Local Recurrence After Lung Segmentectomy—Risk Factors and Future Directions: A Contemporary Review

Background: Anatomical segmentectomy has increasingly emerged as an accepted surgical strategy for selected patients with early-stage non-small cell lung cancer (NSCLC), particularly following the JCOG0802/WJOG4607L and CALGB/Alliance 140503 randomized trials. Although these studies demonstrated oncologic equivalence—or even superiority in overall survival—compared with lobectomy in carefully selected tumors, concerns persist regarding increased locoregional recurrence after segmentectomy. Recent evidence suggests that recurrence is influenced not only by surgical technique but also by tumor biology, radiological characteristics, nodal assessment, and patient-specific factors. Methods: This narrative review critically summarizes contemporary evidence regarding local recurrence after anatomical segmentectomy for early-stage NSCLC. A literature review was performed using PubMed/MEDLINE database and recent thoracic surgical literature published primarily from 2015 onwards. Randomized trials, prospective and retrospective studies, meta-analyses, and expert consensus statements were included, with particular focus on recurrence patterns, tumor biology, radiological features, surgical factors, lymph node assessment, and emerging technologies. Results: Segmentectomy provides comparable overall survival to lobectomy in selected patients with small peripheral NSCLC; however, locoregional recurrence remains more frequent after segmentectomy. Major predictors of recurrence include pure-solid radiological appearance, high consolidation-to-tumor ratios, larger tumor size, STAS positivity, lymphovascular invasion, aggressive adenocarcinoma subtypes, inadequate lymph node assessment, and insufficient surgical margins. Hypermetabolic tumors on PET imaging and occult nodal disease further increase recurrence risk. Several studies identified delayed recurrence patterns occurring beyond 5 years after surgery. Conclusions: Local recurrence remains the principal oncologic limitation of segmentectomy. Contemporary evidence supports a shift from size-based toward biology-driven surgical decision-making integrating tumor morphology, metabolic activity, histopathological aggressiveness, STAS status, and nodal involvement into surgical planning.