Generalized or personalized treatment for stage IIIA-N2 non-small-cell lung cancer?

The optimal approach to and the role of surgery in stage IIIA-N2 (ipsilateral lymph node metastases) non-small-cell lung cancer (NSCLC) remains a challenge for many clinical oncologists. Much of the question relates to the choice between a generalized or personalized approach. We should realize that a generalized approach--'chemoradiotherapy fits all'--as advocated by some based on Phase III trials--is not optimal for these patients, just as 'any platinum doublet fits all' is no longer the best choice in stage IV NSCLC. While chemoradiotherapy may be the choice for patients with bulky or multilevel N2-disease, for others surgery will be an important part of the multimodality treatment. To make this distinction, 'personalization factors' should be considered: complete resectability, downstaging of mediastinal nodes and favorable clinical and pathological response of the primary tumor. A personalized approach making the appropriate choice based on multidisciplinary assessment of stage, resectability and cardiopulmonary fitness is in the interest of each of our individual stage IIIA-N2 patients.