How would you treat superior sulcus NSCLC with small volume N2 disease?

The question of surgery for N2 NSCLC patients in light of current survival and LC rates in the modern RT era with immunotherapy remains unclear. Historically, for these superior sulcus NSCLC patients, surgery played a large role due to our inability to deliver adequate dose of RT because of proximity to the spinal cord. I think if you are able to deliver 60 Gy adequately to the tumor with more modern techniques then the need for surgery may be less in my opinion. If coverage to 60 Gy is less than ideal then a 45 Gy pre-op dose may be used and the patient undergoes resection. The decision for resection should be made prior to initiating therapy to prevent any gaps in RT delivery should the patient be found unresectable afterwards. As a side ...

In our center, we deliver 60Gy in 30 using VMAT with concurrent chemotherapy. The surgeons tell us they have no issues operating after delivering 60Gy, so I don't plan for 45Gy. Majority of the patients receive maintenance immune therapy, surgery is done in highly selected patients.

I have had issues with the typical preoperative approach for many years. The problem here is that, even in the best surgical hands, we expect a 20-25% R1 resection rate after pre-operative radiotherapy with a non-curative dose of 45Gy. At MDACC, we addressed this with a trial of postoperative treatment. Obviously, this had a higher R1 resection rate. However, we could better target the known disease because of extensive clipping of the tumor bed and involving the surgeon in target volume delineation. Since then, we have also been able to safely give a larger preoperative dose because of improvements in IMRT/VMAT delivery. Also, as well stated by Dr. @Dr. First Last, modern treatments with immunotherapy make combined modality therapy much be...