Surgical approach to locally advanced non-small cell lung cancer

Treatment for locally advanced non-small cell lung cancer is complex. It may best be described as chemotherapy-based multimodality therapy, but there is little consensus on the optimal approach for local therapy. With the integration of the 7th edition of the staging system, the role for surgery in stage IIIB is limited to only biopsies and staging procedures. Surgery plays a more important role in stage IIIA disease, when the extent of mediastinal lymph node involvement is the principal factor dictating the benefit that can be derived from resection. In N2-negative, stage IIIA patients (T4N0, T3N1, T4N1), surgery is the primary therapy. These tend to be large and complex resections that include removal of neighboring involved structures. In the larger cohort of N2-positive, stage IIIA patients, surgery is reserved for those with occult or resectable N2 involvement and not used for bulky mediastinal disease. Significant controversy exists regarding which patients with potentially resectable N2 should receive surgery and how to best integrate a resection with chemotherapy and radiation.