THE PRESENT STATUS OF SURGERY FOR LUNG-CANCER

Surgical resection of non-small cell lung cancer (NSCLC) is the treatm ent of choice if complete resection is possible. There is consensus re garding a pretreatment minimal staging. For the pre-operative explorat ion CT scan (with contrast) and mediastinoscopy are complemental. Acce pted is the New International Staging system with TNM. The 5-year surv ival following complete resection is stage-dependent. For stage I dise ase (T-1-2, N(0)M(0)) lobectomy is generally possible. The overall 5-y ear postoperative survival is 65%. No postoperative adjuvant treatment is necessary. For stage II (T-1-2 N(1)M(0)) lobectomy is possible in 70% of patients. The overall 5-year postoperative survival is 42.9%. S urvival is affected by histology and T-status. The incidence of local recurrence can be reduced by postoperative radiotherapy. For stage III A (T-1-3 N(0-2)M(0)) surgery or combined modality treatment is indica ted. The overall 5-year postoperative survival is 22.2%. For chest wal l involvement (T-3) en bloc resection of lung and partial chest wall i s performed if possible. The 5-year survivors share common features:as ymptomatic before operation, non-smokers, no rib erosion, squamous cel l carcinoma, limited chest wall resection and N-0 status. Pancoast tum ours (T-3) are treated according to the Paulson protocol with low dose pre-operative radiotherapy, complete en bloc resection, and postopera tive radiotherapy in case of incomplete resection. Long-term survival after pre-operative irradiation and complete resection is possible. N- 1 or N-2 disease is an adverse prognostic factor. When N-2 disease is unsuspectedly discovered at operation, complete resection with mediast inal lymphadenectomy is indicated. The subgroup with the best prognosi s is the group with negative mediastinoscopy, lobectomy and minimal N- 2. Multimodal therapy with chemo- or chemoradiotherapy is investigated . The results demonstrate the longest survival in patients with comple te resection after major response to chemotherapy. For stage III B (T- 4 any NM(0); any T N(3)M(0)) surgery is usually not indicated and most patients are candidates for radio- or chemotherapy or both. The overa ll 5-year postoperative survival is 5.6% with 0% for N-3 but 8.2% for T-4 patients, after extended resection as intrapericardial pneumonecto my, sleeve pneumonectomy, partial resection of the superior vena cava and miscellaneous partial resections. Postoperative radiotherapy may i mprove local control. For stage IV (any T any NM(1)) combined surgery can be effective for solitary adrenal or brain metastases. A reported 7.5% 5-year survival was mainly for intrapulmonary metastases, also co nsidered as satellite nodules. Careful follow-up of patients operated for lung cancer is necessary, as the incidence of metachronous lung ca ncer is as high as 10% for the long survivors. Reoperation with an eco nomic but complete resection is the treatment of choice in the absence of metastases or other contraindications.