Abstract

Lung cancer surgery with curative intent has significantly developed over recent years, mainly focusing on minimally invasive approaches that do not compromise medical efficiency and ensure a decreased burden on the patient. It is directly linked with an efficient multidisciplinary team that will perform appropriate pre-operative assessment. Caution is required in complex patients with several comorbidities to ensure a meaningful and informed thoracic surgery referral leading to optimal patient outcomes.

Shareable abstract

Lung cancer surgery with curative intent is mainly focused on minimally invasive techniques and relies on an efficient multidisciplinary team https://bit.ly/45EVfSW

Educational aim

To provide an overview of lung cancer surgery with curative intent, its pre-operative assessment and surgical approaches, for an audience of international healthcare professionals.

Introduction

Lung cancer is the predominant cause of cancer-related global mortality. It accounts for ∼15% of all new cancer diagnoses, and it is the second most common solid tumour after prostate cancer in men and breast cancer in women [1]. The mean age of lung cancer detection is 70 years old with men more likely to be affected, despite the rising incidence of lung cancer in women over recent years most probably due to an increased smoking habit. In addition to smoking, higher proportions of epidermal growth factor receptor (EGFR) mutations and oestrogen effects have made women more susceptible to lung cancer [1]. Nonsmall cell lung cancer (NSCLC) histology is the most frequently encountered lung malignancy, accounting for ∼85% of all cases. Surgery broadly remains the mainstay of treatment for early-stage disease at diagnosis, in patients with adequate baseline fitness [2].

Recently, the increasing use of ERAS (Enhanced Recovery After Surgery) protocols has improved the post-surgical outcome and quality of life in lung cancer patients. A recent systematic review and meta-analysis of randomised controlled trials showed that ERAS pathways in lung cancer surgery are correlated with lower incidence of complications and a shorter length of stay, eventually leading to a global cost saving [2, 3]. The authors of the ERAS guidelines highlighted the need to develop standardised, evidence-based guidelines for thoracic surgery to ensure all patients receive optimal treatment, thus avoiding any heterogeneity among the currently applied treatment protocols [3].

This review aims to provide a comprehensive summary of existing evidence and the main recommendations about pre- and post-operative care in lung cancer surgery with radical intent, focusing on workup, fitness evaluation and clinical outcomes.

Pre-operative workup

Prior to treatment, a multidisciplinary team (MDT) of specialists in the diagnosis and management of lung cancer, composed of thoracic surgeons, (interventional) pulmonologists, (interventional) radiologists, oncologists, nuclear medicine physicians, radiotherapists, pathologists and palliative care specialists, is required to determine the safest and most efficient route to tissue or to provide a consensus that histological confirmation is not feasible and to establish a clinical diagnosis of lung cancer where treatment is warranted [4]. A multidisciplinary approach is essential to provide the optimal treatment strategy ensuring improved clinical outcomes.

Imaging

In the realm of precision medicine, accurate pre-operative staging in patients with NSCLC is of paramount importance as it will lead to treatment options appropriate for the stage of the disease. It can also predict prognosis and treatment outcomes. The pre-operative diagnostic approach should be tailored according to a risk–benefit analysis, centre expertise and individual patient preferences. Ideally, centres with a dedicated MDT can provide an excellent forum of lung cancer specialists collaborating on key decision making and anticipated challenges, resulting in a more accurate pre-operative staging [5, 6]. Baseline noninvasive workup assessment should always include contrast-enhanced computed tomography (CT) of the chest, with detailed images of the liver and the adrenal glands. CT scans provide valuable information about the tumour size and extent with increased sensitivity (98–100%) and variable specificity (54–93%) [7]. Due to the accurate information, a chest CT scan needs to precede bronchoscopy, endobronchial ultrasound (EBUS) or mediastinoscopy to guide the appropriate route to tissue. CT should be followed by fluorodeoxyglucose (FDG) positron emission tomography–computed tomography (PET/CT) to facilitate accurate clinical staging (c-TNM). FDG-PET/CT is the single most sensitive noninvasive modality to detect locoregional lymph node involvement and metastatic disease with higher accuracy compared with CT alone. PET/CT has been reported to have 90% accuracy on mediastinal lymph node status and a sensitivity of 87–92% [8], thus orienting the physician on the need for further invasive investigation (i.e. EBUS, mediastinoscopy) for histological confirmation. In selected patients, combining PET/CT with EBUS–transbronchial needle aspiration can dramatically increase the diagnostic accuracy of mediastinal nodal staging.

A PET/CT scan provides valuable information for the presence of mediastinal or distal metastasis, and about the tumour's metabolic activity and differentiation between the tumour and other pathology. PET/CT sensitivity for detecting brain metastasis is limited; metastatic lesions in the brain can be disguised by increased FDG uptake of the brain as it consumes increased glucose quantities at its baseline. Therefore, current guidelines recommend head magnetic resonance imaging (MRI) with contrast to stage the patients’ brain for stages IB–IIIA when they are candidates for treatment with curative intent. Pre-operative brain MRI is currently indicated as a favourable pre-operative assessment of brain metastasis in NSCLC only in patients with a high probability of extrathoracic disease spread, i.e. cStage II or greater, pure solid centrally located lesions, mediastinal lymph node involvement [9]. When MRI is unavailable, a brain CT with intravenous iodinated contrast is a valid alternative [4].

Pre-operative histology

An ongoing debate in lung cancer MDTs concerns the surgical resection of high-risk lung nodules without a preceding histological confirmation of malignancy.

In general, current guidelines favour a pre-operative biopsy in patients with a pulmonary nodule suspected for lung cancer to obtain pre-operative histology when technically feasible. In particular, when the risk of malignancy according to the Herder model after PET/CT is between 10% and 70% pre-operative biopsy is recommended [10].

With regards to peripheral lesions, CT-guided percutaneous biopsy could be considered for persistent or growing solid lesions larger than 8 mm or part-solid lesions larger than 15 mm. An absolute contraindication for the procedure is the presence of vascular lesions, while relative contraindications are coagulopathy, respiratory failure, a forced expiratory volume in 1 s (FEV1) <35% predicted, severe emphysema, the presence of only one functional lung and uncooperative patients. In addition, guidelines suggest that if a part-solid lesion is strongly suspected for lung cancer, it is conceivable to perform surgery directly without pre-operative diagnosis [4, 11].

Bronchoscopy is another alternative to obtain a biopsy. However, its diagnostic yield in the evaluation of pulmonary nodules is usually low when there is no airway involvement, even if it can be increased with the use of fluoroscopy, EBUS or electromagnetic navigation [10].

EBUS or endoscopic ultrasound (EUS) is a valid and less invasive alternative to mediastinoscopy for mediastinal pre-operative staging, which is strongly recommended when mediastinal lymph nodes are enlarged at CT, or with increased FDG uptake at PET/CT, or when there is no suspicion of mediastinal involvement at pre-operative imaging but the tumour is bigger than 3 cm, is centrally located or there is evidence of cN1 disease [12]. Even though PET/CT is usually required prior to EBUS for mediastinal staging, evidence suggests that patients can be referred straight to EBUS after an initial chest CT and before PET/CT to reduce the time to treatment decision by providing both diagnosis and nodal stage at once with good clinical outcomes [13]. However, the current standard of care remains for PET/CT to precede EBUS.

Despite all these possible strategies for pre-operative staging, patients with a very high pre-test probability of stage IA lung cancer may not require a biopsy before surgery due to the increase in time to treatment, costs and procedural risk. Therefore, the most recent National Comprehensive Cancer Network guidelines suggest by-passing this procedure in this subgroup of selected patients [4]. In particular, when the nodule is characterised by large diameter, spiculated margins, absence of calcifications, increased FDG uptake or it has a part-solid aspect, surgical resection should be directly offered, possibly with intraoperative frozen section, in order to detect malignancy at an early stage and perform diagnosis and treatment with a single procedure without the added waiting time for a bronchoscopic or CT-guided biopsy and subsequent pathological confirmation that will not affect the decision to treat [14].

Fitness assessment

Pre-operative fitness assessment is pivotal in patients considered for lung cancer surgery. It is mainly based on the patient's general performance status, cardiological and pulmonary function parameters. Fitness assessment relies initially on the clinical evaluation of the referring healthcare professional [15].

Performance status

The Eastern Cooperative Oncology Group (ECOG) performance status is commonly used to assess the patient's overall health and ability to withstand surgery (table 1) [15]. Assessment can be made by trained healthcare professionals, including medical practitioners, nurses and physiotherapists.

TABLE 1

Eastern Cooperative Oncology Group (ECOG) performance status

Cardiological evaluation

Given the association between lung cancer and cardiovascular disease, cardiological evaluation is of paramount importance. ECG, echocardiography, and stress testing in high-risk patients assess cardiac function and fitness for surgery from a cardiological point of view.

All patients should initially be assessed with validated cardiological risk scores, such as the Revised Cardiac Risk Index (table 2). Patients with a poor functional status or history of cardiac disease should be submitted to noninvasive stress tests. If the results are consistent with the need for coronary intervention, lung surgery should be postponed for at least 6 weeks after the procedure. Furthermore, pre-operative echocardiography should be considered in cases suspected of left ventricular dysfunction, pulmonary hypertension or valvular diseases [17].

TABLE 2

Detailed Revised Cardiac Risk Index (RCRI) breakdown and its clinical interpretation translating the index score into a specific risk of major cardiac event for each patient

Pulmonary function tests

Pulmonary function tests are integral in determining a patient's lung function reserve. FEV1 and diffusion capacity of the lung for carbon monoxide (DLCO) are crucial parameters in the evaluation of a patient's ability to tolerate surgery. If they are both over 80% of the predictive value, resection up to pneumonectomy is feasible. If one of these values is <80% predicted, exercise tests (i.e. cardiopulmonary exercise testing (CPET)) with peak oxygen consumption (VʹO2) evaluation are highly recommended. A peak VʹO2 value >75% of the predicted value or >20 mL·kg−1·min−1 qualifies for up to pneumonectomy; a value <35% predicted or <10 mL·kg−1·min−1 is related to high risk for any resection; for intermediate values, it is possible to predict post-operative lung function and assess the number of resected lung segments the patient could tolerate [17, 18]. The majority of patients undergoing lung cancer surgery have impaired lung function secondary to COPD; therefore, it is of vital importance for the surgeon to consider lung function in combination with optimal clinical outcome (table 3).

TABLE 3

Summary of cut-off values for pulmonary function tests that guide the thoracic surgeons’ management plans for the extent of resection

Although CPET is the gold standard test for exercise capacity measurement, it has limited availability, occasionally long waiting lists and it is resource intensive. In these cases, low-technology exercise tests (e.g. shuttle and 6-min walk tests, 30 s sit-to-stand test) may be used as an alternative to CPET [19].

Nutritional assessment

Malnutrition is common in cancer patients and can impact surgical outcomes. Current evidence strongly suggests that the pre-operative nutritional and immunological status not only impacts short-term post-operative complications but also significantly influences the long-term outcomes of cancer patients [20]. This association can be attributed to the link between systemic inflammation and nutritional impairment, characterised by increased catabolic process and energy consumption. Low levels of nutritional markers such as serum albumin, inhibited by systemic inflammation and cholesterol (an essential component of cellular membranes involved in cell homeostasis), can be indicative of poor prognosis. In the context of lung cancer, pre-operative nutritional scores like Prognostic Nutritional Index (PNI) and Controlling Nutritional Status (CONUT) score have emerged as independent prognostic factors [21]. Additionally, the albumin component of PNI indicates the nutritional status of cancer patients, with low levels associated with malnutrition and weight loss, ultimately contributing to poor overall survival and increased cancer-related mortality. The comprehensive understanding of these interconnections highlights the importance of PNI as a valuable prognostic marker in lung cancer and various other solid tumours.

In 2017, Galizia et al. [22] introduced the Naples Prognostic Score (NPS), a novel scoring system for colorectal cancer surgery patients, incorporating both inflammatory and nutritional biomarkers. This score incorporated pre-operative measures such as neutrophil-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, serum albumin and total cholesterol, demonstrating a robust association with long-term survival. Elia et al. [23] recently investigated the same score with a retrospective score matching analysis of 260 patients undergoing surgery for NSCLC. The results showed a significant correlation between the NPS, overall survival (p=0.018) and cancer-related survival (p=0.007). Thus, highlighting the importance of pre-operative nutritional assessment for prediction of prognosis, further validated by the multivariate Cox regression analysis. In patients affected by NSCLC the nutritional index, calculated within the NPS proved to be a prognostic indicator for overall and cancer-related survival [23].

Surgical approaches

Lobectomy is still considered the standard of care for NSCLC. The introduction of video-assisted thoracic surgery (VATS) lobectomy led to the thoracoscopic approach to lung cancer. In this way, open surgical procedures requiring open thoracotomies (wider incisions) are avoided. Possible concerns about its oncological safety and adequacy have been clearly addressed and solved by the recently published VIOLET trial, which confirmed that the VATS approach is oncologically safe, showing no differences in both overall survival and disease-free survival in comparison with open procedures. The VIOLET trial also showed VATS performs better in terms of post-operative physical function and post-operative pain, without increasing post-operative complications [24].

Evidence is still lacking on whether a multiportal or uniportal approach is preferable, and it largely remains a surgeon's choice based on their own experience and expertise. A multiportal technique might bear greater post-operative pain due to the multiple sites of incision compared with the single one, but this is still a question of debate.

With the advent of robotic surgery, interest in robotic-assisted thoracic surgery (RATS) has been emerging. The ROMAN study, published in 2021, was the first international randomised controlled trial to compare the outcomes of RATS with those of VATS in early-stage lung cancer and although RATS was not superior to VATS, RATS allows for a more thorough lymph node dissection during surgery [25].

Recently, two multicentre randomised clinical trials, from Japan and the Alliance for Clinical Trials in Oncology Group in North America, showed that for early stage (T1a–b N0 M0, stage IA) NSCLC sublobar resection was noninferior to lobectomy for primary tumours measuring 2 cm or less in size [26–28]. These findings somehow change the consolidated “dogma” of better results after lobectomy for T1 N0 M0 NSCLC measuring up to 3 cm in size. Moreover, in a post hoc analysis by the Alliance trial there was no significant difference in the reported outcomes after segmentectomy versus wedge resection. Such results open a new scenario even though surgeons are now called to a more responsible approach in terms of selection of patients, negative resection margins, and precise nodal staging. In fact, the improvement of systemic therapy alternatives, i.e. immune checkpoint inhibitors (ICIs) and targeted therapies, requires a more extensive removal of N1 lymph nodes to warrant a proper adjuvant treatment. The greater risk of local recurrence (micropapillary) or systemic progression (solid) after sublobar resection for some histological subtypes of adenocarcinoma should also be taken into consideration before planning the type of resection. However, it is now clear that the majority of published studies have shown that upfront videothoracoscopic parenchyma-sparing surgery, i.e. segmentectomy and wedge resections to diagnose/cure early-stage cancer, is a feasible strategy that has comparable results in terms of overall and disease-free survival versus standard lobectomy in selected patients with peripheral lesions [26–28]. Regardless of the type of surgical approach, all NSCLC cases with a tumour diameter ≥4 cm and/or ≥pN1 require programmed death-ligand 1 (PD-L1) testing and adenocarcinomas, in particular, require next-generation sequencing to inform the decision to treat [4].

Oligometastatic disease

The advances in systemic therapies, including targeted or immune therapy, have led to significant improvements in stage IV NSCLC survival. Even if systemic therapies are still the gold standard at this stage, surgery might be considered for patients with a limited burden of metastatic disease. There is no general consensus on the definition of oligometastatic disease. Nonetheless, the European Society of Radiotherapy and Oncology and American Society for Radiation Oncology recommended the use of this term when there are from one to five metastatic lesions and all the sites fall into surgical resectability. In these cases, the removal of both the primary tumour and the metastases, in selected patients after MDT discussion, might be related to improvements in overall survival, maintaining at the same time a low risk of post-operative mortality or morbidity thanks to the diffusion of mini-invasive approaches [29].

Non-intubated surgery

Current surgical strategies for radical lung cancer resection are increasingly based on minimally invasive surgery that include VATS anatomical or non-anatomical resections selectively performed through single, two or multiple ports, as well as robot-assisted surgical approaches. Recent technical advances are driving towards minimised surgical trauma by limiting the number and extension of the surgical accesses. In addition, it has been thought that by reducing the anaesthesia-related trauma as well optimised results can be achieved with minimised overall operative trauma. In this setting spontaneous ventilation (SV) anaesthesia protocols without tracheal intubation have been shown in initial series to reduce operative morbidity and hospital stay in patients with poor pulmonary function [30]. If compared with the pioneering strategies of the initial era, which entailed adoption of epidural catheter analgesia in fully awake patients, SV-VATS strategies continue to be refined to improve safety, reproducibility and patients' comfort in the operating room. Current anaesthesia protocols have entailed simple intercostal block analgesia with target control sedation under bi-spectral index monitoring, adoption of spontaneous ventilation with placement of a laryngeal mask without tracheal intubation, and even adjuvant negative-pressure ventilation to eliminate completely positive pressure ventilation and achieve full lung re-expansion at the end of the procedure [31].

Amongst the potential advantages of SV-VATS lung resection, a more rapid recovery to normal physiology with less impairment of immune system has been hypothesised. In this respect, following SV-VATS, total lymphocyte count and natural killer cells are better preserved than following intubated one-lung ventilation VATS. Non-intubated VATS surgery is associated with improved post-operative neurocognitive recovery, more stable intraoperative cerebral oxygenation, ameliorated perioperative inflammation and attenuated post-operative complication severity.

Long-term data comparing SV-VATS lung resection versus conventional VATS with intubation and one-lung ventilation are warranted to reinforce the encouraging early results published so far, although initial data have shown that SV-VATS lobectomy resulted in similar survival rates to those observed with intubated one-lung ventilation VATS [32].

No drain surgery

Thoracic drains have traditionally been placed in the thoracic cavity after surgical procedures in order to evacuate both fluid and air. However, they play a major role in increasing post-operative pain. Drain-related pain can increase post-operative complications, increasing sputum retention and limiting early mobilisation, rendering patients prone to respiratory infections and atelectasis. To improve post-operative outcomes, contribute to early recovery after thoracic surgery and shorten the length of stay, some groups have tried to overcome the need to place thoracic drains after surgery. While most studies in the literature refer to wedge resections, some authors have also implemented a drainless strategy in more complex procedures, such as lobectomy and segmentectomy for lung cancer. Nevertheless, these cases should always be carefully selected, and the absence of air leaks must be confirmed intraoperatively. Important criteria to take into account while selecting patients for drainless surgery are the absence of air leak during end-operative airtightness test, the absence of pleural adhesions, no history of previous thoracic surgery, and the absence of macroscopic emphysema or moderate-to-severe pulmonary obstructive or restrictive disease. Suture reinforcement and air sealants may also be used to improve sutures' airtightness, although there are no studies confirming its clinical efficacy [33].

The impact of neoadjuvant ICIs and targeted therapies in lung cancer surgery

Over the past few years there has been significant progress in the use of ICIs in the neoadjuvant setting with improved clinical outcomes [4]. Neoadjuvant targeted therapies and in particular EGFR-tyrosine kinase inhibitors (TKIs) are a novel area of interest which is currently studied in EGFR-mutated potentially resectable NSCLC and has yet to be adopted in daily clinical practice [34, 35]. Landmark trials have provided evidence regarding improved clinical outcomes with the use of ICIs in the neoadjuvant setting; however, there was no reference to the intraoperative surgical experience and the surgical outcome per se as both points were beyond the scope of those trials [36–38]. However, it has been reported that neoadjuvant ICIs seem to increase surgical complexity therefore leading to more invasive approaches. It has been shown that significant nodal response to neoadjuvant ICI therapy is linked with an increased possibility of more invasive and advanced surgical manoeuvres for the completion of vascular dissections due to a nodal sclerotic effect following induction treatment [39, 40]. In addition to the nodal sclerotic effect, surgeons raise concerns for nodal adherence and mediastinal fibrosis following neoadjuvant ICIs as well as increased frailty in the pulmonary artery, vein and trachea, which may further complicate surgical resection [40, 41].

Currently, there are no randomised controlled trials to support that these effects lead to an increased conversion rate to open thoracotomy, although it is of note that the majority of post-induction case series were initiated via open thoracotomies [39, 40].

Post-operative complications

Post-operative complications in thoracic surgery can range from 9% to 53.4%, although most of them are preventable [42]. The most important intra- and post-operative complications include bleeding, atelectasis, hospital-acquired infection and prolonged air leak (table 4). Early detection and appropriate intervention are critical for minimising adverse outcomes and reduce the length of hospital stay.

TABLE 4

The most important thoracic surgery complications and considerations on how to avoid them

Bleeding is usually detected shortly after surgery either though clinical signs and haemoglobin drop, or profound blood in the chest drain, and it may be accompanied by haemodynamic instability. The rapid evolution to a haemothorax is associated with increased mortality (up to 17.8%) and usually occurs in 0.6–4.6% of cases [43]. Active bleeding requires immediate attention with intravenous blood and plasma administration as a bridge surgical exploration aimed at identifying the source of bleeding and treating it surgically.

Atelectasis and non-expansion of the operated lung can cause impairment in gas exchange and respiratory mechanics, and if it leads to lung collapse then this results in pneumonia and a prolonged hospital stay. Post-operative atelectasis is usually due to mucus plugging, lack of expectoration and reduced mobilisation after surgery. To avoid this, early mobilisation, respiratory physiotherapy, bronchoscopic removal of dense secretions, with a main emphasis in patients with COPD, good hydration and expectorants are measures that can prevent this adverse event. ERAS protocols are efficient in reducing post-operative atelectasis and subsequent pneumonia as their overall approach aims to minimise stress response, offer early mobilisation and reduce post-operative pulmonary complications with the view to improve patient outcomes [44].

Hospital-acquired infections are not specific to thoracic surgery as they can occur in the entire spectrum of hospital admissions, and they can prolong hospital stay and lead to adverse clinical outcomes. However, surgical site infections are more common in all surgical admissions, including thoracic surgery, and they can only be addressed by improved infection control and reduced hospital stay [45].

Prolonged air leak (i.e. >5 days after surgery) is the most common post-operative complication in patients undergoing lung cancer surgery and it has an overall incidence ranging from 5% to 25% [46]. Risk factors are related to the presence of emphysema, diabetes and long-term corticosteroids in combination with the extension of the surgical resection and the presence of pre-existing pleural adhesions [46]. Although one cannot prevent the pre-existing risk factors, the thoracic surgeon can reduce the risks related with the procedure per se with the conventional approach of reinforcing the staple line or even consider biological glues, although these have been debated in the literature. Prolonged air leak is usually managed with watchful waiting and suction application to the chest drain and subsequently a prolonged hospital stay [46].

Efficient lung cancer surgery relies on an efficient MDT

Thoracic surgery plays a pivotal role in the management of stage I and II lung cancer and it is a key player in the multimodality approach of stage III [4]. Its efficiency relies on the patients' fitness assessment, their accurate pre-operative staging, and the operating centre's expertise and resources [12, 15, 47]. Fitness assessment relies initially on the clinical evaluation of the referring respiratory physician, including performance status, comorbidities and lung function [15]. Continuing further, the diagnostic pathway leading to lung cancer surgery is a multidisciplinary activity involving radiologists, nuclear medicine specialists, bronchoscopists, lung function technicians, pathologists and surgeons (figure 1). To ensure an appropriate referral for surgical resection with radical treatment intent, the team must have expertise in the field, work seamlessly and meet certain standards [46, 47]. Despite the national shortages of dedicated chest radiologists, it is acknowledged that their special interest is important in meaningful radiology reporting that impacts on thoracic surgeons' views [48]. The bronchoscopist's learning curve and sensitivity impact on the accuracy of pre-operative staging, and they will affect the MDT discussion regarding the decision for surgical treatment [49]. Optimisation of EBUS samples processing and pathologists' expertise in reporting them also contributes to the decision to undergo surgical treatment of lung cancer [50].

FIGURE 1

Key players contributing to an informed decision for lung cancer surgery.

In addition to pre-operative fitness assessment and accurate staging informing the surgical decision to treat with a radical intent, prognostic indicators of post-operative clinical outcomes seem to pave a promising way to identifying in advance the patients that will benefit the most from surgery. However, further clinical validation is required prior to implementation in daily clinical practice [14, 23].

Clinical outcomes in lung cancer surgery are closely associated with the centre's volume of cases and surgeon's experience. Patients undergoing lung cancer surgery in big centres present with a lower in-hospital mortality and higher 5-year survival [47]. Although the surgeon's volume has been associated with improved operative mortality in lobectomies, there has been a lack of a consistent agreement as there seems to be some evidence demonstrating that the volume does not associate with in-hospital mortality [51]. More recent evidence showed that low-volume thoracic surgeons present with higher in-hospital mortality compared with high-volume surgeons, with the caveat that most low-volume thoracic surgeons operate on black patients who have, by default, an independent risk factor for worse clinical outcomes [52]. This important observation adds an additional factor to consider when assessing clinical outcomes and deciding on centralisation of thoracic surgery services.

Conclusions

Lung cancer surgery with curative intent is an ever-evolving field that relies on an efficient MDT that will perform accurate staging. It will assess the patient's overall fitness including comorbidities and lung function to ensure an optimal surgical approach and clinical outcome. MDT input is essential as these patients frequently have significant comorbidities and complicated disease courses. Minimally invasive techniques have gained new ground as they do not compromise oncological efficacy and they have a significantly decreased burden on the patient.

Key points

Lung cancer surgery with curative intent needs to involve an efficient and experienced multidisciplinary team.

A thorough pre-operative staging in combination with pulmonary function and pre-operative assessment informs the surgeon's view on a tailored surgical management plan.

Minimally invasive approaches are the mainstay of treatment.

Footnotes

Conflict of interest: E. Caruana reports payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing or educational events for AtriCure and AstraZeneca, and is the Chair of the Pleural Disease Working Group (ESTS), all disclosures made outside the submitted work. The remaining authors have nothing to disclose.

Received March 14, 2024.Accepted June 17, 2024.http://creativecommons.org/licenses/by-nc/4.0/

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