Surgical Management of Non-Small Cell Lung Cancer

Jacob A. Klapper, Matthew G. Hartwig

Key Points

  • Completely remove the tumor and all associated intrapulmonary lymphatic drainage.
  • Lobectomy remains the surgical procedure of choice for patients with adequate lung function, but lesser resections, such as segmentectomy, are acceptable for patients with small tumors and compromised pulmonary function or small semi-solid lesions.
  • Take care not to transgress the tumor during resection in order to avoid tumor spillage.
  • Make an effort to perform en-bloc resection of adjacent or invaded structures rather than discontinuous resection.
  • Perform frozen section analysis on the bronchial margin and any other margins in close proximity to the tumor.
  • Remove or sample all accessible mediastinal lymph node stations for pathologic evaluation.

The American Cancer Society projected a lung cancer incidence of 224,390 new cases during 2016. Lung cancer is the leading cause of cancer death worldwide.In the year 2016, 158,080 deaths are expected to occur secondary to lung cancer, thus this disease in the United States alone accounts for 1 in 4 cancer deaths.[1]

Most patients ultimately die of their disease; for those with limited disease, surgical resection is the most effective method of controlling the primary tumor and provides the best opportunity for cure. Therefore, every patient with locoregional NSCLC is approached as a surgical candidate. However, even with appropriate staging and physiologic evaluation, only 35% of patients diagnosed with NSCLC are eligible for resection.

The surgical goal is complete resection of localized tumors (stages I and II) as the definitive primary therapy. Selected patients with mediastinal nodal metastases (stages IIIA and IIIB) are considered for multimodality therapy, ideally as part of a clinical trial. Patients with distant metastatic disease (stage IV) are not candidates for curative surgical resection, with rare exception (i.e. solitary brain or adrenal metastases). Recent years have brought impressive contributions to the understanding of tumor biology in NSCLC. However, with a long-term survival of only 70% in patients with completely resected stage I tumors, there remains enormous opportunity for improvement. This chapter reviews past and present approaches to the surgical treatment of NSCLC, and reflects surgical management strategies based on the 8th edition of the AJCC/UICC staging system.

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Last updated: December 26, 2022