| Surgical key issues |
| 1) Small nodules (5–10 mm) that are clearly 100% pure GGO lesions on chest CT and are suspected to be AIS or MIA should be considered for CT follow-up rather than immediate resection |
| 2) Lobectomy is the standard surgical treatment for patients with early-stage lung cancer; limited resection may be an appropriate option for AIS and MIA but results of prospective trials are awaited to determine the precise incidence of local recurrence |
| 3) At least a lobe-specific systematic nodal dissection is advised for current intraoperative nodal staging; in some specific subgroups (cT1–2N0 or non-hilar N1), lymph node sampling, rather than systematic nodal dissection, may be appropriate |
| 4) For small AIS or MIA, lymph node sampling or systematic nodal dissection may not be required, but no randomised studies are yet available |
| 5) Multiple lung adenocarcinomas are considered for resection when considered to be multiple synchronous or metachronous, early-stage primary tumours rather than intrapulmonary metastases |
| Surgical areas of uncertainty |
| 1) The precise role of limited resection has not yet been determined due to a lack of randomised prospective trials |
| 2) The extent of lymph node dissection also remains controversial |
| 3) The accuracy of frozen section in assessing the presence of invasive adenocarcinoma and the accuracy of frozen section or cytology of resection margins in sublobar resections needs to be investigated further; specific guidelines for frozen section analysis should be developed to guide intraoperative decisions |
| 4) Treatment of multiple lesions has not been standardised |
| 5) When there is no pleural invasion, how should one identify a tumour located deep in the lung parenchyma during VATS? |
| 6) What is the specific value of pathological evaluation of markers for intraparenchymal nodules, such as needles or dye? |
| 7) The role of new emerging techniques, including stereotactic radiotherapy and radiofrequency ablation, in the management of NSCLCs of ≤3 cm needs to be defined |
| 8) The optimal management of elderly patients with stage I–II lung adenocarcinoma needs to be defined |
| 9) How to differentiate between multiple primary adenocarcinoma nodules of same histologic subtype and synchronous metastases |
| 10) The role of VATS for diagnosis, staging and treatment of early lung cancer should be investigated further |
GGO: ground-glass opacity; CT: computed tomography; AIS: adenocarcinoma in situ; MIA: minimally invasive adenocarcinoma; c: clinical; T: tumour; N: node; VATS: video-assisted thoracic surgery; NSCLC: nonsmall cell lung cancer.