Seventy-two patients with limited small cell lung cancer were identified as candidates for adjuvant operation after chemotherapy. All patients received preoperative chemotherapy with cyclophosphamide, doxorubicin HCl (Adriamycin), and vincristine, or the epipodophyllotoxin derivative VP-16 and cisplatin. The rate of response to chemotherapy was 80% (complete response 38% and partial response 42%). After chemotherapy, 57 patients (79.1%) were candidates for adjuvant surgical resection, but only 38 underwent thoracotomy. Eight required a pneumonectomy, 25 a lobectomy, and five patients had no resection. Postoperative pathologic study revealed only small cell lung cancer for 29 patients, mixed and non-small cell lung cancer for two, non-small cell lung cancer for four, and no residual tumor in three patients. Pathologic staging revealed seven patients in stage I (N0), nine in stage II (N1), and 22 in stage III. The median survival time for the 38 surgical patients was 91 weeks and projected 5-year survival rate 36%. Patients with pathologic stage I disease had significantly longer survival times (median not reached) than did patients in stage II or stage III (median survival 69 and 52 weeks, respectively). Within the group not undergoing operation, 19 patients responded to therapy and were eligible for adjuvant surgical resection, but did not undergo thoracotomy (10 patients were randomized to radiation only, and nine patients refused operation). Their median survival of 51 weeks was inferior to that of the 38 surgical patients (p = 0.049). Adjuvant surgical resection after chemotherapy resulted in long-term survival and cure for a significant proportion of patients with pathologic stage I disease. A significant improvement in survival could not be documented for patients in stages II and III. Intensive pretreatment investigation including mediastinoscopy is essential to exclude patients who will not benefit from adjuvant surgical resection.