Updated Feb. 2008

The majority of patients with a normal mediastinum at mediastinoscopy and negative metastatic work-up preoperatively prove to be resectable at the time of thoracotomy. Occasionally intraoperative findings deem the patient unresectable. These findings include unsuspected pleural metastases, invasion of the heart, great vessels, or esophagus.

At thoracotomy, all important node stations must be sampled and labelled in accordance with the IASLC/UICC staging diagram. Lymph nodes at the planned resection margin, including the bronchial resection margin, should be assessed by intraoperative frozen section if there is a question of obtaining a clear margin.

Stage I

Standard lobectomy is the treatment of choice for Stage I lung cancer. Occasionally, pneumonectomy may be required because of extension of tumour across the fissure. Sleeve lobectomy may be performed in selected patients who have limited lung function with superficial tumour extension to a main bronchus or lower trachea,, thus avoiding pneumonectomy. Sleeve resection should be avoided in patients with N1 nodal disease. Segmental or wedge resection may be performed for small peripheral T1N0 lesions in patients with limited lung function, however, lobectomy is the preferred treatment of choice for patients with satisfactory pulmonary reserve.

Key Reference:

1. Ginsberg RJ, Rubenstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small-cell lung cancer. Ann Thorac Surg 1995;60;615-23

Stage II

Standard lobectomy is performed if technically feasible however, pneumonectomy may be necessary if the cancer is central, involving the hilum, or involving intralobar location 11 lymph nodes.

Stage IIIA

Extended pulmonary resection may be performed for potential cure in selected lesions. These include peripheral lesions invading chest wall, apical lung carcinomas, central lesions with limited mediastinal invasion, or focal pericardial or phrenic nerve invasion. Tumours within 2 cm of the carina, or carinal tumours occasionally may be amenable to resection with airway reconstruction. Extended resection is indicated for selected patients with positive N2 nodes. Stage IIIA cases where resectability is uncertain should be considered for combined modality therapy (see 6.1.6).

Key References:

1. Feins RH: Surgery for early-stage non-small-cell lung cancer. Semin Oncol 1997; 24:419-422

2. Warren WH, Faber LP. Extended resections for locally advanced pulmonary carcinomas. Lung Cancer: Principles and Practice. Pass H, Mitchell J, Johnson D, Turrisi A Eds. Lippincott-Raven, Philadelphia, 1996;567.