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Surgical resection is the standard of care for early-stage non-small cell lung cancer (NSCLC). A significant body of evidence from population-based observational studies shows that surgery offers patients the highest cure rate. Nevertheless, following lobectomy or pneumonectomy and mediastinal lymph node staging as standard therapy, only a 67% 5-year survival for stage IA (T1N0) and a 57% 5-year survival for stage IB (T2N0) is expected, with most patients succumbing to metastatic disease. A subset of patients exists with clinical stage I disease and limited cardiopulmonary reserve where a sublobar resection is required and is associated with an increased frequency of local recurrence compared to lobectomy or pneumonectomy. to lobectomy or pneumonectomy. Traditionally, efforts to improve survival and decrease local recurrence following lung resection for NSCLC have consisted of adjuvant chemotherapy and radiation therapy alone or in combination.

Surgical resection of lung cancer is the mainstay for potentially curative cancer therapy. However, controversy exists regarding appropriate surgical management of centrally located tumors. Initially, surgical therapy of central tumors consisted of pneumonectomy as the only surgical option with favorable outcomes. However, parenchymalsparing procedures, such as sleeve lobectomy, were subsequently described for patients unable to tolerate pneumonectomy because of poor pulmonary reserve. The favorable results in terms of operative morbidity and mortality after sleeve lobectomy in patients with inadequate cardiopulmonary function stimulated the use of parenchymal-sparing procedures for patients with adequate pulmonary function. Increasing clinical evidence suggests that short-term outcomes for sleeve lobectomy are similar to those for pneumonectomy, regardless of cardiopulmonary reserve.

Historically, the surgical procedure of choice for curative resection of lung cancer, even in its early stages, has been a lobectomy or pneumonectomy. The role of a more conservative resection, such as a segmentectomy or wedge resection, has been explored by many, paralleling the interest in conservative resection of breast cancer, where studies determined that clinical results of lumpectomy compared favorably with modified radical mastectomy.

The prospect for cure is excellent for fit patients treated with anatomical resection for pathological stage IA non-small cell lung cancer (NSCLC). Unfortunately, a substantial subset of patients diagnosed with early-stage NSCLC suffer from cardiopulmonary disease and/or other underlying medical comorbidities, and therefore are not suitable candidates for standard therapy. Treatment options for patients unable to tolerate lobectomy are typically guided by the severity of comorbid disease and traditionally have included limited resection (via open thoracotomy or a thoracoscopic approach) and external beam radiotherapy. Newer approaches including stereotactic radiosurgery and radiofrequency ablation are now utilized with increasing frequency. Recently, brachytherapy has been introduced as an adjuvant to wedge resection.

Lung cancer is classified as N3 when metastases to the contralateral mediastinal and hilar lymph nodes, the supraclavicular nodes, and the scalene nodes are present at the time of diagnosis. N3 lung tumors have been included in stage IIIB since 1986, when it appeared clear that such locally advanced disease needs to be grouped in a separate stage III category because of the extremely poor prognosis. In the large series reported by Mountain, 5-year survival for N3 patients was 3%. These tumors have always been considered inoperable due to the difficulties in eradicating all the detectable disease that markedly limits the applicability of primary surgery in this setting.

The earliest reports of minimally invasive lobectomies were published more than a decade ago. The reaction to this development was summarized by the results of an opinion survey conducted of members of the General Thoracic Surgery Club in 1997. The results showed that 4% of surgeons deemed video-assisted thorascopic suegery (VATS) major lung resections preferable to thoracotomy, 15% deemed it acceptable, 45% viewed it as an investigational procedure, and 36% thought it was unacceptable. The reasons are manifold. Perhaps most importantly, because lung cancer is the most common indication for performing lobectomy, the question of adequacy of the operation in satisfying surgical oncologic principles remains a hurdle in many surgeons’ minds.

Almost all patients with stage IV non-small cell lung cancer (NSCLC) have diffusely metastatic disease, and therefore, the standard of care for NSCLC is chemotherapy or palliative care. A small percentage of patients with newly diagnosed and untreated stage IV disease are found to have a solitary synchronous site of extrathoracic disease, and a small number of patients who have undergone curative resections of intrathoracic disease experience metachronous solitary extrathoracic recurrences. There have been retrospective case reports or limited series that suggest that some such patients may be effectively treated by resection of both the primary tumor and the metastasis. Most of these studies have reported patients with cerebral or adrenal metastases, although there are reports describing the surgical management of metastases to the small bowel, spleen, skeletal muscle, and bone.

The rebirth of thoracoscopy in the 1990s led to its utilization in nearly all areas of thoracic surgery, both diagnostic and therapeutic. Because of its minimally invasive nature, thoracoscopy has been accepted as the approach of choice for many thoracic surgical procedures such as pleural biopsy and sympathectomy. There are, however, areas of great controversy in which the utility of thoracoscopy continues to be highly debated and one such area is the therapeutic resection of pulmonary metastases.

The term refers to surgical excision of malignant lesion(s) of the lung of extrapulmonary origin. Several retrospective studies, including the International Registry of Lung Metastases, have observed increased survival following pulmonary metastasectomy when compared to historical control patient cohorts who did not undergo resection. Over the years these observations have led to widespread acceptance of pulmonary metastasectomy in appropriately selected patients. The lack of randomized, controlled trials and the continued evolution in imaging technology, chemotherapeutics, and surgical technique pose significant challenges to clinicians as they struggle with appropriate patient selection for and the optimal surgical approach to metastasectomy.

Bronchoalveolar carcinoma (BAC) is a distinct subtype of non-small cell lung adenocarcinoma classified by the World Health Organization (WHO) as a peripheral well-differentiated neoplasm demonstrating lepidic spread along preexisting alveolar structures. An important histological feature is the preservation of the underlying lung architecture and the absence of invasion into stroma, pleura, or lymphatics of all pure BACs. Lung adenocarcinomas with a BAC component are now more appropriately classified as adenocarcinomas, mixed subtype. Despite the WHO designation as a subtype of adenocarcinoma, BAC has pathological, radiologic, and clinical features that are distinct from those of adenocarcinomas.