Surgery is the treatment of choice for patients with stage II NSCLC. A lobectomy, pneumonectomy, or segmental resection, wedge resection, or sleeve resection may be performed as appropriate. Careful preoperative assessment of the patient's overall medical condition, especially the patient's pulmonary reserve, is critical in considering the benefits of surgery.
Despite the immediate and age-related postoperative mortality rate, a 5% to 8% mortality rate with pneumonectomy or a 3% to 5% mortality rate with lobectomy can be expected.
The Cochrane Collaboration group reviewed 11 randomized trials with a total of 1,910 patients who underwent surgical interventions for early-stage (I-IIIA) lung cancer. A pooled analysis of three trials reported the following:
Four-year survival was superior in patients with resectable stage I, II, or IIIA NSCLC who underwent resection and complete ipsilateral mediastinal lymph node dissection (CMLND) compared with those who underwent resection and lymph node sampling; the hazard ratio (HR) was estimated to be 0.78 (95% confidence interval [CI], 0.65-0.93; P = .005).[Level of evidence: 1iiA]
There was a significant reduction in any cancer recurrence (local or distant) in the CMLND group (relative risk [RR] = 0.79; 95% CI, 0.66-0.95; P = .01) that appeared mainly as the result of a reduction in the number of distant recurrences (RR = 0.78; 95% CI, 0.61-1.00; P = .05).
There was no difference in operative mortality.
Air leak lasting more than 5 days was significantly more common in patients assigned to CMLND (RR = 2.94; 95% CI, 1.01-8.54; P = .05).
Current evidence suggests that lung cancer resection combined with CMLND is associated with a small-to-modest improvement in survival compared with lung cancer resection combined with systematic sampling of mediastinal nodes in patients with stage I, II, or IIIA NSCLC.[Level of evidence: 1iiA]
CMLND versus lymph node sampling was evaluated in a large randomized phase III trial (ACOSOG-Z0030).
Preliminary analyses of operative morbidity and mortality showed comparable rates from the procedures.
Limitations of evidence:
Conclusions about the efficacy of surgery for patients with local and locoregional NSCLC are limited by the small number of participants studied to date and potential methodological weaknesses of the trials.
The role of chemotherapy prior to surgery was tested in clinical trials. The proposed benefits of preoperative chemotherapy include the following:
A reduction in tumor size that may facilitate surgical resection.
Early eradication of micrometastases.
Preoperative chemotherapy may, however, delay potentially curative surgery.
The Cochrane Collaboration Review group reported a systematic review and meta-analysis of seven randomized controlled trials that included 988 patients and evaluated the addition of preoperative chemotherapy to surgery versus surgery alone. These trials evaluated patients with stages I, II, and IIIA NSCLC.
Preoperative chemotherapy provided an absolute benefit in survival of 6% across all stages of disease from 14% to 20% at 5 years (HR = 0.82; 95% CI, 0.69-0.97; P = .022).[Level of evidence: 1iiA]
This analysis was unable to address questions such as whether particular types of patients may benefit more or less from preoperative chemotherapy.
In the largest trial reported to date, 519 patients were randomly assigned to receive either surgery alone or three cycles of platinum-based chemotherapy followed by surgery. Most patients (61%) had clinical stage I disease; 31% had stage II disease; and 7% had stage III disease.
Postoperative complications were similar between groups, and no impairment of quality of life was observed.
There was no evidence of a benefit in terms of overall survival (OS) (HR = 1.02; 95% CI, 0.80-1.31; P = .86).
Updating the systematic review by addition of the present result suggests a 12% relative survival benefit with the addition of neoadjuvant (preoperative) chemotherapy (1,507 patients; HR = 0.88; 95% CI, 0.76-1.01; P = .07), equivalent to an absolute improvement in survival of 5% at 5 years.