Beyond feasibility: defining surgical quality in second pulmonary resection

With the refinement of lung cancer screening, postoperative surveillance, and curative-intent treatment, the population of long-term lung cancer survivors continues to grow. A consequence of this progress is the increasing discovery of metachronous pulmonary malignancies after initial curative resection (1). The second primary lung cancer has evolved from a relatively uncommon clinical scenario into an important challenge in longitudinal lung cancer survivorship. This growing burden highlights the need for evidence-based strategies for surveillance, accurate diagnosis, and therapeutic intervention. While non-surgical local therapies have expanded the therapeutic landscape, surgical resection remains a central curative-intent option for patients who develop a new resectable pulmonary malignancy after prior lobar or sublobar resection (2-4). In this context, using the Society of Thoracic Surgeons General Thoracic Surgery Database, Reddington et al. (5) reported that second pulmonary resection (SecPR) achieved comparable R0 resection rates (97.5% vs. 96.6%, P=0.09) with single pulmonary resection and was not independently associated with increased 30-day major morbidity or mortality. Nevertheless, they also found that reduced pulmonary function, postoperative complications and unexpected escalation of care after the initial operation, and more extensive resection during SecPR were associated with increased morbidity or mortality. These findings suggest that the field should now move beyond the binary question of feasibility and toward a broader assessment of oncological surgical quality.

In the context, the quality of SecPR logically begins before the second operation, but longitudinal quality control is difficult in real-world practice, particularly when the initial resection and subsequent operation are performed by different surgeons or at different institutions. Therefore, improving SecPR outcomes requires not only technical expertise at the second operation, but also a longitudinal quality framework encompassing patient selection, perioperative optimization, and surgical quality across the entire treatment pathway.

Patient selection

Previous evidence has shown that smoking history, chronic obstructive pulmonary disease, solid tumor consistency, and multiple baseline lung nodules are associated with new pulmonary malignancies after lung cancer resection (6). Among these factors, persistent smoking after the initial lung cancer diagnosis and resection deserves particular attention (7). Continued smoking may not only increase the risk of subsequent pulmonary malignancy but also impair perioperative tolerance if SecPR becomes necessary, through progressive smoking-related lung injury, reduced pulmonary reserve, and increased cardiopulmonary risk. Smoking history, chronic obstructive pulmonary disease, and reduced pulmonary reserve are closely interrelated. Therefore, patients with chronic pulmonary disease should be regarded as a high-risk subgroup in the SecPR setting.

Using the Surveillance, Epidemiology, and End Results database, Potter et al. (2) reported that sublobar resection was the predominant surgical strategy for second primary lung cancer after initial segmentectomy or lobectomy. This pattern is clinically understandable, given the importance of preserving residual pulmonary function after a prior pulmonary resection. Procedure-specific evidence has also suggested that, in selected patients undergoing SecPR, wedge resection or segmentectomy may achieve acceptable postoperative and survival outcomes compared with lobectomy (8,9). These findings align with outcomes of Japan Clinical Oncology Group 0802/West Japan Oncology Group 4607L and Cancer and Leukemia Group B/Alliance 140503 (10,11). Moreover, existing evidence showed that tumour size and location seemed key considerations when patients had sublobar resection in the setting of SecPR (12). However, these factors should guide rather than rigidly determine surgical indication, particularly for anatomical segmentectomy. In well-selected clinical stage IA3 non-small cell lung cancer, or even selected central lesions, segmentectomy may still be feasible (13,14).

Surgical quality

For lobectomy during SecPR, the principles of oncologic surgical quality are relatively well established and generally follow the standards of primary lung cancer surgery. In contrast, when sublobar resection is considered for SecPR, the risk of variability in surgical quality may be greater. Margin distance adequacy and lymph node evaluation should therefore not be regarded as technical details, but as two central pillars of oncologic surgical quality.

Although direct evidence regarding the optimal margin distance for sublobar resection in SecPR remains limited, its application should generally follow the principles established for first primary early-stage non-small cell lung cancer. Current guideline-based practice recommends achieving either a parenchymal margin distance of at least 2 cm or a margin-to-tumour ratio of at least 1, whenever technically feasible (15). The requirement of margin distance may ultimately need to be individualized according to radiological invasiveness, such as consolidation-to-tumour ratio or invasive component size. Since pathological invasiveness and other high-risk features cannot always be reliably confirmed before or during surgery, adherence to established margin principles, particularly a margin distance of at least 20 mm when technically feasible, remains a safer and more reasonable strategy. This threshold has also been examined in previous cohort studies, especially in the context of segmentectomy (16). Compared with segmentectomy, wedge resection more often has inadequate margin distance because the resection plane is non-anatomical and is strongly influenced by tumour location. Although a previous study observed that a margin threshold of approximately 9–11 mm may be associated with improved long-term outcomes after wedge resection (17), insufficient margin distance remains an important concern and may partly explain the worse oncologic outcomes observed after wedge resection compared with segmentectomy in some studies.

In terms of lymph node dissection, SecPR may differ substantially from the initial pulmonary resection for the first lung cancer. For ipsilateral SecPR after prior systematic lymph node dissection, repeat complete mediastinal lymphadenectomy may be technically difficult and not always feasible because of adhesions and altered anatomy. In such cases, selective lymph node dissection, guided by preoperative imaging, intraoperative findings, and nodal stations not previously assessed, may represent a pragmatic approach. Conversely, when SecPR is performed on the contralateral side, nodal evaluation should generally follow current standards for primary lung cancer surgery, including appropriate hilar and mediastinal assessment. Radiological features, including ground-glass opacity predominance, should be considered in tailoring the extent of nodal evaluation, but should not replace careful oncologic staging when invasive disease is suspected. Therefore, nodal evaluation in SecPR should be individualized, but not neglected.

Perioperative optimization

The surgical approach is an important component of surgical quality in SecPR. In the study by Reddington et al. (5), minimally invasive surgery was associated with more favorable postoperative outcomes than thoracotomy, supporting its use when technically and oncologically feasible. A minimally invasive approach may reduce surgical trauma, preserve chest wall mechanics, decrease postoperative pain, and facilitate earlier mobilization, all of which are important for patients who have already undergone prior pulmonary resection. Recent systematic reviews and meta-analyses have further strengthened the evidence that video-assisted thoracoscopic surgery improves perioperative outcomes and is associated with better long-term survival in selected patients (18). However, these benefits should not be interpreted as an indication to pursue minimally invasive surgery at all costs. Conversion to thoracotomy should remain an acceptable and timely decision when required to maintain procedural safety or oncologic completeness. Robotic-assisted surgery may provide additional technical advantages in selected complex procedures, particularly segmentectomy or ipsilateral SecPR, through enhanced visualization, instrument articulation, tremor filtration, and precise dissection around previously operated hilar structures. Nevertheless, dedicated evidence of robotic-assisted surgery in SecPR cohorts remains limited.

Beyond the operative approach, perioperative optimization should also be regarded as an integral component of surgical quality. Patients undergoing SecPR have already experienced prior operative stress and may have reduced functional reserve, making their recovery trajectory different from that of patients undergoing a first pulmonary resection. The decision to proceed with SecPR should therefore incorporate not only tumour resectability, but also the interval between the initial operation and SecPR, baseline pulmonary function, predicted postoperative function, frailty, nutritional status, comorbidity burden, and patient preference. Importantly, several risk factors are potentially modifiable before surgery. Structured smoking cessation, nutritional optimization, pulmonary rehabilitation, prehabilitation, and meticulous management of chronic obstructive pulmonary disease or cardiovascular comorbidities may improve surgical tolerance and postoperative recovery. Furthermore, standardized enhanced recovery protocols (19), including early mobilization, optimized analgesia, careful fluid management, and proactive respiratory physiotherapy, should also be integrated into perioperative care. These measures are especially relevant for patients undergoing SecPR, because surgical success should be defined not only by technical completion of the operation, but also by clinically meaningful preservation of postoperative function.

In summary, Reddington and colleagues provide important contemporary evidence that SecPR can be performed safely in carefully selected patients. However, the value of SecPR should not be judged solely by 30-day morbidity, mortality, or technical feasibility. Its actual quality depends on a longitudinal framework that begins with the initial oncologic treatment and extends through surveillance, patient selection, perioperative optimization, procedure selection, margin adequacy, nodal evaluation, and postoperative recovery. Future studies should link these granular surgical quality metrics with long-term oncologic outcomes, pulmonary function, quality of life, and patient-centered recovery. SecPR is therefore not only a question of whether surgery can be performed, but whether oncologic quality can be preserved across time.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Shanghai Chest. The article has undergone external peer review.

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-2026-0019/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-2026-0019/coif). R.H.P. reports speaker fees from Medtronic, AstraZeneca, Boehringer Ingelheim, Intuitive, Pfizer, MSD, travel support from AstraZeneca, consulting fees from AstraZeneca, MSD, BMS, and research grants from Novo Nordisk Foundation, X-vivo, Medtronic. The other author has no conflicts of interest to declare.

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