Surgery for non-small cell lung cancer

Although never proven to be superior in a randomized trial, surgical resection remains the treatment of choice for early stage non-small cell lung cancer (NSCLC). In stages IA, IB, IIA, IIB and selected stages IIIA surgical treatment offers the best long-term prognosis when a complete resection can be performed. Standard operations include lobectomy, bilobectomy and pneumonectomy. Whenever possible, lobectomy is the procedure of choice. Lesser resections like segmentectomy or wedge excision are not indicated in primary NSCLC due to a higher local recurrence rate and poorer long-term survival. Specific lung parenchyma saving operations include tracheo- and bronchoplastic procedures which are indicated in selected cases of centrally located NSCLC. Extended resections include removal of lung together with another organ or structure as thoracic wall, pericardium, diaphragm or superior sulcus. En bloc excision of the involved structure is advised. Technically more demanding is lung resection after induction therapy, especially after combined chemoradiotherapy. A dense fibrotic reaction may render operative staging and dissection difficult. The precise, necessary extent of resection after induction therapy has not been determined yet. Although combined modality treatment has an overall increased morbidity and mortality rate, it may improve survival in selected cases of locally advanced NSCLC. Its precise role, however, still remains to be defined in large randomized trials.