Segmentectomy vs Lobectomy for Peripheral Early-Stage Non-Small Cell Lung Cancer in Patients With Radiologically High Risk Tumors.

BACKGROUND: The increasing use of segmentectomy for early-stage peripheral non-small cell lung cancer (NSCLC) raises questions about its oncologic adequacy compared with lobectomy, particularly for tumors with high-risk features. This study aimed to compare oncologic outcomes between segmentectomy and lobectomy for clinical stage IA1-2 peripheral NSCLC, stratified by radiologic tumor risk. METHODS: This retrospective single-center study analyzed 527 patients with peripheral NSCLC ≤2 cm who underwent either lobectomy (n = 240), or segmentectomy (n = 287) from January 2017 to December 2024. High-risk tumors were defined as cT1b, solid dominant, and hypermetabolic (maximal standardized uptake value >2.5). Primary end points included 4-year overall survival (OS) and event-free survival (EFS). Cox regression analysis was performed to identify independent predictors of EFS. RESULTS: High-risk tumors comprised 122 lobectomies (51%) and 73 segmentectomies (25%). For low-risk tumors, there was no significant difference in 4-year OS or EFS (OS: lobectomy 85% vs segmentectomy 84% [P = .74]; EFS: lobectomy 75% vs segmentectomy 72% [P = .74]). For high-risk tumors, 4-year OS and EFS were also not different after lobectomy or segmentectomy (OS: lobectomy 80% vs segmentectomy 68% [P = .18]; EFS: lobectomy 72% vs segmentectomy 60% [P = .33]). In the inverse probability weighting-adjusted Cox proportional hazards model, lobectomy was not independently associated with improved EFS (hazard ratio, 0.86; 95% CI, 0.59-1.25; P = .43). CONCLUSIONS: Segmentectomy demonstrates oncologically equivalent outcomes compared with lobectomy for both low-risk and high-risk clinical stage IA1-2 peripheral NSCLC. These findings support the oncologic safety of segmentectomy as an alternative to lobectomy in appropriately selected patients with small peripheral NSCLC, even in the high-risk tumor subset.