Surgical Management of Stage IIIA Non-Small Cell Lung Cancer

Abstract

According to the eighth edition of the tumor–node–metastasis classification, stage III non-small cell lung cancer is subdivided into stages IIIA, IIIB, and IIIC. They represent a heterogeneous group of bronchogenic carcinomas with locoregional involvement by extension of the primary tumor and/or ipsilateral or contralateral lymph node involvement. Surgical indications have not been definitely established but, in general, long-term survival is only obtained in those patients in whom a complete resection is obtained. This mini-review mainly focusses on stage IIIA disease comprising patients with locoregionally advanced lung cancers. Different subcategories of N2 involvement exist, which range from unexpected N2 disease after thorough preoperative staging or “surprise” N2, to bulky N2 involvement, mostly treated by chemoradiation, and finally, the intermediate category of potentially resectable N2 disease treated with a combined modality regimen. After induction therapy for preoperative N2 involvement, best surgical results are obtained with proven mediastinal downstaging when a lobectomy is feasible to obtain a microscopic complete resection. However, no definite, universally accepted guidelines exist. A relatively new entity is salvage surgery applied for recurrent disease after full-dose chemoradiation when no other therapeutic options exist. Equally, only a small subset of patients with T4N0-1 disease qualify for surgical resection after thorough discussion within a multidisciplinary tumor board on the condition that a complete resection is feasible. Targeted therapies and immunotherapy have recently become part of our therapeutic armamentarium, and it might be expected that they will be incorporated in current regimens after careful evaluation in randomized clinical trials.

Association Between Treatment Facility Volume, Therapy Types, and Overall Survival in Patients With Stage IIIA Non–Small Cell Lung Cancer

“…The resectability of T4 or N2 disease is highly dependent on the local expertise of the surgeon and the management of complications by the comprehensive care team. 7 Moreover, despite an increased association between toxicity and combined chemoradiotherapy (CRT) in stage IIIA disease, previous studies have shown an advantage for combination CRT. 8 This survival advantage may be attributed to better management of the complications or toxicities.…”

Interdisciplinary multimodality management of stage III nonsmall cell lung cancer

“…Whereas large tumours without mediastinal lymph node involvement are usually resected, if possible, the possible role of surgery in the management of patients with stage IIIA disease with mediastinal involvement (T1-3N2M0) is the topic of considerable debate [5,67]. Randomised controlled trials have generally found no significant difference in overall survival when surgery was compared with radiotherapy/ chemoradiotherapy for stage IIIA-N2 disease.…”

MEDIASTinal staging of non-small cell lung cancer by endobronchial and endoscopic ultrasonography with or without additional surgical mediastinoscopy (MEDIASTrial): study protocol of a multicenter randomised controlled trial

“…Patients with pathologically proven N2–3 mediastinal lymph node metastases are usually recommended to undergo first line chemoradiation instead of surgery since no survival benefit has been demonstrated by additional surgery [ 4 ]. When mediastinoscopy demonstrates potentially resectable N2 metastases several treatment strategies can be followed: induction chemotherapy followed by surgery, induction chemoradiotherapy followed by surgery or definitive chemoradiotherapy [ 5 , 6 ].…”

“…To strengthen these figures, recent survival data from the ASTER trial demonstrated equal 5-yr survival rates of 35% in both randomization groups, despite significantly different detection rates of upfront N2 disease [ 15 ]. Therefore, surgical treatment of minimal unforeseen N2 disease instead of definite chemoradiation is increasingly considered as treatment option as well [ 5 , 6 ]. In addition, the revised European Society of Thoracic Surgery (ESTS) guideline of mediastinal staging states that there is room for trials evaluating surgical treatment instead of chemoradiation for minimal N2 disease [ 16 ].…”