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Published on: February 27, 2026
Long-term Outcomes of Surgery for Clinical T4 Non-Small Cell Lung Cancer: Implications for Surgical Decision Making
Ryu Kanzaki1, Jiro Okami2, Toshiteru Tokunaga3
1Department of General Thoracic Surgery, Osaka International Cancer Institute, Osaka, Japan.
Background:
Real-world evidence regarding surgery for clinical T4 (cT4) nonsmall cell lung cancer (NSCLC) is limited. We evaluated outcomes and prognostic factors of cT4 NSCLC using the 9th edition TNM classification.
Patients And Methods:
This multi-institutional retrospective study included patients who underwent pulmonary resection for cT4N0-2bM0 NSCLC between 2010 and 2019. Prognostic factors for relapse-free survival (RFS) and overall survival (OS) were analyzed in patients who achieved R0 resection. OS was compared across cT4 subgroups and cN categories.
Results:
Among 165 patients, 71 were classified as cT4 owing to invasion of neighboring organs. Clinical nodal status was cN0 in 97, cN1 in 40, cN2a in 21, and cN2b in 7. Preoperative therapy was administered in 44 patients. Postoperative complications occurred in 48%, with 90-day mortality of 2.4%. OS after R0 resection was significantly longer than after R1-2 resection. The 5-year RFS and OS of 149 R0-resected patients were 43 and 61%, respectively. The 5-year RFS rates were 47% for pN0-1, 28% for pN2a, and 17% for pN2b; corresponding OS rates were 63, 48, and 50%, respectively. Multivariable analysis identified pN status and preoperative therapy as independent predictors of RFS, and pN status was an independent predictor of OS. OS did not differ among cT4 subgroups (size alone, invasion alone, or both). Prognosis was similar between cT4cN0-1 and cT4cN2a, whereas cT4cN2b had significantly worse outcomes.
Conclusions:
Surgery for cT4 NSCLC can achieve favorable results when R0 resection is feasible. Tumors with dual T4 factors and selected cT4N2a disease may benefit from surgery-inclusive treatment.
