Initial extended resection or neoadjuvant therapy for T4 non-small cell lung cancer—what is the evidence?

Ilkka Ilonen, David R. Jones


Locally advanced non-small cell lung cancer (NSCLC) tumors that invade surrounding structures within the chest (T4) are a heterogeneous group, and, as such, there are no straightforward guidelines for their management. Advances in imaging, invasive mediastinal staging, and neoadjuvant therapies have expanded the role of surgery with curative intent for this patient group and have also diminished the rate of explorative thoracotomies. Unlike for T4 superior sulcus tumors, the use of neoadjuvant therapy for central T4 tumors is not clearly defined. The most important determinants of a successful outcome after surgery are achieving an R0 resection and avoiding incidental pathologic N2 disease. Use of neoadjuvant therapy in this setting may yield better outcomes after surgery, as both of these variables can be altered if the tumor responds to neoadjuvant therapy. Moreover, response to induction therapy has been shown to have prognostic value.