The Latest in Surgical Management of Stage IIIA Non–Small Cell Lung Cancer: Video-Assisted Thoracic Surgery and Tumor Molecular Profiling

Abstract

Stage IIIA non–small cell lung cancer (NSCLC) remains a treatment challenge and requires a multidisciplinary care team to optimize survival outcomes. Thoracic surgeons play an important role in selecting operative candidates and assisting with pathologic mediastinal staging via cervical mediastinoscopy, endobronchial ultrasound, or esophageal ultrasound with fine needle aspiration. The majority of patients with stage IIIA disease will receive induction therapy followed by repeat staging before undergoing lobectomy or pneumonectomy; occasionally, a patient with an incidentally found, single-station microscopic IIIA tumor will undergo resection as the primary initial therapy. Multiple large clinical trials, including SWOG-8805, EORTC-8941, INT-0139, and ANITA, have shown 5-year overall survival rates of up to 30% to 40% using triple-modality treatments, and the best outcomes repeatedly are seen among patients who respond to induction treatment or who have tumors amenable to lobectomy instead of pneumonectomy. The need for a pneumonectomy is not a reason to deny patients an operation, because current operative mortality and morbidity rates are acceptably low at 5% and 30%, respectively. In select patients with stage IIIA disease, video-assisted thoracic surgery and open resections have been shown to have comparable rates of local recurrence and long-term survival. New developments in genetic profiling and personalized medicine are exciting areas of research, and early data suggest that molecular profiling of stage IIIA NSCLC tumors can accurately stratify patients by risk within this stage and predict survival outcomes. Future advances in treating stage IIIA disease will involve developing better systemic therapies and customizing treatment plans on the basis of an individual tumor's genetic profile.KEY POINTSThoracic surgeons should be involved early in the multidisciplinary management of stage IIIA disease in patients to identify operative candidates and help guide pathologic staging of the mediastinum.A triple-modality treatment approach in patients with N2 mediastinal disease can achieve 5-year overall survival rates of up to 30% to 40%; good prognostic indicators are a response to induction treatment and the need for lobectomy instead of pneumonectomy.Pneumonectomy outcomes have improved over time, and the need for a pneumonectomy is not a reason to avoid a surgical resection in patients who can tolerate the procedure.Video-assisted thoracic surgery survival outcomes are comparable to those after open thoracotomy, though no randomized trials have directly compared the two approaches in stage IIIA disease.In the era of personalized medicine, genetic profiling of stage IIIA tumors for prognostic risk stratification is a promising area of new research that could help guide treatment decisions and better predict patient-specific outcomes within this heterogeneous stage.