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Abstract Objectives LVRS improves survival and quality of life in selected patients with emphysema. In view of the great improvement in the detailed information available from CT, it is important to evaluate the benefit of routine pathological assessment of the resected specimen. We reviewed the histopathological findings in our contemporary LVRS series to determine the rate of pathological findings in addition to emphysema. Method Prospectively collected data from a specialised higher volume LVRS centre. The CT and histopathology reports of 189 consecutive LVRS procedures were reviewed. One underwent thoracotomy, 188 were by VATS, of which one was converted to thoracotomy and of which 22 were by a subxiphoid approach. The target reduction volume was 30-50% of the lung. Results All patients were reported to have emphysematous changes in both CT and histology. Ten patients, all with radiographic evidence of a lesion preoperatively, had squamous carcinoma (x2), adenocarcinoma, atypical adenomatous hyperplasia (AAH) (x2), squamous metaplasia (x2), carcinoid tumourlet, chondroid hamartoma, and DIPNECH. There were 39 neoplastic histological findings which were not radiologically reported; these were adenocarcinoma (1), AAH (10), squamous metaplasia (7), carcinoid tumourlet (5), squamous dysplasia (3), neuroendocrine hyperplasia (2), and chemodectoma. In addition, 21 inflammatory/infective cases were also reported. Conclusions Our systemic retrospective CT and histopathology review of LVRS operations shows that the rate of additional findings is 32%. Of these 83% were not reported on the pre-operative review of the CT. This supports the value of systematic pathological assessment of resected samples.