Should surgery be part of the multimodality treatment for stage IIIB non-small cell lung cancer?

Traditionally, treatment for stage IIIB (T4N2M0 and T1-4N3M0) NSCLC consists in definitive chemoradiation. Surgery is used only anecdotally. Here, we studied outcome for patients treated with multimodality including surgery.

Patients who underwent surgery for stage IIIB between 2000 and 2015 were retrospectively reviewed and data analyzed. Patients were selected for surgery if they would tolerate multimodality treatment, the tumor was deemed upfront resectable, and N2-N3 involvement was limited to a non-bulky single site. Survival was calculated from the date of surgery until last follow-up. Univariate and multivariate analysis were performed to identify prognostic factors.

During the study period, 5416 patients underwent resection for NSCLC in our center. Sixty patients (1%) had clinical stage IIIB. Thirty-two patients had T4N2 NSCLC involving the carina and/or superior vena cava (n = 25, 78%), left atrium (n = 5, 16%), or other (n = 2, 6%). Half of the 28 patients with N3-disease had supraclavicular node involvement. Pneumonectomy was performed in 27 patients (45%). Twenty-nine patients (48%) had induction therapy, with chemotherapy alone. Adjuvant therapy was administered to 52 patients (87%), mostly chemoradiation. Complete resection rate was 92%. Post-operative mortality was 3%. Three- and 5-year overall survivals were 51% and 39%, respectively. Multivariate analysis identified incomplete resection (P = 0.008) and absence of adjuvant treatment (P = 0.032) as poor survival prognostic factors.

Surgery can be considered as a component of multimodality therapy in highly selected patients with stage IIIB NSCLC based on encouraging 5-year survival of 39%.