Surgery after Chemoradiotherapy in Patients with Stage III (n2 or N3, Excluding T4) Non-Small-Cell Lung Cancer: A Systematic Review

Background: Chemoradiation with curative intent is considered the standard of care in patients with locally advanced, stage III non-small-cell lung cancer (NSCLC). However, some patients with stage III (N2 or N3, excluding T4) NSCLC might be eligible for surgery. The objective of the present systematic review was to investigate the efficacy of surgery after chemoradiotherapy compared with chemoradiotherapy alone in patients with potentially resectable locally advanced NSCLC. Methods: A search of the MEDLINE, EMBASE, and PubMed databases sought randomized controlled trials (RCTS) comparing surgery after chemoradiotherapy with chemoradiotherapy alone in patients with stage III (N2 or N3, excluding T4) NSCLC. Results: Three included RCTS consistently found no statistically significant difference in overall survival between patients with locally advanced NSCLC who received surgery and chemoradiotherapy or chemoradiotherapy alone. Only one rct found that progression-free survival was significantly longer in patients treated with chemoradiation and surgery (hazard ratio: 0.77; 95% confidence interval: 0.62 to 0.96). In a post hoc analysis of the same trial, the overall survival rate was higher in the surgical group than in matched patients in a chemoradiation-only group if a lobectomy was performed (p = 0.002), but not if a pneumonectomy was performed. Furthermore, fewer treatment-related deaths occurred in patients who underwent lobectomy than in those who underwent pneumonectomy. Conclusions: For patients with locally advanced NSCLC, the benefits of surgery after chemoradiation are uncertain. Surgery after chemoradiation for patients who do not require a pneumonectomy might be an option.