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SURGICAL MANAGEMENT OF STAGE IIIA NON–SMALL CELL LUNG CANCER
The Latest in Surgical Management of Stage IIIA Non–Small
Cell Lung Cancer: Video-Assisted Thoracic Surgery and Tumor
Molecular Profiling
Gavitt A. Woodard, MD, and David M. Jablons, MD
OVERVIEW
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.
Stage IIIA non–small cell lung cancer (NSCLC) encompasses
a heterogeneous group of tumors with a wide range
of sizes, degrees of local invasion, and mediastinal lymph node
involvement. The variety of presentation within this stage poses
an ongoing challenge to thoracic oncologists to make evidencebased
treatment recommendations and accurately predict outcomes
in different subgroups of patients. The features that
defıne stage IIIA presentation suggest imminent systemic disease,
and 5-year overall survival outcomes remain poor at only
24% for stage IIIA tumors and 9% for stage IIIB tumors. 1 However,
certain patient populations, particularly those whose tumors
are downstaged by induction therapy and those who
undergo lobectomy, have decent outcomes with the appropriate
multimodality regimens. Thoracic surgeons play an important
role as part of an interdisciplinary care team in selecting operative
candidates with stage IIIA disease for whom defınitive local
control offers the best chance of long-term survival.
ROLE OF THORACIC SURGEON IN PROPER STAGING
AND PATIENT SELECTION
Accurate clinical staging in patients with newly diagnosed
NSCLC is important to optimize the benefıts from surgery
and to avoid attempting curative resections in the setting of
systemic disease. After a complete staging work-up that includes
a PET/CT and brain MRI, staging for patients with
locally advanced, stage IIIA, and select T4 disease should be
discussed by a multidisciplinary care team that includes a
thoracic surgeon. Initiating thoracic surgeon involvement at
the time of diagnosis is particularly important in stage IIIA
NSCLC, because surgeons play a critical role in determining
which patients are surgical candidates and in planning mediastinal
biopsies during initial staging and restaging.
Nearly half of all patients will have mediastinal disease at
the time of diagnosis; therefore, any mediastinal lymph
nodes suspicious for metastatic disease on PET/CT require
pathologic confırmation. Cervical mediastinoscopy remains
the gold-standard approach to pathologically stage the mediastinum,
but other methods—including endobronchial ultrasound
(EBUS) and esophageal ultrasound (EUS) with fıne
needle aspiration (FNA)—have the benefıt of being easily repeated
if restaging is necessary. This is an important consideration
in stage IIIA disease; many of these patients will
require pathologic mediastinal staging at the time of diagnosis
and again after induction treatment before a surgical re-
From the Department of Surgery, University of California, San Francisco, CA.
Disclosures of potential conflicts of interest are found at the end of this article.
Corresponding author: David M. Jablons, MD, 500 Parnassus Ave., MUW-424, San Francisco, CA 94143-0470; email: david.jablons@ucsfmedctr.org.
© 2015 by American Society of Clinical Oncology.
asco.org/edbook | 2015 ASCO EDUCATIONAL BOOK
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