General Thoracic

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. 

Determining the optimal management strategy for pleural mesothelioma (PM) remains one of the most challenging areas in thoracic oncology. As a rare and aggressive malignancy, PM requires careful coordination of diagnostic, surgical, and systemic therapies. While surgery has historically played a central role, its benefit continues to be debated.

The Society of Thoracic Surgeons (STS) 2026 Expert Consensus on the Multimodal Treatment of Pleural Mesothelioma, developed by a multidisciplinary panel and published in The Annals of Thoracic Surgery, provides updated recommendations on the multimodal management of PM, with particular emphasis on the role of surgical intervention.

Bridging Evidence and Real-World Practice

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A key challenge addressed in the document is the gap between clinical evidence and real-world outcomes. According to lead author Jeffrey Velotta, MD, of Kaiser Permanente Oakland Medical Center, that gap is often driven by differences in surgical experience. “The biggest divide is between general thoracic surgeons and those with high-volume mesothelioma experience,” Velotta said, noting that outcomes are closely tied to disease-specific expertise and case volume. He emphasized that many studies and guidelines do not fully account for this variability. “Mesothelioma-specific experience—not just general surgical skill—can significantly impact outcomes,” he added.

Refining Diagnosis and Staging

A central theme of the recommendations is the importance of accurate diagnosis and staging. The panel strongly emphasizes that adequate pleural biopsy is essential for confirming histologic subtype, which directly influences prognosis and treatment decisions.

In addition, the consensus highlights the critical role of advanced imaging:

• CT and PET imaging: Required at a minimum to assess disease extent.
• Multidisciplinary Tumor Board (MTB): Essential for treatment planning, involving surgeons, oncologists, radiologists, and pathologists with specific PM expertise.

Multimodal Therapy as the Standard Approach

The consensus emphasizes that PM treatment should integrate surgery with systemic therapies such as chemotherapy, immunotherapy, or radiation. When evaluating surgical candidates, the panel suggests focusing on several key clinical indicators:

• Histologic subtype: Greatest benefit is seen in epithelioid, localized disease; outcomes remain poorer for sarcomatoid and biphasic subtypes.
• Performance status: A patient's overall functional ability is an independent prognostic indicator.
• Physiologic reserve: Careful assessment of cardiopulmonary function and nutritional levels.
• Case volume: Surgery should be concentrated in high-volume centers with documented experience in PM management.

“Patients benefit most from a multimodal approach that combines surgery with systemic therapy,” Velotta said.

Surgical Approach: Moving Toward Lung-Sparing Techniques

One of the most definitive recommendations is the strong preference for lung-sparing surgical techniques. Pleurectomy/decortication (P/D) and extended P/D (EPD) are favored over extrapleural pneumonectomy (EPP), which carries higher morbidity without a clear survival advantage in contemporary studies. “Lung-sparing surgery, when performed in experienced centers, can offer meaningful long-term benefits with acceptable risk,” Velotta noted.

Treatment Sequencing and Ongoing Uncertainty

Therapy sequencing remains an area of active debate, with both neoadjuvant and adjuvant approaches considered reasonable. Velotta highlighted two key unanswered questions: “We still don’t know whether chemotherapy is best given before or after surgery, and whether intraoperative adjuncts should be used routinely.”

Recent data, including the MARS-2 trial, have also questioned the overall benefit of surgery, though the panel emphasizes ongoing controversy related to trial design and differences in surgical expertise.

A Framework for Complex Decision-Making

As treatment strategies for pleural mesothelioma continue to evolve, the STS consensus provides a structured yet flexible framework for clinicians. While acknowledging gaps in high-quality evidence, the panel emphasizes the importance of expertise, multidisciplinary care, and individualized treatment planning which includes surgery in a multimodal regimen to optimize patient outcomes.

Read the Annals article.

On Sunday, Feb. 1 at 10:45 a.m., during the “Advancing Lung Cancer Screening Implementation in Real World Settings” session, Dr. Elliot Servais of Lahey Hospital and Medical Center will present The Society of Thoracic Surgeons Expert Consensus on Surgical Quality Standards for Lung Cancer Screening Detected Nodules. As chair of the STS Task Force responsible for the consensus document, Dr. Servais will walk attendees through comprehensive, multidisciplinary recommendations designed to standardize perioperative care for CT lung cancer screening programs nationwide.

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Lung cancer screening with low-dose CT has proven effective in reducing disease-specific mortality, but wide variation in how programs manage screen-detected nodules persists. To address this, the STS convened a multidisciplinary panel to review the evidence and establish clear benchmarks for diagnostic evaluation, complication rates, and timeliness of intervention. Through a structured literature review and modified Delphi process, the panel produced 23 consensus statements focused on improving safety, consistency, and coordination in screening pathways.

Key recommendations include permitting surgery without a preoperative tissue diagnosis in select patients—preferably using minimally invasive, parenchymal-sparing techniques—and rejecting pneumonectomy without a diagnosis.

In his presentation, Dr. Servais will also highlight why certain targets, such as achieving a benign resection rate below 10%, may challenge some programs. “Meeting this benchmark requires consistent multidisciplinary review, judicious use of preoperative biopsy, and a willingness to follow equivocal lesions closely—approaches that can reduce unnecessary surgery and improve patient outcomes,” says Dr. Servais.

By integrating diverse clinical perspectives, programs can better determine when invasive intervention is warranted versus when surveillance is safest, improving decision-making and minimizing avoidable procedures.

“Thoracic surgeons must remain central to lung cancer screening programs, and adherence to strong perioperative quality standards—rooted in multidisciplinary evaluation, operative safety, and timely intervention—is critical to ensuring that lung cancer screening continues to save lives with minimal harm to patients,” adds Dr. Servais.