The article by Jaklitsch and colleagues (see page 237) is an important contribution to the challenge of making appropriate surgical decisions in the care of patients with non-small cell lung cancer (NSCLC). To use “Goldilocksian” analysis, the challenge for thoracic surgeons is to get the operation neither too hot (a resection of more lung than necessary) nor too cold (an insufficient resection), but to get it just right.
To put this issue into perspective, through the first decades of the twentieth century there were only a few, anecdotal reports of lung resection for lung cancer. The description by Graham and Singer1 in 1993 of the performance (and not unimportantly the patient’s survival) of the first pneumonectomy for lung cancer established a role for surgical resection in the treatment of lung cancer patients. In fact, surgical resection became relatively standard with pneumonectomy being the cancer operation of choice. Over time, however, experience has showed that an anatomic lobectomy was technically feasible and resulted in the same outcomes as the more extensive operation, for patients with a similar stage of disease, if the primary tumor was limited to a lobe. This then resulted in a transition in the thoracic surgery community to lobectomy as the preferred procedure to preserve the maximum amount of pulmonary reserve. At present, pneumonectomy is reserved for patients with such centrally located cancers that even the technique of sleeve resection does not allow a lobectomy to encompass all disease. Resections less than lobectomy, which leave behind intrapulmonary lymphatics as well as parenchyma, such as wedge resection and segmentectomy have been generally considered to be marginally or completely inadequate cancer procedures and employed sparingly and selectively for patients with limited pulmonary reserve and/or comorbid conditions leading to the assessment of the patient as a poor candidate for a “major” operation.