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The Clinical Practice Standards Committee of the American Association for Thoracic Surgery assembled an expert panel and conducted a systematic review of the literature detailing studies directly comparing treatment options for high-risk patients with stage I non-small cell lung cancer (NSCLC). A systematic search was performed to identify publications comparing outcomes following image-guided thermal ablation (IGTA), stereotactic ablative radiotherapy (SABR; also called stereotactic body radiation therapy [SBRT] and stereotactic radiosurgery [SRS]), and sublobar resection-the main treatment options applicable to high-risk patients with stage I NSCLC. There were no publications detailing completed randomized controlled trials comparing these treatment options. Several retrospective studies with comparisons were identified, some of which used large, population-based registries. The findings of several of these studies are summarized in this Expert Review article. Registry studies comparing IGTA with SABR in propensity-score matched patients with stage I NSCLC found no difference in overall survival. The use of thermal ablation was less frequent and had wider variation depending on geographic region as compared with SABR, however. Studies yielding high-quality data comparing SABR with sublobar resection have been limited. When comparing sublobar resection with IGTA, sublobar resection was associated with superior primary tumor control and overall survival in the retrospective cohort studies. Retrospective comparative studies are difficult to assess due to the inherent biases or treatment selection and the definitions of loco-regional control. Prospective randomized trials are needed to fully evaluate the outcomes of treatment options applicable to high-risk patients with early-stage lung cancer., (Copyright © 2025. Published by Elsevier Inc.)

Stereotactic ablative radiotherapy (SABR) has emerged as an alternative, non-surgical treatment for high-risk patients with stage I non-small cell lung cancer (NSCLC) with increased use over time. The American Association for Thoracic Surgery (AATS) Clinical Practice Standards Committee (CPSC) assembled an expert panel and conducted a systematic review of the literature evaluating the results of SABR, which is also referred to as stereotactic body radiation therapy (SBRT) or stereotactic radiosurgery (SRS), prior to developing treatment recommendations for high-risk patients with stage I NSCLC based on expert consensus. Publications detailing the findings of 16 prospective studies of SABR and 14 retrospective studies of SABR for the management of early-stage lung cancer in 54,697 patients were identified by systematic review of the literature with further review by members of our expert panel. Medical inoperability (93-95%) was the primary reason for utilizing SABR. The median rate of histologically confirmed cancer in treated patients was 67% (range 57-86%). In retrospective studies and prospective studies, the most common dosing regimens were 48-54Gy in 3-5 fractions and 44-66Gy in 3-5 fractions respectively. The median follow-up after SABR was 30 months (range 15-50). The complications, oncological results and quality of life after SABR in high-risk patients with early-stage NSCLC are summarized in this Expert Review article. Further prospective randomized trials are needed and are currently underway to compare outcomes after SABR with outcomes after sublobar resection to fully evaluate treatment options applicable this high-risk group of patients., (Copyright © 2025. Published by Elsevier Inc.)

Sublobar resection offers a parenchymal-sparing surgical alternative to lobectomy and includes wedge resection and segmentectomy. Sublobar resection has been historically utilized in high-risk patients with compromised lung function; however, the technique is becoming more prevalent for normal-risk patients with peripheral stage IA non-small cell lung cancer (NSCLC) <2 cm. In this article, we summarize the technique of sublobar resection, the importance of surgical margins and lymph node sampling, patient selection, perioperative complications, outcomes, and the impact of sublobar resection on the quality of life. There is limited data on short-term and long-term outcomes after sublobar resection for stage I NSCLC in high-risk patients. Results from randomized clinical trials (RCTs) of sublobar resection have been variable. We have summarized the results of the ACOSOG Z4032 RCT, which compared outcomes in high-risk patients who underwent sublobar resection alone versus sublobar resection with brachytherapy for stage I NSCLC. In addition, we have summarized recent findings of the CALGB/Alliance 140503 RCT comparing sublobar resection and lobectomy, which suggested that disease-free survival after sublobar resection in patients with small (<2 cm) peripheral stage IA NSCLC was non-inferior to lobectomy, and another RCT (JCOG 0802) of segmentectomy vs. lobectomy for small peripheral clinical stage IA NSCLC, where segmentectomy was associated with better overall survival despite a higher local recurrence rate. Sublobar resection is primarily performed with minimally invasive approaches, including robotic-assisted and video-assisted thoracoscopic techniques. From an oncologic perspective, obtaining adequate surgical margins and performing an adequate lymph node evaluation are critical for good outcomes after sublobar resection., (Copyright © 2025. Published by Elsevier Inc.)

Image-guided thermal ablation (IGTA) applied to pulmonary pathology is an alternative to surgery in high-risk patients with stage I non-small cell lung cancer (NSCLC). Its application to lung neoplasm was first introduced in 2001 and has been implemented to treat metastatic disease to the lung or in select medically inoperable patients with peripheral stage I NSCLC. IGTA may also be an alternative to treat stage I NSCLC in non-operable patients with interstitial lung disease in whom a radiation modality is deemed too high risk. There are 3 methods of delivery: radiofrequency ablation (RFA), microwave ablation and cryoablation. Observational series and some prospective trials have shown safety and efficacy across all three modalities. Despite accumulating experience, there are no large randomized clinical trials comparing the outcomes of lung IGTA to alternative locoregional therapies (eg, stereotactic body radiotherapy or sublobar pulmonary resection) for the treatment of stage I NSCLC. Because IGTA is a local therapy, a higher risk of locoregional recurrence is inherently understood as compared with anatomic resection. In the literature, primary tumor control after RFA ranges from 47 to 90% and is dependent on tumor size and proximity to bronchovascular structures. Local failure ranges from 10 to 47%, and tumors ≥3 cm have the highest rate of local recurrence. The most prevalent side effects are pneumothorax and reactive pleural effusion; hemorrhage is uncommon. Of note, observational series show no significant loss of lung function after IGTA. This expert review contextualizes limitations, complications and outcomes of IGTA in patients with stage I NSCLC., (Copyright © 2025. Published by Elsevier Inc.)

Lung cancer is the most common cause of cancer-related mortality in the United States. Surgical resection with a lobectomy is the standard treatment for stage I non-small cell lung cancer. With an aging population, however, there are a significant number of patients who have other comorbidities that preclude surgical resection. Image-guided radiofrequency ablation is a new emerging modality of treatment which may be applicable in this high-risk group of patients. In this article, we review the principles of radiofrequency ablation, the common devices in use, the results of ablate and resect studies, future directions, and the results of treatment for stage I non-small cell lung neoplasm., (Copyright 2010 Elsevier Inc. All rights reserved.)

The use of sublobar resection techniques (anatomic segmentectomy; extended wedge) in the treatment of early-stage non-small cell lung cancer has been associated with increased local recurrence rates compared with lobectomy. Recent data, however, have suggested that sublobar resection of smaller tumors (especially those < or =2 cm) can be performed with no significant difference in local recurrence or long-term survival. These findings have particular relevance in elderly patients and in those patients who may be at high risk for lobectomy because of underlying medical comorbidities. Careful patient selection on the basis of individualized assessment of specific patient and tumor characteristics will aid in selecting the optimal approach. For larger tumors, or when adequate surgical margins are not obtainable, lobectomy should be performed. Currently, active, prospective, randomized studies (Cancer and Leukemia Group B [CALGB] 140503 and American College of Surgeons Oncology Group [ACOSOG] Z4032) will provide critical insights in delineating the efficacy of sublobar resection techniques in early-stage non-small cell lung cancer., (Copyright 2010 Elsevier Inc. All rights reserved.)

Endoscopic techniques for the treatment of reflux disease were first introduced in 2000 as an alternative to laparoscopic antireflux operations. Because of reports of long-term treatment failure with laparoscopic fundoplication and the fact that surgery is increasingly being reserved for the relatively small proportion of patients with complicated reflux disease, attempts to develop safe, effective, and durable endoscopic approaches to antireflux surgery continue. Techniques include radiofrequency ablation, injection therapy, and suturing/stapling techniques. Of these, the suturing/stapling techniques are most similar to the anatomic restructuring of the gastroesophageal junction provided by fundoplication. While early attempts at endoscopic suturing have been disappointing, significant advances in endoscopic instrumentation, a more complete understanding of the gastroesophageal junction anatomy, and improvements in the technical skills of the endoscopic surgeon have been realized. As a result, techniques now being tested, such as the endoluminal fundoplication, may prove more effective and durable than previous endoscopic antireflux procedures.

In an effort to identify those patients at risk for developing esophageal adenocarcinoma, the American College of Gastroenterology recommends screening endoscopy in patients with chronic gastroesophageal reflux disease. Surveillance endoscopy is recommended every 3 years in those patients without dysplasia. For those patients with verified low-grade dysplasia, yearly surveillance endoscopy is recommended. In the case of high-grade dysplasia (HGD), either intensive endoscopic surveillance (focal HGD) or ablation/resection can be performed (multifocal HGD). Both observational and cost-effectiveness analyses suggest a potential benefit of endoscopic screening and surveillance, though these findings remain to be validated in controlled clinical trials. The development of new endoscopic imaging modalities may enhance the yield of biopsies obtained during screening and surveillance regimens.

Esophagectomy is a complex procedure that is associated with significant morbidity and mortality in even the best of hands. With the introduction and widespread application of minimally invasive techniques, the possibility of improving outcomes has been entertained. In a series of 222 patients that underwent minimally invasive esophagectomy at the University of Pittsburgh, the mortality rate was 1.4%, with major morbidity occurring in 32%. The overall spectrum of complications encountered was similar to that previously reported in the largest open series. The marked reduction in mortality and hospital stay when compared with many open series may be an important consequence of the minimally invasive approach, though prospective randomized studies will be required to further assess this potential benefit.