What is the role for surgery in patients with stage III non-small cell lung cancer?

Locally advanced non-small cell lung cancer (NSCLC) represents a therapeutic challenge. Although combined modality has become the standard treatment in stage III NSCLC, the role of surgery in it remains controversial. This review will address recent evidence on the potential role of surgery in either superior sulcus tumors, T4N0-1 tumors with central extension multifocal tumors with nodule(s) in the same lobe, or stage III disease with mediastinal lymph node involvement.

Two recent phase 2 trials, exploring surgical resection preceded by induction chemoradiotherapy for tumors of the superior sulcus, have reported an impressive survival with acceptable mortality rate. They confirm the outcome observed in other prospective and retrospective series for T3-4N0-1. For subsets of T4 NSCLC with central extension or with satellite nodule(s) in the primary lobe, cumulative data suggest that these tumors behave differently than other stage IIIB tumors and might benefit from upfront surgery, possibly followed by postoperative chemotherapy and/or radiotherapy. Whenever clinical mediastinal lymph node invasion is present, surgery after induction treatment is not proven superior to radiotherapy, and is best restricted to clinical trials.

Combined modality treatment is the standard of care for locally advanced NSCLC and the optimal role for surgery remains a challenging issue for the clinicians.