Accurate preoperative imaging is essential for determining operability, guiding surgical planning, and optimizing outcomes in the treatment of non-small cell lung cancer (NSCLC). This paper outlines thoracic surgeons’ expectations from radiologists in the preoperative evaluation of NSCLC, aiming to enhance multidisciplinary collaboration and improve radiologic reporting standards. A narrative review of imaging modalities—including CT, PET-CT, and MRI—was conducted to identify key radiologic parameters relevant to surgical decision-making. The paper integrates current Tumor, nodes, metastasis (TNM) staging criteria, tumor morphology, anatomical localization, and invasion patterns, with practical surgical implications. Radiologists are expected to provide precise measurements of tumor size and morphology, assess nodal involvement and metastatic spread, and identify critical anatomical relationships and variations. Imaging should detail tumor invasion into adjacent structures such as the chest wall, mediastinum, and vascular or airway components. The paper also emphasizes the importance of imaging in evaluating suitability for minimally invasive surgery, guiding lesion localization, and assessing underlying lung pathology and post-induction therapy response. A standardized, surgeon-oriented imaging report enhances surgical planning, reduces intraoperative risks, and supports personalized treatment strategies. This paper serves as a practical guide for radiologists to align imaging assessments with thoracic surgical needs, ultimately improving patient outcomes.
BrayFLaversanneMSungH, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin2024; 74: 229–263. DOI: 10.3322/caac.21834.
2.
ArgentieriGValsecchiCPetrellaF, et al. Implementation of the 9th TNM for lung cancer: practical insights for radiologists. Eur Radiol2025; 35: 4395–4402. DOI: 10.1007/s00330-024-11345-8.
3.
StefanidisKKonstantellouEYusufG, et al. The evolving landscape of lung cancer surgical resection: an update for radiologists with focus on key chest CT findings. AJR Am J Roentgenol2022; 218: 52–65. DOI: 10.2214/AJR.21.26408.
4.
DetterbeckFCFranklinWANicholsonAG, et al. The IASLC Lung Cancer Staging Project: Background data and proposed criteria to distinguish separate primary lung cancers from metastatic foci in patients with two lung tumors in the forthcoming eighth edition of the TNM Classification for Lung Cancer. J Thorac Oncol2016; 11: 651–665. DOI: 10.1016/j.jtho.2016.01.025.
5.
DetterbeckFCMaromEMArenbergDA, et al. The IASLC Lung Cancer Staging Project: Background data and proposals for the application of TNM staging rules to lung cancer presenting as multiple nodules with ground glass or lepidic features or a pneumonic type of involvement in the forthcoming eighth edition of the TNM Classification. J Thorac Oncol2016; 11: 666–680. DOI: 10.1016/j.jtho.2015.12.113.
6.
RemonJSoriaJCPetersS, et al. Early and locally advanced non-small-cell lung cancer: an update of the ESMO Clinical Practice Guidelines focusing on diagnosis, staging, systemic and local therapy. Ann Oncol2021; 32: 1637–1642. DOI: 10.1016/j.annonc.2021.08.1994.
7.
RizzoSRadiceDFemiaM, et al. Metastatic and non-metastatic lymph nodes: quantification and different distribution of iodine uptake assessed by dual-energy CT. Eur Radiol2018; 28: 760–769. DOI: 10.1007/s00330-017-5015-5.
8.
ElsholtzFHJAsbachPHaasM, et al. Introducing the Node Reporting and Data System 1.0 (Node-RADS): a concept for standardized assessment of lymph nodes in cancer. Eur Radiol2021; 31: 6116–6124. DOI: 10.1007/s00330-020-07572-4.
9.
AltorkiNWangXKozonoD, et al. Lobar or sublobar resection for peripheral stage IA non-small-cell lung cancer. New Eng J Med2023; 388: 489–498. DOI: 10.1056/NEJMoa2212083.
10.
SajiHOkadaMTsuboiM, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet2022; 399: 1607–1617. DOI: 10.1016/S0140-6736(21)02333-3.
11.
MasaiKSakuraiHSukedaA, et al. Prognostic impact of margin distance and tumor spread through air spaces in limited resection for primary lung cancer. J Thorac Oncol2017; 12: 1788–1797. DOI: 10.1016/j.jtho.2017.08.015.
12.
MoonYParkJKLeeKY. The effect of resection margin distance and invasive component size on recurrence after sublobar resection in patients with small (</=2 cm) lung adenocarcinoma. World J Surg2020; 44: 990–997. DOI: 10.1007/s00268-019-05276-5.
13.
TakahashiNSawabataNKawamuraM, et al. Optimal sublobar resection for c-stage I non-small cell lung cancer: significance of margin distance to tumor size ratio and margin cytology (Supplementary analysis of KLSG-0801): complete republication. Gen Thorac Cardiovasc Surg2019; 67: 690–696. DOI: 10.1007/s11748-019-01069-8.
14.
MatsuuraNIgaiHOhsawaF, et al. Novel thoracoscopic segmentectomy combining preoperative three-dimensional image simulation and intravenous administration of indocyanine green. Interact Cardiovasc Thorac Surg2022; 35. DOI: 10.1093/icvts/ivac064.
15.
ChenSZhouJZhangJ, et al. Video-assisted thoracoscopic solitary pulmonary nodule resection after CT-guided hookwire localization: 43 cases report and literature review. Surg Endosc2011; 25: 1723–1729. DOI: 10.1007/s00464-010-1502-3.
16.
DetterbeckFCKumbasarULiAX, et al. Lung cancer with air lucency: a systematic review and clinical management guide. J Thorac Dis2023; 15: 731–746. DOI: 10.21037/jtd-22-1199.
17.
YankelevitzDFYipRSmithJP, et al. CT Screening for Lung Cancer: Nonsolid Nodules in Baseline and Annual Repeat Rounds. Radiology2015; 277: 555–564. DOI: 10.1148/radiol.2015142554.
18.
RakovichGFerraroPTherasseE, et al. Preoperative embolization in the management of a mediastinal paraganglioma. Ann Thorac Surg2001; 72: 601–603. DOI: 10.1016/s0003-4975(00)02293-1.
19.
SchiemanCMacGregorJHKellyE, et al. Can preoperative computed tomography of the chest predict completeness of the major pulmonary fissure at surgery?Can J Surg2011; 54: 252–256. DOI: 10.1503/cjs.007910.
20.
VenutaFRendinaEADe GiacomoT, et al. Technique to reduce air leaks after pulmonary lobectomy. Eur J Cardiothorac Surg1998; 13: 361–364. DOI: 10.1016/s1010-7940(98)00038-4.
21.
HigashinoTOhnoYTakenakaD, et al. Thin-section multiplanar reformats from multidetector-row CT data: utility for assessment of regional tumor extent in non-small cell lung cancer. Eur J Radiol2005; 56: 48–55. DOI: 10.1016/j.ejrad.2005.04.002.
22.
AkataSKajiwaraNParkJ, et al. Evaluation of chest wall invasion by lung cancer using respiratory dynamic MRI. J Med Imaging Radiat Oncol2008; 52: 36–39. DOI: 10.1111/j.1440-1673.2007.01908.x.
23.
TahiriMKherebaMThiffaultV, et al. Preoperative assessment of chest wall invasion in non-small cell lung cancer using surgeon-performed ultrasound. Ann Thorac Surg2014; 98: 984–989. DOI: 10.1016/j.athoracsur.2014.04.111.
BruzziJFKomakiRWalshGL, et al. Imaging of non-small cell lung cancer of the superior sulcus: part 2: initial staging and assessment of resectability and therapeutic response. Radiographics2008; 28: 561–572. DOI: 10.1148/rg.282075710.
26.
BruzziJFKomakiRWalshGL, et al. Imaging of non-small cell lung cancer of the superior sulcus: part 1: anatomy, clinical manifestations, and management. Radiographics2008; 28: 551–560; quiz 620. DOI: 10.1148/rg.282075709.
27.
DavidEACanterRJChenY, et al. Surgical management of advanced non-small cell lung cancer is decreasing but is associated with improved survival. Ann Thorac Surg2016; 102: 1101–1109. DOI: 10.1016/j.athoracsur.2016.04.058.
28.
PostmusPEKerrKMOudkerkM, et al. Early and locally advanced non-small-cell lung cancer (NSCLC): ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol2017; 28: iv1–iv21. DOI: 10.1093/annonc/mdx222.
29.
LeoFScanagattaPVannucciF, et al. Impaired quality of life after pneumonectomy: who is at risk?J Thorac Cardiovasc Surg2010; 139: 49–52. DOI: 10.1016/j.jtcvs.2009.05.029.
30.
BackhusLPuneetBBastawrousS, et al. Radiographic evaluation of the patient with lung cancer: surgical implications of imaging. Curr Probl Diagn Radiol2013; 42: 84–98. DOI: 10.1067/j.cpradiol.2012.08.001.
TamburiniNMarchiIBassiM, et al. Misdiagnosis of anomalous pulmonary venous connections in a patient with lung cancer and a review of the literature. J Thorac Dis2017; 9: E723–E726. DOI: 10.21037/jtd.2017.07.36.
33.
LimEHarrisRAMcKeonHE, et al. Impact of video-assisted thoracoscopic lobectomy versus open lobectomy for lung cancer on recovery assessed using self-reported physical function: VIOLET RCT. Health Technol Assess2022; 26: 1–162. DOI: 10.3310/THBQ1793.
34.
CiriacoPNegriGPuglisiA, et al. Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization. Eur J Cardiothorac Surg2004; 25: 429–433. DOI: 10.1016/j.ejcts.2003.11.036.
35.
DetterbeckFCHomerRJ. Approach to the ground-glass nodule. Clin Chest Med2011; 32: 799–810. DOI: 10.1016/j.ccm.2011.08.002.
36.
SaitoHMinamiyaYMatsuzakiI, et al. Indication for preoperative localization of small peripheral pulmonary nodules in thoracoscopic surgery. J Thorac Cardiovasc Surg2002; 124: 1198–1202. DOI: 10.1067/mtc.2002.127331.
37.
KawasakiHNagaiKYoshidaJ, et al. Postoperative morbidity, mortality, and survival in lung cancer associated with idiopathic pulmonary fibrosis. J Surg Oncol2002; 81: 33–37. DOI: 10.1002/jso.10145.
38.
KroenkeKLawrenceVATherouxJF, et al. Postoperative complications after thoracic and major abdominal surgery in patients with and without obstructive lung disease. Chest1993; 104: 1445–1451. DOI: 10.1378/chest.104.5.1445.
39.
CasconeTWeissferdtAGodoyMCB, et al. Nodal immune flare mimics nodal disease progression following neoadjuvant immune checkpoint inhibitors in non-small cell lung cancer. Nat Commun2021; 12: 5045. DOI: 10.1038/s41467-021-25188-0.
