/AnnalsATS.201409-429OC.

40. Hwangbo BPark EYYang Bet alLong-term survival according to N stage diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration in non-small cell lung cancerChest2022;161:138292DOI10.1016/j.chest.2021.11.032.

41. Vachani AMaldonado FLaxmanan Bet alThe effect of definitions and cancer prevalence on diagnostic yield estimates of bronchoscopy: A simulation-based analysisAnn Am Thorac Soc2023DOI10.1513/AnnalsATS.202302-182OC.

42. Naaman RKapp CMInnovations in bronchoscopy: Robotic-assisted bronchoscopytouchREVIEWS in Respiratory & Pulmonary Diseases2022;7:413DOI10.17925/USRPD.2022.7.2.41.

43. Fan YZhang A-MWu X-Let alTransbronchial needle aspiration combined with cryobiopsy in the diagnosis of mediastinal diseases: A multicentre, open-label, randomised trialLancet Respir Med2023;11:25664. DOI10.1016/S2213-2600(22)00392-7.

44. Herth FJMayer MThiboutot Jet alSafety and performance of transbronchial cryobiopsy for parenchymal lung lesionsChest2021;160:15129DOI10.1016/j.chest.2021.04.063.

45. Thiboutot JIllei PBMaldonado Fet alSafety and feasibility of a sheath cryoprobe for bronchoscopic transbronchial biopsy: The FROSTBITE trialRespiration2022;101:11318DOI10.1159/000526876.

46. Carillo GAOVázquez JERVillar AFPrevalence of benign pulmonary lesions excised for suspicion of malignancy: Could it reflect a quality management index of indeterminate lung lesions Korean J Thorac Cardiovasc Surg. 2014;47:45864DOI10.5090/kjtcs.2014.47.5.458.

47. Song JWPark IKBae SYet alElectromagnetic navigation bronchoscopy-guided dye marking for localization of pulmonary nodulesAnn Thorac Surg2022;113:16639DOI10.1016/j.athoracsur.2021.05.004.

48. Taton OSokolow YBondue Bet alCryobiopsy and dye marking guided by electromagnetic navigation bronchoscopy before resection of pulmonary noduleRespir Med Res2022;81:100911DOI10.1016/j.resmer.2022.100911.

49. Ng CS-HOng B-HChao YKet alUse of indocyanine green fluorescence imaging in thoracic and esophageal surgeryAnn Thorac Surg2023;115:106876DOI10.1016/j.athoracsur.2022.06.061.

50. ClinicalTrials.govBronchoscopic Microwave Ablation of Lung Tissue (AB1MALT). Identifier: NCT057866252023Available at (Date last accessed10 July 2023).

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