Objectives: To evaluate outcomes of patients undergoing lung segmentectomy using open thoracotomy, Video-Assisted Thoracoscopic Surgery (VATS), or Robotic-Assisted Thoracoscopic Surgery (RATS) approaches. Methods: A total of 157 patients (mean age: 68.7 years; 58% male) who underwent lung segmentectomy from 2015 to 2024 at the Thoracic Surgery of Siena were retrospectively enrolled and divided into groups based on the surgical approach: thoracotomy (n = 60), VATS (n = 58), and RATS (n = 39). No significant differences were observed between groups in terms of age, gender, or tumor stage. Peri-operative outcomes, and, in patients with non-small cell lung cancer (NSCLC, n = 104), long-term outcomes, were analyzed. Group comparisons were conducted using Kruskal–Wallis, Dunn’s test, Chi-squared, or Fisher’s exact test and Kaplan–Meier analysis with log-rank test. Results: Conversion rate was 13% and 0% for VATS and RATS, respectively (p = 0.005). Pleural effusion on first post-operative day was lower in RATS than VATS (p = 0.0006) and open (p < 0.0001). The maximum Visual Analogue Scale (VAS) value recorded was lower in RATS than open (p = 0.016) and VATS (p = 0.013). Surgery time was longer for RATS than open (p = 0.001) and VATS (p = 0.013). No differences were found in hospital stay and post-operative complications. In patients with NSCLC, the median follow-up was 25 months. The 90-day mortality rate was 9.5% in thoracotomy, 0% in VATS and RATS (p = 0.05). The 1- and 2-year overall survival was higher in VATS and RATS groups than thoracotomy (p = 0.001 and p = 0.040, respectively). The number of harvested lymph nodes was larger in the open group (p = 0.010), while a higher number of stations were harvested in RATS and open than VATS (p = 0.001). No differences were found in local recurrence (p= 0.08). Conclusions: RATS segmentectomy ensures a lower conversion rate, less post-operative pain, reduced daily pleural effusion, and a greater number of harvested lymph node stations compared to VATS, providing comparable peri-operative outcomes. RATS and VATS segmentectomy offer an advantage over the open approach in short- and long-term survival.

Background: Most predictive models for assessing the invasiveness of pure ground-glass nodules (pGGOs) have been developed in Asian populations, which may limit their applicability to Western cohorts. As the detection of pGGOs continues to increase, there is a growing need for reliable, population-specific tools to support preoperative decision-making. Methods: This multicenter retrospective study analyzed patients from the GORDON database who underwent surgical resection for pGGOs < 40 mm between January 2013 and June 2024. Radiologic features were assessed using preoperative high-resolution and contrast-enhanced CT scans. Univariate and multivariable logistic regression analyses were performed to identify independent predictors of invasive adenocarcinoma (IAC). A radiologic nomogram was developed and internally validated using a training (80%) and validation (20%) cohort. Results: A total of 490 pGGOs were included, of which 421 (85.9%) were IAC and 69 (14.1%) noninvasive (Adenocarcinoma in Situ or Minimally Invasive Adenocarcinoma). Upon multivariable analysis, maximum radiologic diameter (adjusted odds ratio [aOR] = 1.09, p = 0.001), spiculated margins (aOR = 3.07, p = 0.006), and unenhanced CT attenuation (aOR = 1.01, p < 0.001) were independent predictors of invasiveness. These variables were incorporated into a nomogram demonstrating good discrimination, with an area under the curve (AUC) of 0.86 (95% CI, 0.81–0.90) in the training cohort and 0.80 (95% CI, 0.70–0.90) in the validation cohort. Conclusions: A radiologic nomogram based on routinely available CT features enables accurate estimation of invasive adenocarcinoma risk in pGGOs. By integrating parameters beyond lesion size, this tool supports personalized management and may improve preoperative decision-making.