Multidisciplinary determination of resectability incorporates tumor biology and perioperative systemic therapy in stage III NSCLCNew Guidelines Redefine Surgery Options for Lung Cancer Patients

Resectability in non-small cell lung cancer (NSCLC) is shifting from a purely anatomic and surgical concept, based on technical feasibility of an R0 resection, to an integrated, multidisciplinary determination that incorporates tumor biology, expected benefit from perioperative systemic therapy and operative risk. Contemporary guidelines emphasize that resectability—particularly in stage III disease—should be defined by an experienced multidisciplinary team (MDT) with thoracic surgical input, alongside standardized staging and biomarker assessment to guide systemic options. Perioperative immune checkpoint inhibitor (ICI) plus chemotherapy regimens have expanded the population considered for curative-intent surgery by improving pathologic response and event-free survival, while also introducing new determinants of resectability, such as likelihood of completing multimodality therapy and managing treatment-related toxicity. Resectability in locally advanced (stage III) NSCLC is a multidisciplinary determination that complete oncologic resection is achievable with acceptable operative risk, and that surgery adds value within a multimodality plan rather than being based on anatomy alone. Key elements of resectable stage III NSCLC are: R0 resection goal with guideline-concordant nodal dissection; nodal extent drives resectability more than T stage as N3 is generally unresectable while single-station, non-bulky N2 is most commonly considered potentially resectable, whereas bulky and - or multistation N2 often argues against surgery, with persistent lack of consensus in the literature. The aim of this review is to focus on the key elements currently redefining the concept of resectability in the landscape of perioperative treatment for lung cancer, with particular regard to locally advanced disease, which represents the most challenging scenario for all professionals involved in the multidisciplinary management of lung cancer.