Surgery

Please consider Diagnostic and Staging section. 

Full pulmonary function tests including TLCO should be performed prior to referral for surgery.
Perform a functional segment count to predict postoperative lung function.

Patients with a ppo FEV1 or ppo TLCO greater than 40% can be offered surgery without additional tests of respiratory fitness.

For patients with a ppo FEV1 or ppo TLCO less than 40% consider using additional tests such as shuttle walk test, stair climbing test or cardiopulmonary exercise test to assess fitness.

Use a distance walked of more than 400 m in a shuttle walk test as a cut-off for good function.

Use a VO2 max more than 15 ml/kg/min in a cardiopulmonary exercise test as a cut-off for good function.

Patients with ppo FEV1 or ppo TLCO below 30% can be offered surgery if they accept the risks of dyspnoea and associated complications.

Last cross sectional imaging CT or PET should be within 2months of procedure date.

MRI Brain should be performed for cN2 and consider CT Brain for earlier stages.

Selection for surgery

• Surgery is the preferred option of treatment in stages I and II.
• Lobectomy with lymph node dissection is the procedure of choice.
• A minimally invasive approach (VATS or RATS) is the default. If necessary refer to another centre.
• Lymph node dissection should be performed for all patients undergoing surgery with curative intent.
• As much lymph node tissue as possible should be removed from both hilar and mediastinal stations.

Mode of surgery

• Offer more extensive surgery (bronchangioplastic surgery, bilobectomy, pneumonectomy) only when needed to obtain clear margins.

• Offer less extensive surgery (segmentectomy or wedge resection) when pulmonary function is compromised or there is significant comorbidity. Alternatively consider SABR.

• Patients with T3 NSCLC with chest wall involvement who are having surgery, aim for complete resection of the tumour using either extrapleural dissection or en bloc chest wall resection.

• Segmentectomy or wedge resection including intraoperative node and lung margin assessment is an acceptable alternative to lobectomy in patients with tumours <2cm, node negative on PET and normal lung function

Stage IIIA

• Patients with Stage IIIA single zone N2 (resectable N2 excluding pneumonectomy) consider surgery with lymph node dissection and adjuvant chemotherapy versus neoadjuvant chemoradiotherapy and surgery with lymph node dissection.

• Patients should be assessed by a thoracic oncologist and a thoracic surgeon before starting treatment.

• Surgery should be scheduled 3-5 weeks after completion of chemoradiotherapy.

• Resectable N2 disease is best judged by individual surgeon. In general terms N2 nodes should not be bulky and not involve multiple zones.

Metastatic disease

• Lung surgery for Stage IV maybe considered in cases of solitary treatable brain or adrenal or other metastasis.

Adjuvant treatment options should be discussed at MDT. For details please see the section on SACT.

Offer SACT if any N1-N2 and good performance status.

Consider SACT in T2b-T4 N0 and good performance status with tumours greater than 4cm diameter.

Where an incomplete pulmonary resection has been made, consider undertaking additional surgery to achieve a complete resection or consider adjuvant radiotherapy.