To Resect or Not to Resect in Stage III NSCLC

SINGAPORE — When is stage III non–small cell lung cancer (NSCLC) resectable?

The introduction of “novel therapeutics into the neoadjuvant space and now the perioperative space has really transformed the care for patients with stage III disease and has even transformed our understanding of what’s resectable, said Sandip P. Patel, MD, of UC San Diego Health, California.

However, stage III NSCLC remains a highly heterogeneous disease, and there is currently no expert consensus on the definition of resectable stage III NSCLC.

“Although guidelines can help distinguish between resectable and unresectable, stage III NSCLC, resectability is not uniformly defined,” said Ilias Houda, MD, PhD candidate, of Amsterdam University Medical Center, the Netherlands.

Experts at the IASLC 2023 World Conference on Lung Cancer (WCLC) attempted to clarify and reach a consensus on this question of resectability.

Houda presented survey findings from a Delphi consensus project led by the EORTC Lung Cancer Group. The survey aimed to establish agreement among experts on the definition of resectable stage III NSCLC for clinical trial use.

Houda and colleagues assessed the current level of consensus among physicians working in the field using a 13-item online survey. Survey participants rated the resectability of tumors in 37 different T- and N-stage scenarios.

At least 75% of participants had to agree on a given clinical scenario to reach a consensus.

Responses from 558 thoracic surgeons, radiation oncologists, and other professionals reached agreement on T3 (size), N1 staging as resectable and another eight clinical scenarios, typically with N0-N2 single-station tumors, as potentially resectable.

The participants also reached a consensus on 17 T-N combinations as unresectable, which is typically N2 bulky and invasive disease regardless of the T stage.

However, for another 11 clinical scenarios, respondents did not reach a consensus. This included N2 single-station lung cancer with all levels of T4 disease, and N2 multi-station, T1-3 tumors.

Mariana Brandão, MD, PhD, from Institut Jules Bordet, Brussels, then highlighted findings from a systematic literature review and from various clinical scenarios, which explored the core question of resectability in stage III NSCLC.

In stage IIIA disease, for instance, clinical T3N1 tumors and single-station N2, nonbulky and noninvasive, tumors were considered resectable.

However, the consensus broke down when assessing multiple-station N2 tumors. Findings from the systematic review suggested that these tumors were frequently unresectable; the clinical case review deemed them all unresectable, though as many as 40% of survey respondents found them potentially resectable depending on the T stage.

For these tumors, a “case-by-case discussion” is important. Carefully selected patients with nonbulky noninvasive N2 multi-station tumors could be considered for resection, Brandão explained.

Experts also did not reach a consensus on resectability of bulky N2 disease. The systematic literature review suggested that most cases were unresectable, but the clinical case discussion indicated that 14% of N2 tumors may be resectable.

“The bottom line is tumor boards are more important than ever,” Patel said. “The ability to have the discussions not only with the pulmonologist but the thoracic surgeons, the radiologists, the radiation oncologist, and medical oncologist remains key.”

Houda’s and Brandão’s study were sponsored by the European Organisation for Research and Treatment of Cancer. The INCREASE trial was funded by Bristol-Myers Squibb. No relevant financial relationships declared.

IASLC 2023 World Conference on Lung Cancer: Session OA06. Presented September 10, 2023.

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