Surgical Decision-Making: Resectable vs Borderline Resectable NSCLC

Patients with potentially operable lung cancer require expert surgical evaluation to determine true resectability, as this assessment depends heavily on surgeon expertise and institutional capabilities rather than standardized criteria. The fundamental question for patients shifts from “Can this tumor be removed?” to “Should this tumor be removed?” and incorporates oncologic factors, patient fitness, and available alternative treatments. Thoracic surgeons emphasize that most tumors can technically be resected, but the decision requires careful consideration of patient-specific factors including age, overall health, tumor characteristics, and expected functional outcomes.

Patient access to appropriate surgical expertise significantly impacts resectability determinations, as complex cases may require specialized techniques including cardiac bypass support during resection. Not all medical centers possess the infrastructure and expertise necessary for advanced thoracic surgical procedures, potentially leading to inappropriate designation of patients as unresectable when they could benefit from surgery at specialized centers. Health care systems must ensure patients have access to dedicated thoracic surgeons, as studies indicate that 50% of lung resections in the United States are performed by nonspecialized surgeons, potentially compromising patient outcomes.

The evolving understanding of N2 disease management demonstrates that multistation nodal involvement alone does not preclude surgical resection in carefully selected patients. Patients with bulky but encapsulated lymph nodes may be better surgical candidates than those with invasive nodal disease that lacks clear anatomic boundaries. Treatment decisions require multidisciplinary input considering the interplay between tumor biology, patient factors, and available treatment modalities including advanced radiation techniques and systemic therapies. Patients benefit most when their care teams include dedicated thoracic surgeons who can provide expert assessment of resectability within the context of comprehensive multidisciplinary treatment planning.