Stage IA2 squamous lung cancer: lung-sparing segmentectomy after COPD optimization

What happened, in summary

This 75-year-old man had a 2.5 cm left upper-lobe lung nodule found during routine chest CT screening. He had smoked about 20 cigarettes per day for more than 50 years and had chronic obstructive pulmonary disease that had not been regularly treated. Imaging showed a suspicious lesion with cystic change, spiculation, and a solid component greater than 50%. Further imaging also revealed unusual anatomy: a tracheal bronchus, a displaced left apicoposterior bronchus, an adjacent variant segmental artery, a persistent left superior vena cava, and a fissureless left lung. Pulmonary function testing showed moderate-to-severe obstruction, with FEV1 of 1.20 L, so lobectomy was not considered safe. After multidisciplinary review, he completed 4 weeks of preoperative optimization using inhaled triple therapy and structured pulmonary rehabilitation. FEV1 improved to 1.64 L. Surgeons then used preoperative 3D reconstruction to plan a lung-sparing operation. During two-port VATS surgery, the team performed combined left S1+2 and S6 segmentectomy, using indocyanine-green fluorescence to define the intersegmental plane and preserve lung function. A station 12 lymph node was negative on frozen section. Final pathology showed moderately to poorly differentiated squamous cell carcinoma, 2.0 cm, with no visceral pleural invasion, no perineural invasion, station 12 node 0/1, PD-L1 TPS 10%, and final stage pT1bN0M0 / Stage IA2. He recovered without air leak or pulmonary complications and went home on postoperative day 5. At 18 months, he remained recurrence-free with good quality of life, no dyspnea, and no chronic cough. This outcome supports the choice of a lung-sparing strategy rather than lobectomy in a patient with limited baseline breathing reserve. It also shows why careful preoperative mapping can matter when cancer surgery is complicated by both COPD and unusual bronchovascular anatomy.