Dr Chudgar on Resection Eligibility in NSCLC

Neel P. Chudgar, MD, assistant professor, Cardiothoracic and Vascular Surgery, Albert Einstein College of Medicine; thoracic surgeon, associate director, Clinical and Translational Research, Thoracic Surgery, attending physician, Montefiore Medical Center, discusses patient considerations when determining eligibility forlung cancer resection and highlights how neoadjuvant immunotherapy may affect resectability in this patient population.

Determining the resection eligibility of patients with stage IIIB non–small cell lung cancer (NSCLC) presents a complex challenge due to the heterogeneous nature of this patient population, Chudgar begins. The classification of resectability encompasses a diverse range of patients, including those with positive mediastinal nodes (N2), further stratified into single-station N2 vs multi-station N2, as well as patients with bulky or invasive N2 disease, he reports. A lack of definitive data regarding resection candidacy complicates surgical decisions, he adds.

Patients with single-station N2 disease generally face less contention for resection if they meet standard criteria for surgical operability, Chudgar expands; however, challenges escalate in cases involving bulky, multi-station N2 disease. Recent neoadjuvant trials, such as those combining chemotherapy and immunotherapy like the phase 2 NADIM II trial (NCT03838159) in patients with resectable stage IIIA disease, demonstrate promising outcomes even in cohorts of patients with multi-station N2 disease, he explains. Notably, patients enrolled in these trials exhibit favorable 2-year overall survival rates, indicating the potential for surgical intervention in NSCNC cases that were previously deemed unresectable, Chudgar reports.

The integration of neoadjuvant immunotherapy further complicates resectability assessment, he continues. As response rates to neoadjuvant immune checkpoint inhibitors combined with chemotherapy show promise, the definition of resectability undergoes continual re-evaluation, Chudgar elucidates. Despite initial doubts regarding resectability based on radiological and oncological perspectives, a patient with bulky N2 disease demonstrated an exceptional response to chemotherapy/immuno-oncologic treatment, he says. Subsequent restaging revealed a favorable position for safe resection, resulting in complete pathological response.

Such instances highlight the NSCLC paradigm shift facilitated by immunotherapy, challenging traditional boundaries and extending surgical options to previously ineligible patients, Chudgar concludes.