Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Video assisted thoracoscopic surgery and lobectomy, sublobar resection, radiofrequency ablation, and stereotactic radiosurgery: advances and controversies in the management of early stage non-small cell lung cancer Arjun Pennathur, Ghulam Abbas, Neil Christie, Rodney Landreneau and James D. Luketich Purpose of review Lung cancer is the most common cause of cancer related mortality in the United States. The fastest growing segment of the population has been the elderly, who frequently have other significant co-morbidities. In the medically inoperable, high-risk patient, new treatment options including minimally invasive surgery, computed tomography-guided ablative therapy and sterotactic radiosurgery are encouraging. The purpose of this article is to review some of these advances and emerging technologies in the management of early stage lung cancer, particularly in the high-risk patient. Recent findings In this article, we review the results of video-assisted thoracoscopic lobectomy, controversies surrounding lobectomy versus sublobar resection, and results of brachytherapy mesh as an adjunct to sublobar resection. Finally, we will review emerging technologies such as radiofrequency ablation and stereotactic radiosurgery in the treatment of lung neoplasm. Summary Lobectomy remains the standard for early stage lung cancer. In compromised patients, minimally invasive surgical approaches via thoracoscopy allow sublobar resection (wedge resection or segmentectomy) with or without adjunct brachytherapy mesh to offer results that approach that of lobectomy in some cases. Radiofrequency ablation and stereotactic radiosurgery are emerging technologies for the treatment of lung neoplasm, which are particularly applicable in high-risk patients who are not fit for even minimally invasive surgery. Prospective studies are underway in our center and others to further define the role of these new technologies in the treatment of lung neoplasm. Keywords high-risk patients, lung cancer, radiofrequency ablation, stereotactic radiosurgery, video assisted thoracoscopy Curr Opin Pulm Med 13:267–270. ß 2007 Lippincott Williams & Wilkins. Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA Correspondence to James D. Luketich, MD, Sampson Family Endowed Professor of Surgery, Chief, The Heart, Lung, and Esophageal Surgery Institute, University of Pittsburgh Medical Center, 200 Lothrop Street, C-800, Pittsburgh, PA 15213, USA Tel: +1 412 647 2911; fax: +1 412 647 0050; e-mail: luketichjd@upmc.edu Current Opinion in Pulmonary Medicine 2007, 13:267–270 Abbreviations CT computed tomography NSCLC non-small cell lung cancer RFA radiofrequency ablation SRS stereotactic radiosurgery VATS video assisted thoracoscopic surgical ß 2007 Lippincott Williams & Wilkins 1070-5287 Introduction Lung cancer is the most common cause of cancer-related mortality in the United States. Lobectomy is the standard treatment in resectable disease and offers the best chance of cure particularly in the earlier stages. In patients with comorbidities that preclude surgery, including pulmonary dysfunction, conventional external beam radiotherapy is one option for treatment but the reported 5-year survival rates of 10–21% are far inferior to surgery [1]. Newer innovative technologies in the treatment of this high-risk group of patients with lung cancer are being investigated. In this article we will discuss video assisted thoracoscopic surgical (VATS) lobectomy, and alternatives for the high- risk patient when conventional surgical resection is not feasible, such as performance of a limited resection and image-guided ablative therapies such as computed tom- ography (CT)-guided radiofrequency ablation (RFA) and stereotactic radiosurgery (SRS). Video assisted thoracoscopic surgical lobectomy VATS lobectomy is a minimally invasive alternative to open thoracotomy. Potential benefits of thoracoscopic lobectomy include equivalent oncologic outcomes to open lobectomy and less morbidity. Two large series were published last year [2  ,3  ], with McKenna and colleagues reporting their results in 1100 patients who underwent VATS lobectomy. The mortality was 0.8% with a median length of stay of 3 days. Onaitis and colleagues also reported their results in 500 consecutive patients who underwent thoracoscopic lobectomy. A total of 330 patients had stage I disease and the peri- operative mortality was 1%. The median follow-up was 24 months and the estimated 2-year survival was 85%. 267