Lung and esophageal cancers remain among the most lethal thoracic malignancies, largely because both present late. The last decade has shifted the balance in three areas: earlier detection, less destructive surgery, and structured functional recovery.
Low-dose CT (LDCT) is the only lung cancer screening modality with mortality benefit in randomised data. The NLST demonstrated a 20% reduction in lung cancer mortality, and NELSON confirmed a comparable benefit with volumetric nodule assessment and a lower false-positive rate. Current USPSTF criteria —annual LDCT for ages 50—80 with a 20 pack-year history, current smokers or those who quit within 15 years — capture Western risk profiles well but transfer poorly to Asian populations, where a substantial proportion of adenocarcinoma occurs in never-smokers with driver mutations. Risk-prediction models such as PLCOm2012, standardised Lung-RADS reporting, and emerging blood-based biomarkers offer a route to better-calibrated eligibility.
Esophageal cancer has no equivalent population-level programme. For adenocarcinoma, surveillance is confined to Barrett‘s esophagus, with Seattle-protocol biopsies increasingly supplemented by non-endoscopic cell-collection devices (Cytosponge-TFF3, EsoCheck/EsoGuard) that make case-finding feasible outside endoscopy suites. For squamous cell carcinoma — the dominant histology in India, China and Iran — Lugol's chromoendoscopy and narrow-band imaging in high-incidence regions detect early mucosal disease amenable to endoscopic cure.
In lung cancer, the Iobectomy-for-all era has ended. JCOG0802 showed segmentectomy delivers superior overall survival for peripheral node-negative tumours s2 cm, and CALGB 140503 confirmed non-inferiority of sublobar resection — parenchymal preservation now has level-1 support. Neoadjuvant chemo-immunotherapy (CheckMate 816, KEYNOTE-671, AEGEAN) has redefined resectability while introducing fibrotic hilar planes that raise technical demand. Three-dimensional planning, indocyanine green delineation of intersegmental planes, and navigational bronchoscopic dye marking of ground-glass lesions have become routine adjuncts.
In esophageal cancer, minimally invasive esophagectomy (TIME) reduced pulmonary infection, and hybrid MIE (MIRO) reduced major complications without oncological compromise. Neoadjuvant chemoradiation (CROSS) and perioperative FLOT are standard, and endoscopic resection now cures selected T1a disease. Active surveillance after complete clinical response (SANO) is reshaping the decision to operate at all.
Robotic surgery
Robotic platforms offer wristed instrumentation and stable magnified vision in confined mediastinal spaces. RATS lobectomy achieves higher nodal upstaging and lower conversion rates than VATS, with the RAVAL trial reporting better postoperative quality of life. For esophagectomy, the randomised ROBOT trial showed RAMIE reduced pulmonary and cardiac complications versus open transthoracic surgery, with superior functional recovery — the clearest gain being meticulous dissection along the recurrent laryngeal nerves.Capital cost and a defined learning curve remain the principal constraints.
Post-operative habilitation
Outcome now depends as much on rehabilitation as resection. Multimodal prehabilitation —aerobic and inspiratory muscle training, nutritional optimisation, smoking cessation, psychological preparation — reduces pulmonary complications. ERAS pathways drive early extubation, opioid-sparing regional analgesia, early mobilisation and early enteral feeding via jejunostomy. Esophagectomy patients additionally need swallow rehabilitation, stricture surveillance, reflux and dumping management, and sustained nutritional follow-up; speech therapy is essential where nerve palsy occurs. Diaphragm dysfunction, readily assessed by bedside ultrasound, is an underrecognised driver of prolonged ventilation and should be screened for routinely.
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