Chest
Volume 116, Supplement 3, December 1999, Pages 500S-503S
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Non-small Cell Lung Cancer: Role of Surgery for Stages I-III

https://doi.org/10.1378/chest.116.suppl_3.500SGet rights and content

Survival following surgical resection of non-small cell lungcancer (NSCLC) has improved since the 1960s, although the 5-yearsurvival rate remains low. This article provides an overview of therole of surgery for NSCLC stages I-III, with a focus on optimizinglong-term survival in those patients with resectable disease. Topicsexplored include diagnosis and staging, indications for resection, types of resection, and indications for adjuvant therapy. A review ofthe literature indicates a clear survival advantage for completeresection, and is suggestive of an advantage for mediastinal lymph nodedissection (vs lymph node sampling) and neoadjuvant therapy (vsadjuvant therapy).

Section snippets

Diagnosis and Staging

Accurate diagnosis and histologic classification are made with the assistance of imaging techniques (including CT, MRI, positron emission tomography [PET], and bone scans), sputum cytology, needle biopsy, bronchoscopy, thoracoscopy, mediastinoscopy, bone marrow biopsy, and blood tests. Video-assisted thoracoscopic surgery is also becoming popular due to demonstrated diagnostic accuracy and the ability of the surgeon to visualize the entire lung, pleura, and mediastinum.

In 1997, the

Indications for Resection

The goal of surgery in NSCLC is to provide complete resection of the primary tumor with no macroscopic tumor remaining and microscopically free margins. Only patients in whom a complete resection is anticipated are selected for surgery. These include patients with T1 to T4, N0 and N1 tumors and selected N2 cases. Multiple primary lung cancers can be resected with a reasonable prospect of survival if the tumors appear completely resectable. Survival following metachronous cancer resection has

Limited Resection

Standard resections for primary lung cancer are pneumonectomy, lobectomy, and sleeve lobectomy in selected cases. Lesser or limited operations include wedge resection, segmental resection, nonanatomic limited resection, and sleeve lobectomy. Advantages for these lesser resections include preservation of pulmonary function, decreased perioperative mortality and morbidity, and the potential for future further pulmonary resection, if necessary. In patients with equivocal levels of pulmonary

Indications for Adjuvant Therapy

The current status of adjuvant and neoadjuvant trials in NSCLC were recently reviewed by Einhorn,43 who concluded that no survival benefit is observed following postoperative adjuvant radiotherapy, chemotherapy, or chemoradiation. At present, there is no clear indication for adjuvant therapy in surgically resected cases other than in the context of a clinical trial. In contrast, three studies have demonstrated improved survival following neoadjuvant therapy,44, 45, 46 although the case numbers

Summary

For patients with lung cancer, surgical resection provides the best possibility of cure in selected patients. It is again emphasized that surgical resection is only applicable for patients in whom a complete resection is deemed possible. Accurate diagnosis and staging maximizes this potential. Comprehensive evaluation of nodal status is imperative. Extended resection can be effective in locally advanced disease, with worthwhile survival possible in patients whose tumors are completely resected.

References (46)

  • RJ Landreneau et al.

    Wedge resection versus lobectomy for stage I (T1 N0 M0) non-small-cell lung cancer

    J Thorac Cardiovasc Surg

    (1997)
  • PG Dartevelle et al.

    Long-term follow-up after prosthetic replacement of the superior vena cava combined with resection of mediastinal-pulmonary malignant tumors

    J Thorac Cardiovasc Surg

    (1991)
  • JM Piehler et al.

    Bronchogenic carcinoma with chest wall invasion: factors affecting survival following en bloc resection

    Ann Thorac Surg

    (1982)
  • BC McCaughan et al.

    Chest wall invasion in carcinoma of the lung: therapeutic and prognostic implication

    J Thorac Cardiovasc Surg

    (1985)
  • GA Patterson et al.

    The value of adjuvant radiotherapy in pulmonary and chest wall resection for bronchogenic carcinoma

    Ann Thorac Surg

    (1982)
  • EG Shaw et al.

    Locally recurrent non-small-cell lung cancer after complete surgical resection

    Mayo Clin Proc

    (1992)
  • PG Dartevelle et al.

    Anterior transcervical-thoracic approach for radical resection of lung tumors invading the thoracic inlet

    J Thorac Cardiovasc Surg

    (1993)
  • MP Hagan et al.

    Superior sulcus lung tumors: impact of local control on survival

    J Thorac Cardiovasc Surg

    (1999)
  • RJ Ginsberg et al.

    Influence of surgical resection and brachytherapy in the management of superior sulcus tumor

    Ann Thorac Surg

    (1994)
  • LH Einhorn

    Neoadjuvant and adjuvant trials in non-small cell lung cancer

    Ann Thorac Surg

    (1998)
  • HI Pass et al.

    Randomized trial of neoadjuvant therapy for lung cancer: interim analysis

    Ann Thorac Surg

    (1992)
  • Lung cancer resource center

    American Cancer Society [on-line]

  • B McCaughan

    Recent advances in managing non-small-cell lung cancer: 2. Surgery

    Med J Aust

    (1997)
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