Update: Surgical Resection for NSCLC Stage 3A - 1273900

Thu, 05/05/2016 - 06:43

Good morning Members,

For some of you that have followed my last post or not, here is the background info.

My mom was diagnosed Stage 3A NSCLC. Her tumor is 6cm (4.1xlocated in the central upper left lobe and beginning to invade left main pulmonary artery.

I was told that resection is possible following neoadjuvant therapy. I was given a choice of standard chemotherapy for three months OR 2 infusions of nivolumab as a trial for 4 weeks. I contemplated which first line therapy choice I would use for the last five days.

However, I received a call and now was told that upon further review of the case, the team wants to move forward straight to surgery and do adjuvant chemotherapy afterwards due to fear of disease progression leaving my mom unresectable. I was not informed of what kind of resection is planned just yet.

I'd like to know the risks/recovery expected with a resection of this size and location. Is it typically a lobectomy or a pneumonectomy?

How quickly must chemotherapy be initiated after a surgery?

Is there a strong chance of hidden disease spreading as a result of surgery without having systemic chemo first?

If members can weigh in with their thoughts and experiences, that would be great!

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It is not possible to know about lobectomy vs. pneumonectomy without the images. In general, tumors that abut the main pulmonary artery will often require pneumonectomy, although a sleeve lobectomy with reconstruction is sometimes possible.

It is fairly common that doctors will recommend adjuvant postoperative chemotherapy, often with adjuvant radiation, for Stage 3A tumors. This usually begins 4 - 6 weeks after surgery if the patient has recovered well.

If a tumor is truly resectable with clean margins, then it is often prudent to have surgery first, because preoperative chemotherapy does not always work. We never really know what we will find in the chest until the surgeon attempts the resection. For a case like you describe, there is a possibility that the surgeon may decide that resection is not feasible in the midst of surgery.

The questions about risk and recovery are best addressed with the surgical team.

The management of Stage 3A lung cancer is probably the most divisive and complicated subject in our field. If you put 5 doctors in a room, you'll usually get about 7 conflicting opinions. :wink: That being said, doing surgery upfront seems reasonable.


Thank you, Dr. Creelan.

I appreciate your expertise and feedback. Just to be clear, in general, surgery is the best scenario for a potentially "curative" approach?

Also, typically, do decisions to change plan of treatment happen as a result of a team decision?

Thank you so much.


Hi Greekgirl,

Sorry for the delay in response. Data show that surgery is superior to radiation, however and this is a big however, when studies were tried to test whether surgery or chemo/radiation was the best option the trials wouldn't fill up. People who could have surgery were reluctant to join a trial where they may not have surgery. So data wasn't able to be collected to see if one was better than the other. Another reason to question if surgery is really better than chemo/rads is that those who can't have surgery are often unable because of other health issues making lung surgery out of the question. So these people were already pretty sick so it's possible that these people who didn't have surgery but did have chemo/rads didn't do so well not because of the lack of best possible treatment but because of poor health in the first place.

Another thought about using radiation instead of surgery is radiation has gotten more accurate so that less healthy tissue is radiated leaving the more lung tissue and other structures in tact.

So no we don't really know and may won't ever know if one is better than another, unless we forced people into a trial (which we wouldn't).

As for the team decision, 2 or more heads are better than one. Treatment teams are making more and more decisions together and these doctors tend to believe it's a much better way to help patients. I don't have a quote on hand but Dr. West has stated the weekly team meetings are often the best parts of his week. Dr. Weiss in his "Insider's Guide to 2nd Opinion" post suggests 2 heads are better than one.

On a personal note, I really wanted my husband to have surgery but ended up having chemo/rads. It seems to have worked.

I hope your mom does very well.
All best,