Three-dimensional anatomical reconstruction as a guideline-anchored framework for choosing between lung-sparing resection and image-guided ablation in deep subsolid pulmonary nodules: a thoracic surgeon’s perspective

Low-dose computed tomography screening has markedly increased the detection of small, deeply located subsolid pulmonary nodules, and local therapy for these lesions now encompasses anatomical segmentectomy, tailored sublobar resection, lobectomy, and image-guided thermal ablation. Although multidisciplinary pathways already inform modality selection, three-dimensional (3D) anatomical reconstruction - despite its established role in segmentectomy planning - is rarely used as a shared patient-specific dataset to guide both resection and ablation decisions. In this perspective, a thoracic surgeon argues that, for a deep or cross-segment subsolid nodule with an established indication for local therapy, a single patient-specific 3D dataset can inform both branches of the decision. The same volumetric anatomy - including nodule size and consolidation-to-tumor ratio, segmental boundaries, bronchovascular relationships, pleura, and the chest wall - is first used to determine whether adequate-margin lung-sparing resection is achievable and, if it is not, to assess whether ablation is anatomically feasible through three sequential filters: trajectory safety, perilesional structural risk, and predicted ablative coverage. The approach is illustrated with a representative case and discussed in the contexts of multifocal disease, the post-resection lung, and perivascular lesions, together with the trade-offs associated with forgoing nodal staging and tissue diagnosis. The framework does not expand indications beyond those already supported by guidelines. Rather, it operationalizes these recommendations through patient-specific anatomy, with the aim of making modality selection more transparent, reproducible, and auditable. It remains an unvalidated, single-center proposal that requires prospective evaluation.