Surgical therapy for carcinoma of the lung

Surgical excision of lung cancer remains the treatment of choice for those patients with non-small-cell lung cancer who are determined to have stage I or stage II disease and who have the physiologic capacity to tolerate the planned resection. With proper selection, a number of patients with stage IIIa disease, including a small percentage of those with N2 disease, and a very small highly selected group of patients with stage IIIb (tracheal or carinal involvement) or even stage IV disease (solitary brain metastasis), may be surgical candidates. The resection must be complete to be successful, but also should be as conservative of normal lung tissue as is consonant with this goal. Immediate postsurgical mortality should be no greater than 3% to 6% for the majority of procedures except those associated with some extended resections. Five-year survival rates of 35% to 40% in all resected patients to as high as 80% for those patients with very limited (T1, N0, M0) disease can be anticipated. The use of adjuvant therapy has been disappointing for any significant prolongation of survival. Neoadjuvant therapy has yet to be appropriately evaluated. Surgical resection in the multimodality approach to the treatment of small-cell lung cancer continues under investigation but appears to play a minimal role except in those patients with very early limited disease (stage I and an occasional patient with limited T3, N0 disease). Lymph node involvement appears to preclude beneficial resection except under special circumstances. Currently all resected small-cell lung cancer patients are believed to be most appropriately managed with the addition of standard chemotherapy. The role of irradiation, either local or cranial, in the resected small-cell lung cancer patient is unsettled.