Abstract
With the development of systemic treatments with high response rates, including tyrosine kinase inhibitors and immune checkpoint inhibitors, some patients with unresectable lung cancer now have a chance to undergo radical resection after primary treatment. Although there is no general consensus regarding the definition of “unresectable” in lung cancer, the term “resectable” refers to technically resectable and indicates that resection can provide a favorable prognosis to some extent. Unresectable lung cancer is typically represented by stage III and IV disease. Stage III lung cancer is a heterogeneous disease, and in some patients with technically resectable non-small cell lung cancer (NSCLC), multimodality treatments, including induction chemoradiotherapy followed by surgery, are the treatments of choice. The representative surgical intervention for unresectable stage III/IV NSCLC is salvage surgery, which refers to surgical treatment for local residual/recurrent lesions after definitive non-surgical treatment. Surgical intervention is also used for an oligometastatic stage IV NSCLC. In this review, we highlight the role of surgical intervention in patients with unresectable NSCLC, for whom an initial complete resection is technically difficult. We further describe the history of and new findings on salvage surgery for unresectable NSCLC and surgery for oligometastatic NSCLC.
Highlights
Treatment of patients with lung cancer depends on the histology, tumor stage, molecular characteristics, and assessment of a patient’s overall medical condition
Molecular-targeted therapies such as tyrosine kinase inhibitors (TKIs) are selected if the epidermal growth factor receptor (EGFR) gene is mutated, while an immune checkpoint inhibitors (ICIs) and/or cytotoxic chemotherapy is selected if this gene is not mutated
We describe the role of surgical intervention in patients with non-small cell lung cancer (NSCLC) for whom complete resection is technically difficult (“unresectable” in the narrow sense)
Summary
Treatment of patients with lung cancer depends on the histology, tumor stage, molecular characteristics, and assessment of a patient’s overall medical condition. Patients with stage III NSCLC are generally treated with a multimodality approach, including surgery, chemotherapy, and radiation therapy (RT). Surgical treatment is selected for tumors that can be completely resected, whereas RT or drug therapy is offered for patients whose tumors cannot be completely resected or who cannot tolerate surgery. Unresectable factors in stage III lung cancer are direct invasion to unresectable organs (T4) or mediastinal/extrathoracic lymph node metastasis (N2/N3). In patients with unresectable stage III lung cancer, the current standard treatment is concurrent chemoradiotherapy (CRT) [4,5], which provides a median overall survival (OS) of 22–25 months and a 5-year OS of 20% [6]. We describe the role of surgical intervention in patients with NSCLCs for whom complete resection is technically difficult (“unresectable” in the narrow sense)
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