Surgery for nonsmall cell lung cancer

Abstract

Surgery remains the best curative option in patients with early stage lung cancer (stage I and II). Developments in minimally invasive techniques now allow surgeons to perform lung resections on elderly patients, patients with poor pulmonary function or significant cardiopulmonary comorbidities. New techniques, such as stereotactic radiotherapy and ablative procedures, are being evaluated in early-stage lung cancer and may represent an alternative to surgery in patients unfit for lung resection. Perioperative mortality rates have dropped significantly at most institutions in the past two decades and complications are managed more efficiently. Progress in imaging and staging techniques have helped cut futile thoracotomy rates and offer patients the most adequate treatment options. Large randomised trials have helped clarify the role of neoadjuvant, induction and adjuvant chemotherapy, as well as radiotherapy. Surgery remains an essential step in the multimodality therapy of selected patients with advanced-stage lung cancer (stage III and IV). Interventional and endoscopic techniques have reduced the role of surgery in the diagnosis and staging of nonsmall cell lung cancer, but surgery remains an important tool in the palliation of advanced-stage lung cancer. Large national/international surgical databases have been developed and predictive risk-models for surgical mortality/morbidity published by learned surgical societies. Nonetheless, lung cancer overall survival rates remain deceptively low and it is hoped that early detection/screening, better understanding of tumour biology and development of biomarkers, and development of efficient targeted therapies will help improve the prognosis of lung cancer patients in the next decade.

Figure 1.

Segmentectomy performed using video-assisted thoracic surgery. a) Chest computed tomography of a 68-year-old patient showing a 13-mm nodule in the lingula segment, near the oblique fissure. b) Videothoracoscopic view showing the nodule. Frozen sections revealed a primary lung adenocarcinoma and segmentectomy was started. The lingula segmental artery (c) and the segmental vein (d) were dissected and stapled. The segmental bronchus was divided (e) and stapled, the fissure was opened with an endolinear stapler and the segmentectomy completed. The specimen was extracted within a protective bag. Macroscopic inspection showed a surgical margin >15 mm (f).

Figure 2.

A left pancoast tumour. a) Chest magnetic resonance imaging of a left pancoast tumour arising in the left upper lobe and infiltrating the first rib, brachial plexus and left subclavian artery. The patient received induction chemoradiotherapy: three cycles of vinorelbin and cisplatin, as well as 45 Gy. He underwent en bloc resection through sternotomy and supraclavicular approach, the left upper lobe and the three first ribs were removed and the left subclavian artery was reconstructed. The left phrenic and vagus nerves had to be sacrificed. Histopathology showed a primary lung adenocarcinoma with >90% necrosis. b) Chest radiography of the same patient 4 years post-operatively. There is obvious left phrenic nerve palsy. The patient had a positron emission tomography-computed tomography scan at 5 years which showed no sign of relapse.

Figure 3.

Right sleeve pneumonectomy for T4 squamous cell carcinoma. a) Chest computed tomography (CT) showing squamous cell carcinoma infiltrating the right main bronchus and carina, with marked obstructive changes and bronchiectasis in the right lower lobe. The right pulmonary artery was infiltrated as well. Cervical mediastinoscopy was performed and showed no invasion of lymph node stations 2R, 4R, 3 and 7. Positron emission tomography-CT showed no distant metastases. The patient was offered extended right pneumonectomy. He developed bronchopleural fistula and had an open pleural window 6 weeks post-operatively. b). He underwent reconstructive thoracoplasty at 2 years and remains disease-free at 4 years, with secondary pulmonary hypertension (c).