Multimodality Treatment of Stage IIIA/N2 Non-Small Cell Lung Cancer: When YES to Surgery

Stage III non-small cell lung cancer (NSCLC) is comprised of a heterogeneous cohort of patient presentations that are broadly considered as “locally advanced disease,” but stage IIIA/N2 further selects a subset of this category with a potentially improved prognosis. These individuals may have ipsilateral mediastinal and/or subcarinal lymph node involvement, varying tumor size (up to 7 cm), and possible invasion of surrounding mediastinal structures. Multimodality treatment is universally accepted as the standard-of-care for their management, and historically, definitive concurrent chemoradiotherapy (CRT) has been the preferred paradigm. However, because it has been long recognized that long-term survival is feasible in a small but non-trivial and growing group of these patients, there has been considerable controversy about intensifying their local therapy by using surgical resection. In fact, there are some data that support improved locoregional control and hence progression-free and even overall survival with trimodality therapy potentially warranting the increase in morbidity. This chapter will focus on reviewing the published evidence supporting the incorporation of surgery into the multimodality treatment of stage IIIA/N2 NSCLC patients.