A case against surgery for most IIIa non-small cell lung cancer

Stage IIIa non-small cell lung cancer remains categorically a heterogeneous hodgepodge without clear prospective mandates for clinical care. Poor outcome ensues for patients with mediastinal node-positive cancer when treated with surgery alone, but we are unclear how to define subsets that might benefit from surgery. This article reviews significant trials of surgery and chemoradiotherapy, including those using induction chemotherapy for stage III patients. While many continue to believe that chemotherapy without RT may provide equivalent pathologic complete response and survival rates, there is very little apparent difference in survival between patients managed with surgery or those managed to a higher dose of radiotherapy with concurrent chemotherapy (using an established chemotherapy regimen, 2-dimensional radiotherapy treatment planning, and a dose of only 61 Gy). If there is any benefit to surgery in the IIIa as currently staged, the benefit is very small and is counterbalanced by operative risk.