Abstract
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.