Historically, surgery for lung cancer has been through an open thoracotomy (thorax = chest; otomy = cutting/slicing), which involves a long incision around the side of the chest, removal of ribs, and spreading of the remaining ribs to get a good view of the area of the operation. Even with the most skilled surgeons, it's a procedure that is rigorous for a patient to get through and has a recovery period typically of weeks.

I’m just coming from a meeting on Targeted Therapies in the Treatment of Lung Cancer, which had the interesting format of dozens of 5-minute presentations just introducing or giving a very brief update of many new therapies. Some of these, such as the EGFR monoclonal antibody Erbitux (cetixumab), which I spoke on, have been approved by the US FDA for several years in other cancer settings and are well tested in humans.

When is surgery necessary or just particularly helpful for bone metastases? There are situations in which invasive approaches may be appropriate for the long bones (of the arms and legs). First, surgery can be helpful for persistent or increasing pain despite completing palliative radiation therapy.

While lobectomy or pneumonectomy may be the surgical treatment of choice for most NSCLC tumors in younger, fit patients, a limited resection may be an ideal choice in certain settings. In my previous post I discussed the data supporting a limited resection in older patients, who are likely to have competing health risks that may make it less critical to pursue the most aggressive surgical strategy. Another situation in which a sub-lobar resection may be particularly appealing is when the tumor is quite small and/or has characteristics suggestive of an indolent natural history.

While the prevailing standard of care for resectable lung cancer is a lobectomy or pneumonectomy, we want the surgery to be as appropriate as possible for patients. That means not short-changing patients by doing a lesser surgery than they need to do as well as possible with the cancer, but also not overtreating patients with a more aggressive surgery than they need. There are two main variables that potentially alter the equation and may make a sublobar resection a more appropriate consideration.

Surgery is the standard treatment for early stage lung cancer, sometimes also including other types of threrapy in addition. There are many types of lung cancer surgery, and there is still active debate about whether a pneumonectomy or lobectomy should be the preferred surgery for lung cancer, or whether a sub-lobar resection, either a segmentectomy or a wedge resection, is appropriate for certain patients. We need to start with some definitions.

For patients with locally advanced NSCLC, the question of whether to pursue a surgical or a non-surgical approach has a great deal to do with the extent of mediastinal (middle of the chest) lymph node involvement. The mediastinal nodes are shown here:

As I described in a prior post, pre-operative chemo and radiation are one very reasonable, aggressive option for stage IIIA NSCLC, particularly if the mediastinal lymph nodes involved are not large and there is only a single lymph node area involved.

As a medical oncologist, my primary role is to direct general management plans for many cancer patients and to develop chemotherapy and targeted therapy regimens. These regimens are sometimes directly administered through my office, and sometimes are coordinated with oncologists closer to a patient's home. The treatment is pretty much a cookbook approach, so it's really the same no matter who administers it.

For many patients with early stage, resected NSCLC, chemotherapy after surgery may be a strong consideration to minimize the chance of the cancer returning, in which cases, it is often not possible to cure it. Several clinical trials over the past few years have shown benefits from chemo combinations, but which ones would be the leading considerations now?