Background <p>In non-small cell lung cancer, reduced adipose cross-sectional area at the L3 vertebral level is associated with worse survival, however its association with occult nodal disease (OND) in patients with clinically node negative (cN0) non-small cell lung cancer remains unknown.</p> Methods <p>Patients who underwent lung resection with guideline-concordant nodal staging between 2010–2021 were identified from an institutional database. Occult nodal disease was defined as patients who were cN0 and pathologically node-positive (pN+). Thoracic volumetric body composition analysis of preoperative chest CTs was performed from T1-T12 using Data Analysis Facilitation Suite. Patients in the lowest tertile of each adiposity index were compared to the rest of the cohort for rates of OND. Univariable and multivariable logistic regression/Cox proportional hazards analyses were used to examine associations with OND and disease-free survival, respectively.</p> Results <p>A total of 224 patients met inclusion criteria, of which 55% (123/224) were female, with a median body mass index of 27 kg/m² (interquartile range [IQR] 23–31), and median tumor size of 2.8 cm (IQR 1.8–4.8). Occult nodal disease was identified in 26% (58/224) and recurrence in 25% (57/224) of patients. Upon univariable analysis in 123 female patients, OND was associated with epicardial adipose index (odds ratio [OR] 2.86, 95% confidence interval [CI] 1.23–6.62, <i>p</i> = 0.014) and thoracic subcutaneous adipose index (OR 2.38, 95% CI 1.03–5.5, <i>p</i> = 0.043) in females. Upon multivariable analysis, this association persisted for thoracic subcutaneous adipose index (OR 6.32, 95% CI 1.65–24.18, <i>p</i> = 0.007) and epicardial adipose index (OR 2.96, 95% CI 1.05–8.28,<i> p</i> = 0.039) in females.</p> Conclusions <p>Reduced thoracic subcutaneous and epicardial adipose volume is associated with OND in females.</p>