Newsroom

Determining the optimal surgical approach for early-stage non-small cell lung cancer (NSCLC) has grown more complex with increasing use of sublobar resection. Recent randomized trials show comparable outcomes to lobectomy in carefully selected patients, but questions remain about real-world application.

A new expert consensus document from the Society of Thoracic Surgeons (STS), published in The Annals of Thoracic Surgery and developed by the Workforce on Evidence-Based Surgery and a panel of thoracic surgeons, provides guidance on the use of sublobar resection.

The recommendations focus on patient selection, margin requirements, and lymph node evaluation, offering a practical framework for clinical decision-making.

“These expert consensus statements are designed to provide real-world, practical recommendations,” said Onkar Khullar, MD, a thoracic surgeon at Emory University, who chaired the panel. “At the same time, we hope they place some guard rails around which patients are truly appropriate for sublobar resection, so that this technique is used appropriately, effectively, and safely.”

Bridging Evidence and Practice

The recommendations were developed through a comprehensive literature review and a modified Delphi process, requiring greater than 75% agreement for each statement. The panel reached consensus on 21 statements across seven key areas of controversy, including:

• Sublobar resection versus lobectomy
• Wedge versus segmentectomy
• Central tumor location
• High-risk histologic features
• Adequate margins
• Complex segmentectomy
• Intraoperative lymph node assessment

A major gap identified was the difference between randomized trial criteria and real-world practice, particularly in lymph node staging. In randomized trials, only patients with pathologically confirmed negative nodes were included, which is not always practical in real-world settings, where it may not be feasible to perform intraoperative frozen sections on all nodes.

To address this, the panel recommends proceeding with sublobar resection when preoperative staging is negative and nodes are not clinically suspicious, while maintaining intraoperative vigilance.

“If a surgeon becomes suspicious of a lymph node during the operation, they should perform a frozen analysis,” Dr. Khullar stated. “If that is positive, consideration should be given to converting to an anatomic resection.”

Key Recommendations

The consensus reinforces that sublobar resection—either segmentectomy or wedge resection—is an appropriate option for patients with peripheral, node-negative tumors measuring 2 cm or less, provided that adequate surgical margins and lymph node assessment can be achieved. 

“Sublobar resection should be considered in patients with peripheral, node-negative tumors less than 2 cm if, and only if, appropriate margins and lymph node evaluation can be obtained,” Dr. Khullar noted. “If those criteria cannot be met, and the patient is a candidate for lobectomy, then lobectomy remains the best option.”

The document emphasizes the importance of margin quality, recommending a minimum 10 mm margin for solid tumors and supporting intraoperative frozen section analysis to guide decision-making. It also notes that while segmentectomy is often considered a more anatomic approach, it may involve longer operative times and greater complexity, which should be weighed in older patients or those with limited pulmonary reserve.

Unresolved Questions

Despite growing evidence supporting sublobar resection, important uncertainties remain—particularly regarding high-risk tumor features such as spread through air spaces (STAS), lymphovascular invasion (LVI), and visceral pleural invasion (VPI).

“The biggest gap in current knowledge is whether sublobar resections should be performed in patients with high-risk pathology features,” Dr. Khullar explained. “First, we often cannot identify these features before surgery. Second, even if we do, it’s unclear whether sublobar resection is appropriate.”

Current consensus suggests there is insufficient evidence to recommend routine conversion to lobectomy based on these findings alone. To address this gap, new data fields have been incorporated into the STS General Thoracic Surgery Database, with the goal of generating more robust evidence in the future.

Informing Surgical Decision-Making

As sublobar resection use expands, the panel expects these recommendations to standardize care while maintaining clinical flexibility. The hope is that these statements will influence how surgeons approach case selection, margin assessment, and lymph node evaluation in everyday practice.

Although further research is needed—particularly to refine patient selection and clarify high-risk features—the consensus provides an important foundation for early-stage NSCLC care..

“As more data become available, we expect these recommendations to evolve,” Dr. Khullar added. “But for now, they offer a practical framework to ensure patients receive the most appropriate surgical treatment.”

Read the Annals article. 

Surgeons and multidisciplinary teams from across the country gathered May 14–15 in Norcross, Georgia, for the 2026 STS Workshop on Robotic Cardiac Surgery. This intensive, two-day program combined expert lectures, case discussions, and immersive simulation to help teams launch or advance their robotic cardiac surgery programs.

Designed for all experience levels, the course focused heavily on robotic mitral valve procedures and coronary revascularization.

High-Fidelity Simulation Builds Team Confidence

Image

Participants spent significant time in a state-of-the-art simulation facility, gaining hands-on experience with surgical robotic platforms. Lab sessions covered critical techniques including:

• Robotic mitral valve repair and replacement
• Total endoscopic coronary artery bypass (TECAB)
• Hybrid coronary revascularization

Under expert faculty guidance, attendees practiced port placement, myocardial protection, and intraoperative troubleshooting. The environment allowed surgeons, bedside assistants, and OR staff to refine their real-time coordination.

“STS has been committed to robotic cardiac surgery for the last several years, which has been instrumental as we continue to advance the robotic cardiac surgery subspecialty through both this workshop and its integration into the Annual Meeting,” said course co-director Arnar Geirsson, MD, of NewYork-Presbyterian/Columbia University Irving Medical Center.

A Comprehensive Valve and Coronary Curriculum

Structured didactic sessions reviewed the latest evidence, patient selection criteria, and operative strategies. Faculty experts covered:

• Mitral & Tricuspid Pathways: Resection-based repair, complex pathologies (endocarditis, annular calcification), and concomitant Maze procedures
• Coronary & Aortic Pathways: LITA/BITA harvesting, robotic MIDCAB, and aortic valve replacement
• Advanced Techniques: Multivalve procedures, combined valve/CABG cases, and managing complications

Focus on Program Infrastructure

Image

Beyond technical mastery, the workshop emphasized the business and logistics of robotics. Sessions explored how to optimize OR setup, streamline interdisciplinary communication, and secure institutional support to build a sustainable service line.

“During this year’s workshop, the focus on teams helped bring together the interests of the faculty and allied health professionals, including surgical assistants and scrub teams, so they could learn together and build teams that advance their practice,” said course co-director Arman Arghami, MD, of Mayo Clinic.

Through its powerful mix of high-tech simulation and collaborative learning, the STS Workshop remains a premier launchpad for the future of minimally invasive cardiac surgery.