Heterogeneity of stage IIIA non-small cell lung cancer—different tumours, different nodal status, different treatment, different prognosis: a narrative review

Abstract

Stage IIIA non-small cell lung cancer (NSCLC) consists of a heterogeneous group of disease, ranging from small T1a tumours with ipsilateral mediastinal lymph node involvement over T3 tumours with chest wall invasion, up to T4 tumours with mediastinal invasion with or without positive hilar lymph nodes. Based on this heterogeneity, treatment approaches as well as prognosis are very dependent on specific subgroups. Therapy recommendations should be based on multidisciplinary case discussions in high volume centres including medical and radiation oncologists, pneumologists and experienced thoracic surgeons specialized in thoracic cancer surgery. Recommendations may differ from standards in highly selected cases.Therefore, independent of age, in medically fit (operable) patients with resectable stage IIIA tumours, an aggressive approach in a curative setting is key to obtain good overall survival rates. Moreover, maintaining quality of life is essential. In this narrative review the different aspects of all the subgroups of stage IIIA NSCLC and their heterogeneity as well as the variety of treatment modalities, their combined treatment approaches and survival rates are discussed. Again, the reported 5-year survival rates, ranging from 5% in patients with bulky N2 disease, up to 50% for patients with superior sulcus tumours with hilar lymph node disease, reflect the heterogeneity of stage IIIA NSCLC.

Additional pulmonary resection after pneumonectomy under ECMO support: a narrative review and representative case report

“…For patients with non-small cell lung cancer (NSCLC), radical anatomical surgical resection provides the best longterm survival, especially in patients with early-stage disease (stage I and II) (35)(36)(37)(38)(39)(40)(41). In patients with poor pulmonary reserve or major comorbidities with contraindications for lobectomy, sublobar resection with either segmentectomy (T1a and T1b, tumor <2 cm) or wedge resection is appropriate (35,36,(42)(43)(44)(45)(46)(47).…”

“…In T1c-T4 tumors (>2 cm) lobectomy or pneumonectomy should be aimed for. The indication for pneumonectomy should only be considered when lung-sparing anatomical resection such as sleeve lobectomy are unlikely to achieve complete tumor resection (35,36,39,42).…”

“…These numbers slowly increased in recent years due to improvements in diagnostic possibilities including earlier detection during the postoperative follow-up by CT and PET scan. In addition, advancing treatment approaches such as the development of thoracoscopic pulmonary surgery in the last decades improved outcomes compared to open thoracotomy (19,35,36,(49)(50)(51)(52)(53)(54)(55)(56)(57)(58)(59)(60)(61)(62)(63)(64)(65)(66). It is especially important but simultaneously challenging to differentiate multiple lung cancers.…”

“…Independent of age and medical fitness, an aggressive approach in a curative setting is key to obtain good overall survival rates and maintaining quality of life. Depending on localization, distribution and number of the multiple pulmonary lesions, a definitive local therapy by lungsparing resection or as an alternative local stereotactic ablative radiotherapy (SABR) are therapeutic options (19,20,(35)(36)(37)39,42,48,(69)(70)(71)(72). However, in patients with only one lung, outcome, survival and even approaches may be different.…”

“…Compared to lung-sparing resections, the extent of a pneumonectomy is associated with higher morbidity and mortality and indications should be carefully made based on multidisciplinary recommendations regarding the operability of the patient according to pre-and postoperative pulmonary function, performance status and concurrent comorbidities (35)(36)(37)(38)(39)(40)(41)69,73,74).…”