Surgery for advanced stage lung cancer

Therapeutic strategy in advanced stage disease remains controversial. Theor etically resectable, Stage IIIa disease includes a high proportion of non-r esectable nodal diseases. Overall 5-year survival after surgery remains low er than 15%. Randomized trials comparing the results of surgery alone with induction chemotherapy followed by surgery showed a significant benefit to induction therapy. Currently Stage IIIb diseases are considered unresectabl e; nevertheless, selected patients are able to undergo an extended resectio n after induction treatments. In highly selected cases, a surgical resectio n can be performed in T4 tumors. Surgical resection must be included in a c ombined multidisciplinary strategy of treatment, and is proposed only for r esponders. Resectability criteria have to be defined with clinical trials d esigned to increase the local control by surgery. Thus, so-called Stage III b tumors can be divided in two subcategories: potentially resectable and de finitively non-resectable. Some locally advanced, initially unresectable tu mors (Stage IIIb) can become operable after induction chemoradiotherapy. Th e French staging system, based upon prognostic and therapeutic subcategorie s, splits N2 involvement into two subcategories: mN2 (minimal), found at th e thoracotomy; and cN2 (clinical), histologically proven at the pre-treatme nt staging. T4 tumors are divided in potentially resectable T4(1) (invasion of superior vena cava, carina, lower trachea, left atrium), and definitive ly non-resectable T4(2) (malignant pleural or pericardial effusion, invasio n of oesophagus, and vertebrae). Thus, Stage III can be separated into thre e subcategories, A, B, and C, instead of the two current substages. Stage I IIA includes T3 N1 MO and T1-T3mN2M0 tumors. Stage IIIB includes T1-T3cN2M0 and T4(1)N0-N2MO tumors. Stage IIIC includes T4(2)N0-N3M0 and T1-T4(1)N3M0 tumors. In this way, the therapeutic options in non-small-cell lung cancer (NSCLC) will be clarified with 1) a "primary surgery" subgroup, including Stages I, II, and IIIA, 2) an "induction treatment" subgroup, including Sta ge IIIB, and 3) a "non-surgical" subgroup, including Stages IIIC and IV. (C ) 2000 Wiley-Liss, Inc.