Prognostic Impact of Visceral Pleural Invasion in Node-Negative Non-Small Cell Lung Cancer with Tumors ≤ 3 cm

Background and Objectives: Visceral pleural invasion (VPI) up-classifies non-small cell lung cancer (NSCLC) tumors measuring ≤3 cm from T1 to T2; however, whether this stage migration translates into worse survival in pathologically node-negative disease remains uncertain. This study evaluated the prognostic impact of VPI on overall survival (OS) and progression-free survival (PFS) in this selected population. Materials and Methods: This retrospective single-center cohort study included patients who underwent surgical resection for pathologically node-negative NSCLC with tumors ≤ 3 cm between 2015 and 2021. In the primary analysis, patients with PL0 were compared with those with PL1–PL2, whereas PL3 cases were excluded from the primary comparison and evaluated only in exploratory analyses. Survival outcomes were assessed using Kaplan–Meier analysis and univariable and multivariable Cox regression models. Results: A total of 241 patients were included in the overall cohort (PL0, n = 179; PL1, n = 48; PL2, n = 9; PL3, n = 5). After exclusion of PL3 from the primary analysis, 236 patients remained, including 179 with PL0 and 57 with PL1–PL2. During follow-up, 58 deaths and 81 PFS events occurred in the primary analytic cohort. Kaplan–Meier analysis showed no significant differences between PL0 and PL1–PL2 in OS (log-rank p = 0.655) or PFS (log-rank p = 0.904). In multivariable analysis, VPI was not independently associated with OS (HR 0.785, 95% CI 0.389–1.582; p = 0.498) or PFS (HR 0.908, 95% CI 0.507–1.624; p = 0.744). Increasing age was independently associated with worse OS and PFS, whereas male sex and pneumonectomy were independently associated with worse OS. Conclusions: In surgically treated patients with pathologically node-negative NSCLC and tumors ≤ 3 cm, VPI defined as PL1–PL2 was not independently associated with OS or PFS. These findings suggest that the prognostic implications of VPI-driven up-classification may be context-dependent and should be interpreted together with other clinicopathological factors.