A narrative review of segmentectomy versus lobectomy in elderly patients with early-stage NSCLC: challenging the longstanding standard.

Background and Objective: Lobectomy has historically been regarded as the gold standard for early-stage non-small cell lung cancer (NSCLC). However, concerns about postoperative pulmonary function in elderly patients have fueled growing interest in segmentectomy. This review aimed to synthesize current evidence regarding the comparative outcomes of lobectomy and segmentectomy in patients aged ≥70 years, with attention to demographic trends and clinical practice patterns. Methods: We conducted a narrative review of the literature published from 1913 through 2025, primarily using PubMed (MEDLINE) supplemented by Google Scholar and journal archives. Keywords included "lobectomy", "segmentectomy", "sublobar resection", "elderly", and "survival". Studies were screened by six authors, and data were summarized with a focus on surgical trends, survival outcomes, and factors influencing patient selection in elderly cohorts. Key Content and Findings: Historical trials established lobectomy as the standard due to lower recurrence risk compared with limited resection. Yet more recent evidence has shifted this paradigm. The Cancer and Leukemia Group B (CALGB) 140503 trial demonstrated the non-inferiority of sublobar resection (segmentectomy or wedge resection) compared with lobectomy for small peripheral tumors, whereas the Japan Clinical Oncology Group (JCOG) 0802/West Japan Oncology Group (WJOG) 4607L trial specifically showed that anatomical segmentectomy not only achieved oncologic non-inferiority but also improved overall survival in older patients. Population-based analyses from the Surveillance, Epidemiology, and End Results (SEER), the National Cancer Database (NCDB), and nationwide Korean datasets further show that while lobectomy remains most common, the use of segmentectomy has steadily increased, particularly among patients aged ≥70 years. These data suggest that lobectomy confers survival advantages in younger patients, whereas segmentectomy provides comparable or superior outcomes in elderly populations while preserving lung function. South Korea, one of the world's most rapidly aging societies, illustrates how demographic shifts may influence surgical practice. Conclusions: Segmentectomy represents a clinically meaningful alternative to lobectomy in elderly patients with early-stage NSCLC. Age, along with physiologic status and tumor characteristics, should guide surgical decision-making. Further randomized trials are warranted to establish evidence-based, age-stratified guidelines.