Present views of the surgical treatment of non-small cell lung cancer.

There is consensus regarding a pretreatment minimal staging protocol for non-small cell lung cancer. We adopted the new TNM-classification and staging system. For the preoperative mediastinal exploration CT scan (with contrast) and mediastinoscopy are complemental explorations. We avoid to operate on patients with multiple involved mediastinal lymph nodes (N2) or with involved contralateral (N3) or supraclavicular lymph nodes (N3). The final goal is a complete or potentially curative resection including mediastinal lymphadenectomy. The survival of the patient is mainly dependent of the N-status. When N2 disease is unsuspectedly discovered at operation, complete resection with mediastinal lymphadenectomy is performed. The subgroup with the best prognosis is the group with negative mediastinoscopy, lobectomy for central tumor and minimal N2, intracapsular. Multimodal therapy is investigated via multi-institutional trials. Chest wall involvement by lung cancer (T3) does not imply a hopeless prognosis. 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 riberosion, squamous cell carcinoma, chest wall resection limited to two ribs and N0-status. For Pancoast-tumors (T3) we follow the Paulson treatment protocol. After the usual staging, the candidates for surgery receive preoperative radiotherapy, followed by complete en-bloc resection, and eventual postoperative radiotherapy in case of incomplete resection. Careful follow-up of all patients operated for lung cancer is necessary, as the incidence of a metachronous lung cancer is as high as 10% for the long survivors. When a second or third primary lung cancer appears, reoperation is the treatment of choice in the absence of metastases or other contraindications. In most cases a complete curative resection is possible. Pulmonary resections have to be complete, but as conservative as possible, eventually with broncho- and angioplasty.