Treatment optimization for centrally located lung cancers requires special considerations for determining resectability and patient selection. Evaluation involves an experienced multidisciplinary team performing careful clinical and invasive-disease staging to identify the best management approach and ascertain the need for multimodality therapy. Preoperative imaging alone is often inaccurate in its ability to determine whether the patient is at an advanced clinical T stage that might preclude curative surgical resection. Therefore, other modalities are often necessary to complete the clinical staging. In the absence of irrefutable evidence of unresectability, however, surgical exploration should be undertaken with curative intent. Long-term outcomes can be favorable in select patients, and most of the procedures, including complex reconstructions, can be performed with acceptable morbidity and mortality.