The role of surgery in stage III non-small-cell lung cancer

This case illustrates several quandaries clinicians face in the care of patients with stage III NSCLC. As mentioned earlier, they include the role of surgery, the appropriate induction regimen when surgery becomes part of treatment and the optimal approach to evaluating the mediastinum, to mention a few. The role of surgery in stage III continues to be a debatable issue. Our own approach is to consider surgery for patients with single-station N2 following induction therapy, provided they have adequate pulmonary reserves and are not "obvious candidates" for pneumonectomy. Following induction therapy (chemotherapy or chemoradiation), patients are evaluated by CT and FDG-PET scan before surgery in order to identify those with distant progression. The optimal induction therapy is another matter of continued debate. The Radiation Therapy Oncology Group (RTOG) attempted to study the question of the optimal induction therapy (chemotherapy or chemoradiation) in patients with stage III NSCLC prior to surgery. However, this study had to be closed prematurely because of poor accrual. One of the ongoing quandaries is how to reassess the mediastinum following concurrent chemoradiation and how to use that information to make decisions regarding the addition of surgery. Repeat mediastinoscopy is fraught with dangers, particularly after induction therapy. Simmering inflammation following induction chemoradiation limits the utility of FDG-PET scan as a useful tool. A prospective phase II trial conducted by the CALGB demonstrated that it is feasible to use video-assisted thoracoscopic evaluation (VATS) to restage the mediastinum, with a sensitivity of 75%, specificity of 100%, and negative predictive value of 76%.[10] It is likely that diligent use of endoscopic ultrasound or endobronchial ultrasound may be useful in this setting as well. Hopefully, the next generation of trial in this area will clarify the role of surgery and optimal induction therapy.