Risks of neoadjuvant chemotherapy and radiation therapy.

Pulmonary resection for locally advanced NSCLC after induction chemotherapy or chemoradiotherapy can generally be performed with acceptable morbidity and mortality. Data from several phase II and a few randomized trials showed that patients should be carefully selected for surgery especially with respect to their age, performance status, and pulmonary and cardiovascular function tests. The presence of cardiovascular disease should be actively investigated and preexisting arrhythmias appropriately managed. Similarly, respiratory status should be evaluated and any reversible condition, such bronchial obstruction, infection, pulmonary embolism, and smoking, should be addressed. Surgical resection is technically more demanding; intraoperative blood loss should be minimized. Several studies demonstrated that pneumonectomy especially on the right side is associated with a significantly increased risk of postoperative morbidity and mortality especially in patients after induction chemoradiotherapy. Therefore, pneumonectomy should be performed very selectively and only when alternative procedures such as bronchial or vascular sleeve resection or both are technically not possible. Long-term follow-up reports of bimodality protocols without surgery versus bimodality followed by surgical resection are awaited. These results will heln to define standards of care and the role of surgery for patients with NSCLC stage III disease. Future decision-making will have to take into account treatment morbidity and mortality and parameters of organ-sparing surgery following induction. probably best represented by rates of pneumonectomy or rates of lobectomy in different patient groups.