The Role of Thoracic Surgery in the Therapeutic Management of Metastatic Non–Small Cell Lung Cancer

Abstract

Introduction The majority of non-small cell lung cancer (NSCLC) patients are diagnosed with advanced stage disease for whom the prognosis is poor and survival is typically measured in months. Standard therapeutic treatment regimens for patients with stage IV NSCLC typically include chemotherapy and palliative radiation. Despite newer regimens that may include molecularly targeted therapy and immunotherapy, the overall 5-year survival for stage IV disease remains low at 4–6%. Although therapeutic surgery is performed in a minority of cases, accumulating data suggest that thoracic surgery may play several beneficial roles for these patients. Methods In this narrative review, we summarize the literature on surgical intervention in the multimodality management of stage IV NSCLC; focusing on the potential evidence for and against therapeutic/curative intent procedures to impact outcomes for patients with oligometastatic disease and pleural metastasis. Results In selected patients, surgical resection can result in a 5-year survival of 30–50%, but this is heavily influenced by the presence of mediastinal nodal disease, which should be evaluated before therapeutic surgical procedures are undertaken. Additionally, diagnostic or palliative surgical procedures can play an important role in the personalized management of stage IV disease. These data suggest that for carefully selected patients with advanced stage NSCLC, surgical intervention can be an important component of combined modality treatment. Conclusions Given advances in molecular targeted therapy and immunotherapy, further studies should focus on the possible use of surgery as a strategy of therapeutic “consolidation” for appropriately selected patients with stage IV NSCLC receiving combined modality care.

Multidisciplinary Tumor Board Recommendations for Oligometastatic Malignancies: A Prospective Single-Center Analysis

“…This is in line with the existing literature. Data on oligometastases of lung cancer have frequently been reported [21,22,23]. Oligometastatic prostate cancer and oligometastatic liver disease in colorectal cancer are also often discussed [5,24,25,26].…”

Surgical intervention may be a therapeutic option for NSCLC patients with AJCC stage IV: a large population-based study

“…Further studies should focus on the possible use of surgery as a strategy for therapeutic “consolidation” in appropriately selected patients with stage IV NSCLC receiving combined modality care. 11 , 12 Another study from Duke University Medical Center demonstrated that surgery for cT1–2, N0–1, M1 or cT3, N0, M1 NSCLC tumors is associated with a 5-year survival of 25% and does not appear to compromise outcomes when compared with non-operative therapy. 13 Consistent with these results, the present study showed that OS benefit was observed in NSCLC patients who received surgery therapy.…”

Surgical approaches in patients with oligometastatic non-small cell lung cancer

“…Although done in few patients, the surgical approach could be advantageous for oligometastatic patients. In a narrative review of the literature on surgical intervention in the multimodality management of stage IV NSCLC, surgical resection can result in an excellent 5-year survival heavily influenced by the presence of mediastinal nodal disease (13). Therefore, mediastinal lymph nodes status should be evaluated before therapeutic surgical procedures.…”

“…Therefore, mediastinal lymph nodes status should be evaluated before therapeutic surgical procedures. Additionally, diagnostic or palliative surgical procedures can play a significant role in the tailored treatment of stage IV as a strategy for consolidation (13).…”