Surgery: therapeutic indications

Although never proven to be superior in a large, prospective 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 resectable 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 rarely indicated in primary NSCLC. 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. Accurate peroperative evaluation will determine the extent of resection and if possible, a pneumonectomy should be avoided because of its high mortality and morbidity rate. Surgical resection after induction therapy for early stage or locally advanced NSCLC is feasible, but is often more complex and carries a higher risk, especially when a right pneumonectomy has to be performed after induction chemoradiotherapy.