Lung cancer associated with cystic airspaces in the perioperative immunotherapy era: radiologic and pathologic pitfalls, surgical extent, and management implications.

With expanded use of screening and the rise of perioperative immunotherapy, early-stage non-small cell lung cancer management increasingly hinges on precise radiologic and pathologic staging. Lung cancer associated with cystic airspaces (LCCA) presents distinct challenges because its cystic architecture can distort measurement, complicate T-staging and influence therapeutic decision-making. We review current evidence on LCCA, including morphological classification (thin-walled, thick-walled, mural nodule, mixed), imaging-pathologic discrepancies, and prognostic implications of cyst-wall composition and mural nodules. We highlight key clinical questions: how to define and measure the "functional diameter", whether standard surgical and perioperative guidelines are applicable to LCCA, and when to suspect intrapulmonary metastasis in multifocal cystic lesions. Drawing on our ongoing prospective registry of over 300 computed tomography (CT)-defined LCCA cases (NCT07066813), we outline a research agenda focusing on radiologic-pathologic correlation, subtype-specific trials, and radiomics/artificial intelligence (AI)-based classification. Accurate staging and biologically informed treatment strategies in LCCA will support individualized care and improve outcomes in early-stage lung cancer.