Chest
Volume 106, Issue 6, Supplement, December 1994, Pages 337S-339S
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Current Status of Surgical Resection for Lung Cancer

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There have been no major breakthroughs in surgical management for primary lung cancer during the past 40 years. Improved 5-year survival relates primarily to improved preoperative staging and appropriate selection of patients for resection. Perioperative morbidity and mortality, however, has been significantly reduced. Certain principles pertain to current surgical management: resection remains the best treatment for patients with localized, non-small cell primary lung cancer. Accurate preoperative diagnosis and staging: whenever possible, it is desirable to establish the diagnosis and cell type before operation. Accurate evaluation of the N status warrants wide application of invasive staging with mediastinoscopy or a variant. Indications for resection: only patients in whom a complete resection is anticipated should be selected for surgery. Such cases included T1 to T4 stages, N0 and N1 tumors, and selected N2 cases. The indication for resection in patients with hematogenous metastases are anecdotal. Intraoperative staging: accurate and deliberate intraoperative staging with evaluation of nodes using the American Thoracic Society map is highly desirable. The nature of nodal metastases exerts a critical influence on prognosis and in the selection of patients for surgical resection. At present, there is no clear indication for adjuvant therapy in surgically resected cases other than for evaluation and clinical trials.

Section snippets

Indications for Surgical Resection

It is again emphasized that surgical resection is only indicated in patients at acceptable operative risk, in whom the possibility of a complete resection is anticipated. Although two recently reported randomized trials of adjuvant chemotherapy3,4 report promising results in small numbers of patients, most surgeons still take the position that adjuvant treatment should be reserved for patients entered in trials for all stages of resectable lung cancer.

The state of the art in surgery at the

LIMITED RESECTION

The standard resections for primary lung cancer are pneumonectomy and lobectomy. Lesser, or limited operations include wedge resection, segmental resection, nonanatomic limited resection, and sleeve lobectomy. Initially, all of these lesser resections were employed as compromise operations in patients with poor pulmonary reserve who would not tolerate a traditional lobectomy or pneumonectomy. Tumors amenable to wedge resection or segmental resection are almost always in the T1 stage and are

EXTENDED RESECTION

Locally advanced lung cancer (stages IIIA and IIIB) has a much less favorable prognosis than earlier stages. Nevertheless, in patients with locally advanced tumors which are completely resected, some worthwhile survival is achieved. More importantly, there is no alternative form of treatment which will provide comparable results.

The role of adjuvant therapy in the management of locally advanced, resectable lung cancer has been evaluated in many phase II and phase III trials. Chemotherapy and

SMALL CELL LUNG CANCER

There is a small number of patients who present with locally resectable N0 tumors. Survival in these patients is similar to that reported for non-small cell primaries. Unfortunately, this group represents a very small segment of the population presenting with small cell tumors. There is no reported evidence that these patients benefit from the addition of adjuvant chemotherapy, though many oncologists will recommend combined treatment even for a completely resected T1N0 neoplasm.30

Accepted

REFERENCES (31)

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