# Nodal Upstaging and Oncologic Outcomes After Segmentectomy Versus Lobectomy for Early-Stage Non-Small Cell Lung Cancer

## TL;DR

Segmentectomy for early-stage lung cancer provides similar survival to lobectomy when combined with proper lymph node evaluation and adjuvant therapy, though it detects fewer lymph node metastases.

## Contribution

This review provides evidence that segmentectomy can achieve comparable oncologic outcomes to lobectomy when used with systematic staging and modern therapies.

## Key findings

- Lobectomy detects more N1 lymph node metastases than segmentectomy, but survival outcomes are similar with proper adjuvant therapy.
- Segmentectomy provides comparable survival to lobectomy when combined with systematic nodal dissection and appropriate treatment.
- Completion lobectomy does not consistently improve survival and is associated with significant morbidity.

## Abstract

Segmentectomy is increasingly used to treat small, early-stage non-small cell lung cancer, as recent clinical trials have shown similar survival with better preservation of lung function. However, concerns remain that segmentectomy may detect fewer lymph node metastases, potentially leading to understaging and undertreatment. In this review, we examined contemporary studies comparing segmentectomy and lobectomy with a focus on nodal upstaging, survival outcomes, and the need for completion lobectomy when unexpected lymph node involvement is found. Across large national and multicenter studies, lobectomy identified nodal metastases more frequently than segmentectomy, mainly due to greater detection of lymph nodes located near the lung (N1 nodes). Importantly, survival and recurrence outcomes were similar between the two procedures once lymph node involvement was identified and appropriate postoperative treatments were given. These findings suggest that the lower rate of nodal upstaging after segmentectomy reflects differences in lymph node sampling rather than worse cancer control. When lymph nodes are carefully evaluated and modern adjuvant therapies are used, segmentectomy provides oncologic outcomes comparable to lobectomy, and routine completion lobectomy may not be required and should be considered on a case-by-case basis within a multidisciplinary setting.

Background: Segmentectomy is increasingly used and is emerging as a key treatment option for early-stage non-small cell lung cancer (NSCLC). However, questions remain regarding the adequacy of lymph node evaluation, particularly differences in N1 versus N2 dissection, and the implications for staging accuracy and adjuvant therapy. Methods: This narrative review synthesizes evidence from studies published between 2019 and 2025 comparing nodal upstaging, survival outcomes, and the role of completion lobectomy following segmentectomy versus lobectomy. Results: Twelve studies, including more than 175,000 patients, were analyzed. Lobectomy was associated with a significantly higher overall nodal upstaging rate (14.5% vs. 6.6%, p < 0.001), driven primarily by increased detection of N1 disease (13.3% vs. 3.7%, p < 0.001), while N2 upstaging rates were similar between procedures (5.5% vs. 3.2%, p = 0.07). Despite lower N1 detection, adjusted analyses reported comparable survival outcomes among patients with occult pathologic N1 (pN1) or N2 (pN2) disease who received adjuvant therapy. Segmentectomy provided outcomes comparable to lobectomy, whereas wedge resection was associated with inferior survival (HR 1.23, p = 0.042). Completion lobectomy has not demonstrated a consistent survival benefit and was associated with substantial morbidity in limited retrospective series, including high rates of thoracotomy conversion and major complications. Conclusions: When performed with systematic nodal dissection, adequate surgical margins, and appropriate adjuvant therapy, segmentectomy appears to provide survival outcomes comparable to lobectomy in selected patients with early-stage NSCLC. Completion lobectomy may not be routinely required and should be considered on a case-by-case basis within a multidisciplinary context. These findings support the use of segmentectomy in carefully selected patients when high-quality surgical staging and integrated oncologic care are ensured, while highlighting the need for prospective studies addressing occult nodal disease in the modern treatment era.