Appropriate surgical treatment of resectable non-small-cell lung cancer

Patients with early-stage non-small-cell lung cancer (NSCLC) should be treated with complete surgical resection whenever possible. Incomplete resections do not cure, and the optimal pulmonary resection is anatomic lobectomy. Limited resections (wedge resection and segmentectomy) are associated with a threefold increase in local recurrence, which translates into decreased survival. The addition of mediastinal lymph node dissection produces the best pathologic staging but has never been shown to improve survival. Resections can be performed through a variety of incisions and even using minimally invasive techniques, but posterolateral thoracotomy seems to provide the best exposure and is used most frequently. Adjuvant radiotherapy in both the preoperative and postoperative settings does not improve survival in patients with resected NSCLC. Similarly, postoperative chemotherapy cannot be advocated in these patients based on the current data. Improved survival has been demonstrated in the randomized setting for patients with locally advanced, resectable disease (N2) using preoperative (induction) chemo(radio)therapy, but the numbers are small. Patients with this stage of NSCLC should be enrolled in induction therapy protocols whenever possible to confirm the efficacy of this approach.