Surgery for advanced lung cancer(stage IV)

In those patients with advanced lung cancer (stage IV) who are seeking active treatment, the current standard of care is systemic anti-cancer treatment. This involves chemotherapy, targeted treatments (for those with EGFR or ALK positive tumors) or immunotherapy.

For a proportion of patients, targeted treatments and immunotherapies have achieved spectacular results by holding the disease at bay, or greatly reducing the number and sites of disease. When this occurs, the question on most patients minds is if further (local consolidative) treatment such as surgery, radiotherapy, ablation to all the residual sites of disease can improve survival?

A small study undertaken by Gomez reported that surgery, radiotherapy and/or ablation improved survival by 54% in this setting increasing to 85% in the presence of EGFR or ALK genetic abnormalities.[1] As the trial was relatively small, we need to know if this is a consistent finding with a greater degree of certainty.

In 2021, I led a UK wide multi-center trial called RAMON designed to answer this question but it was not possible to recruit to completion to be able to obtain an answer. In 2024 the results of a larger study NRG LU002 was presented suggesting no survival benefit (published results are awaited) so uncertainty exists (in the thoracic oncology community) whether to routinely recommend local consolidative therapy.

Currently American and European joint radiation guidelines[2], American surgical guidelines[3], and European medical oncology guidelines[4], uniformly recommend and support surgery as part of multi-modality management where appropriate in this setting.

If you would like to discuss your individual management, do not hesitate to contact me.

References

1. Gomez DR, Tang C, Zhang J, Jr GRB, Hernandez M, Lee JJ, Ye R, Palma DA, Louie AV, Camidge DR, et al. Local Consolidative Therapy Vs. Maintenance Therapy or Observation for Patients With Oligometastatic Non–Small-Cell Lung Cancer: Long-Term Results of a Multi-Institutional, Phase II, Randomized Study. Journal of Clinical Oncology. 2019;37:1558-1565. doi: 10.1200/jco.19.00201

2. Iyengar P, Wardak Z, Gerber DE, Tumati V, Ahn C, Hughes RS, Dowell JE, Cheedella N, Nedzi L, Westover KD, et al. Consolidative Radiotherapy for Limited Metastatic Non-Small-Cell Lung Cancer: A Phase 2 Randomized Clinical Trial. JAMA Oncol. 2018;4:e173501. doi: 10.1001/jamaoncol.2017.3501

3. Iyengar P, All S, Berry MF, Boike TP, Bradfield L, Dingemans A-MC, Feldman J, Gomez DR, Hesketh PJ, Jabbour SK, et al. Treatment of Oligometastatic Non-Small Cell Lung Cancer: An ASTRO/ESTRO Clinical Practice Guideline. Practical Radiation Oncology. 2023;13:393-412. doi: 10.1016/j.prro.2023.04.004

4. Antonoff MB, Mitchell KG, Kim SS, Salfity HV, Kotova S, Ripley RT, Neri AL, Sood P, Gandhi SG, Elamin YY, et al. The Society of Thoracic Surgeons (STS) Clinical Practice Guideline on Surgical Management of Oligometastatic Non-small Cell Lung Cancer. The Annals of Thoracic Surgery. 2025;119:495-508. doi: https://doi.org/10.1016/j.athoracsur.2024.11.010

5. Hendriks LEL, Cortiula F, Martins-Branco D, Mariamidze E, Popat S, Reck M, Committee EG. Updated treatment recommendations for systemic treatment: from the ESMO non-oncogene addicted-metastatic NSCLC Living Guideline(dagger). Ann Oncol. 2025. doi: 10.1016/j.annonc.2025.06.004