Surgery after induction immuno-chemotherapy in stage III-N3 non-small cell lung cancer: a single-center retrospective cohort study

OBJECTIVES: To preliminarily evaluate the efficacy of surgery following induction immuno-chemotherapy (IO-CT) and nodal downstaging in patients with stage III-N3 non-small cell lung cancer (NSCLC). METHODS: A retrospective analysis was conducted on patients with stage III-N3 NSCLC who received induction IO-CT at Shanghai Pulmonary Hospital from August 2019 to May 2023. Patients who achieved confirmed N3 lymph node downstaging, had resectable tumors, and maintained adequate performance status subsequently underwent surgery after induction therapy. In this post-induction comparative analysis, baseline characteristics and oncological outcomes were compared between patients who underwent surgery and those who did not. RESULTS: After induction therapy, 28 (24.6%) patients underwent surgery, while 78 (73.6%) did not. The patients in the surgery group were younger (P = 0.012), had a higher body mass index (P = 0.032), and exhibited a higher proportion of contralateral mediastinal or hilar lymph node involvement (P = 0.024). Compared with those who did not undergo surgery, patients who underwent surgery showed better progression-free survival (PFS) (hazard ratio [HR] = 0.46, 95% confidence interval [CI] 0.23-0.92) and overall survival (OS) (HR = 0.31, 95% CI 0.11-0.88). However, in the biopsy subgroup, patients who underwent surgery had better OS (HR = 0.64, 95% CI 0.19-2.20) but similar PFS (HR = 0.97, 95% CI 0.42-2.23) compared with those who did not undergo surgery. CONCLUSIONS: These real-world findings provide early positive signals that surgery after induction IO-CT may be feasible in carefully selected patients with stage III-N3 NSCLC.