OBJECTIVES OF SURGERY IN THE MULTIMODALITY TREATMENT PLAN FOR STAGE-III NONSMALL CELL LUNG-CANCER

Results of isolated surgical resection for stage III lung cancer are n ot satisfactory, since overall 5-year survival rates rarely exceed 15% . Deaths during follow-up are mainly due to metastatic progression. Th e multimodality approach adds chemotherapy to surgery, with the intent to improve the control of micrometastatic disease which potentially e xists at the time of diagnosis. Preoperative or neoadjuvant chemothera py is currently under evaluation. Phase 2 trials demonstrate a treatme nt-related mortality of 5%; complete response and partial response are rated 5-10% and 50% respectively. About 85% of patients are operated upon within an average of 3 months after onset of treatment. Explorato ry thoracotomy without resection is performed in 15% of cases; a compl ete resection may be performed in 75% of cases. Overall post-opertativ e mortality is close to 5%, but considerably higher rates of 10-17.5% have been reported following pneumonectomy. Median survival after trea tment may reach 20 months. Indicators of improved survival are respons e to induction therapy and complete resection. However, there is no ob jective evidence that induction therapy improves survival after resect ion. Interpretation of phase 2 trials is obscured by methodologic draw backs such as heterogenous patient samples or inaccurate staging. The spare phase 3 trials suffer from identical drawbacks, and further from too short sample sizes. Mediastinoscopy prior to induction therapy is mandatory to confirm N2 or N3 disease, because radiologic staging is not reliable. Pathologic and therefore accurate staging is achieved wh en surgical resection is the initial step of treatment. Previous work has concluded that post-operative or adjuvant chemotherapy does not im prove survival; however, these trials did not use optimal drug regimen s, and compliance to treatment was not satisfactory.In fine, the 2 maj or objectives of surgery in the multimodality setting are to secure lo cal control of the disease, and to confirm stage III disease owing to pathologic stating.