The present status of surgery for lung cancer

Surgical resection of non-small cell lung cancer (NSCLC) is the treatment of choice if complete resection is possible. There is consensus regarding a pretreatment minimal staging. For the pre-operative exploration CT scan (with contrast) and mediastinoscopy are complemental. Accepted is the New International Staging system with TNM. The 5-year survival following complete resection is stage-dependent. For stage I disease (T1-2, N0 M0) lobectomy is generally possible. The overall 5-year postoperative survival is 65%. No postoperative adjuvant treatment is necessary. For stage II (T1-2 N1 M0) lobectomy is possible in 70% of patients. The overall 5-year postoperative survival is 42.9%. Survival is affected by histology and T-status. The incidence of local recurrence can be reduced by postoperative radiotherapy. For stage III A (T1-3 N0-2 M0) surgery or combined modality treatment is indicated. The overall 5-year postoperative survival is 22.2%. For chest wall involvement (T3) en bloc resection of lung and partial chest wall is performed if possible. The 5-year survivors share common features: asymptomatic before operation, non-smokers, no rib erosion, squamous cell carcinoma, limited chest wall resection and N0 status. Pancoast tumours (T3) are treated according to the Paulson protocol with low dose pre-operative radiotherapy, complete en bloc resection, and postoperative radiotherapy in case of incomplete resection. Long-term survival after pre-operative irradiation and complete resection is possible. N1 or N2 disease is an adverse prognostic factor. When N2 disease is unsuspectedly discovered at operation, complete resection with mediastinal lymphadenectomy is indicated. The subgroup with the best prognosis is the group with negative mediastinoscopy, lobectomy and minimal N2. Multimodal therapy with chemo- or chemoradiotherapy is investigated. The results demonstrate the longest survival in patients with complete resection after major response to chemotherapy. For stage III B (T4 any N M0; any T N3 M0) surgery is usually not indicated and most patients are candidates for radio- or chemotherapy or both. The overall 5-year postoperative survival is 5.6% with 0% for N3 but 8.2% for T4 patients, after extended resection as intrapericardial pneumonectomy, sleeve pneumonectomy, partial resection of the superior vena cava and miscellaneous partial resections. Postoperative radiotherapy may improve local control. For stage IV (any T any N M1) combined surgery can be effective for solitary adrenal or brain metastases. A reported 7.5% 5-year survival was mainly for intrapulmonary metastases, also considered as satellite nodules. Careful follow-up of patients operated for lung cancer is necessary, as the incidence of metachronous lung cancer is as high as 10% for the long survivors. Reoperation with an economic but complete resection is the treatment of choice in the absence of metastases or other contraindications.