Preoperative chemotherapy for stage IIIA non-small cell lung cancer.

Recent studies have shown that preoperative chemotherapy is feasible and advisable for patients with stage IIIA mediastinoscopically confirmed N2 involvement in non-small cell lung cancer. Such studies confirm the crucial pillar of attaining complete resection, and the importance of downstaging N2 disease as a useful surrogate for long-term survival. Resectability rate is about 70% in almost all studies examined. Better means of predicting resectability and relapse are addressed, such as the potential role of positron emission tomography and some hints for the management of replication error-positive non-small cell lung cancer patients. A major issue for the role of preoperative chemotherapy is how not to confuse apples and oranges. Although the role of surgery alone or radiotherapy is considered suboptimal for treatment of stage IIIA N2, whether surgery is required remains to be clarified. Furthermore, large randomized studies of chemoradiation followed by surgery versus chemoradiation alone are needed as well as modification of the current tumor, node, metastasis classification in order to better select those patients for whom preoperative chemotherapy would be beneficial. The surgeon's judgment and skill are essential in the identification of eligible patients and multimodality treatment research is also spreading toward early disease and some subsets of T4 non-small cell lung cancers.