Perioperative recovery and survival after lobectomy versus sublobar resection in adults aged ≥ 70 years with NSCLC ≤ 3 cm: complementary SEER and real-world cohort analyses

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For older adults with non-small cell lung cancer (NSCLC), the choice of resection must balance durable cancer control against physiological reserve and postoperative recovery. We combined population-level long-term survival data with granular real-world perioperative data to examine this trade-off. The Surveillance, Epidemiology, and End Results (SEER) cohort included 2,630 patients aged ≥ 70 years with NSCLC ≤ 3 cm diagnosed in 2010–2015 (855 lobectomy, 1,421 wedge resection, and 354 segmentectomy). Optimal 1:1 propensity-score matching retained 809 patients per group. The two-center cohort included 223 patients treated by video-assisted thoracoscopic surgery in 2017–2020 (145 lobectomies and 78 sublobar resections: 73 wedge resections and five segmentectomies). Overlap weighting used age, sex, tumor size, clinical stage, consolidation-to-tumor ratio, smoking, and recorded cardiopulmonary comorbidities. The primary real-world survival analysis was restricted to tumors ≤ 2 cm and 36 months. In SEER, matched sublobar resection was not associated with a statistically significant OS difference for tumors ≤ 2 cm (hazard ratio [HR] 1.18, 95% confidence interval [CI] 0.93–1.51; P = 0.177), whereas OS was lower after sublobar resection for tumors > 2–3 cm (HR 1.31, 95% CI 1.03–1.66; P = 0.028). Procedure-specific models showed no significant difference between segmentectomy and lobectomy for tumors ≤ 2 cm (HR 1.03, 95% CI 0.83–1.26), while wedge resection was associated with lower OS (HR 1.32, 95% CI 1.14–1.53). In the real-world cohort, patients selected for wedge-dominant sublobar resection were older and had more recorded comorbidities. After overlap weighting, wedge-dominant sublobar resection was associated with shorter chest-tube duration (mean difference − 2.49 days, 95% CI − 3.56 to − 1.37) and less hypoproteinemia (risk difference − 14.4% points, 95% CI − 27.6 to − 1.7). The composite in-hospital complication risk was 16.4% points lower (95% CI − 34.7 to 1.3), whereas total hospital stay did not differ significantly (mean difference − 1.60 days, 95% CI − 4.62 to 2.04). For tumors ≤ 2 cm, adjusted 3-year OS was 93.0% after lobectomy and 88.5% after wedge-dominant sublobar resection (HR 1.73, 95% CI 0.19–15.63; P = 0.558). In routine practice, wedge-dominant sublobar resection was selected for older adults with greater comorbidity burden and was associated with shorter chest drainage and less hypoproteinemia, while total hospital stay was similar after adjustment. Among patients with tumors ≤ 2 cm, the real-world cohort showed no statistically significant 3-year OS difference. In the longer-term SEER analysis, segmentectomy showed no significant adjusted OS difference from lobectomy for tumors ≤ 2 cm, whereas wedge resection warrants greater oncologic caution.

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