Current surgical treatment of nonsmall cell lung cancer 2001

Recognizing that surgical treatment is still the best option for controlling lung cancer, surgeons want an operation to be performed when the benefits clearly outweigh the possible risks, and when it has been determined that cancer resection is the most appropriate course of management. The necessity for a compulsive attitude toward preoperative assessment is therefore to be emphasized. Approximately 45% of all lung cancers are limited to the chest, where surgical resection is the most effective method of controlling the disease. Patients with tumour (T) 1, node (N) 0 and T2N0 tumours have early lung cancer, and most are curable by resection, with 5-yr survival rates in the range 75-80% for patients with T1N0 status. The "gold standard" of surgery remains lobectomy. Stage T1N1 and T2N1 carcinomas represent a group of patients in whom the disease involves hilar and bronchopulmonary nodes. This group is best treated by complete resection and mediastinal lymphadenectomy. Survival data following surgical resection of T3 tumours clearly show better survival in patients with T3N0 disease than in those with T3N1-2 disease. Five-year survival rates for completely resected T3N0 lesions are in the range 30-50%. Once N1 disease is present, survival decreases to 15-20%. Incomplete resections fail to cure and surgery is not indicated if N2 disease is documented preoperatively. On occasion, T4 tumours involving the carina or vertebral body can be completely resected but T4N1-2 lesions are virtually incurable by surgery. The presence of mediastinal lymph node metastasis (N2/N3 disease) is an ominous prognostic sign and stage III-b disease, by virtue of metastatic contralateral nodes, is an absolute contraindication to surgical resection. Induction treatments with chemoradiation have shown prolongation of survival and three randomized trials have demonstrated a survival advantage over surgery alone.