{"entity":{"id":"resectable-nsclc","kind":"cancer","name":"Resectable stage I to III non-small-cell lung cancer","aka":["Early-stage non-small-cell lung cancer","Operable lung cancer","Stage I, II and IIIA NSCLC","Perioperative NSCLC"],"tldr":"Lung cancer caught before it has spread is treated with surgery, now often keyhole or robotic and sometimes removing only part of a lobe. Immunotherapy given before and after the operation, or a targeted pill afterwards for EGFR or ALK tumours, cuts the chance of the cancer coming back by between a third and four fifths.","summary":"Surgery has cured lung cancer since Evarts Graham's pneumonectomy in 1933, and lobectomy with mediastinal node dissection became the standard after the 1995 Lung Cancer Study Group trial found more recurrences with lesser resections. Staging rests on PET-CT and, for central or node-suspicious tumours, endobronchial ultrasound sampling of the mediastinum; brain MRI is added from stage II. Two trials in 2022 and 2023, JCOG0802 and CALGB 140503, showed that segmentectomy or wedge resection is as good as lobectomy for peripheral tumours of 2 cm or less, the tumours that screening finds, and most resections are now by video-assisted or robotic thoracoscopy. Stereotactic radiotherapy cures most stage I tumours in patients who cannot have surgery (CHISEL, JCOG0403). Adjuvant cisplatin doublet chemotherapy, established by the LACE meta-analysis in 2008, adds about 5 percent to five-year survival in stage II and III.\n\nThe decade since 2020 has added systemic therapy on both sides of the operation. ADAURA (2020) showed that three years of adjuvant osimertinib in EGFR-mutated stage IB to IIIA cut recurrence by 83 percent and improved five-year survival from 78 to 88 percent, and ALINA (2024) did the same for two years of alectinib in ALK-positive disease (hazard ratio 0.24). For the majority without a driver, IMpower010 (2021) showed adjuvant atezolizumab improved disease-free survival in PD-L1-positive stage II to IIIA (hazard ratio 0.66), CheckMate 816 (2022) showed that three cycles of nivolumab with chemotherapy before surgery raised pathological complete response from 2 to 24 percent and improved event-free and, later, overall survival, and the perioperative trials that give immunotherapy before and after surgery, KEYNOTE-671 (pembrolizumab, event-free survival hazard ratio 0.58, overall survival hazard ratio 0.72), AEGEAN (durvalumab, hazard ratio 0.68) and CheckMate 77T (nivolumab, hazard ratio 0.58), all followed, with approvals between 2022 and 2024.\n\nThe open questions are practical: whether the adjuvant phase adds anything for patients who already had a complete pathological response, whether circulating tumour DNA after surgery can pick out who needs more treatment and who needs none, how to avoid immunotherapy toxicity that prevents an operation, and how to stage patients accurately enough to give the right group neoadjuvant treatment. Driver testing before any neoadjuvant immunotherapy is now essential because EGFR- and ALK-positive tumours gain little and should go to targeted adjuvant therapy instead.","asOf":"2026-09-17","wikipedia":"https://en.wikipedia.org/wiki/Lung_cancer_surgery","links":[{"label":"Wikipedia","url":"https://en.wikipedia.org/wiki/Lung_cancer_surgery"},{"label":"NCCN Guidelines: Non-Small Cell Lung Cancer","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1450"}],"tags":["subtype-page","lung"],"related":[],"cancers":[],"sections":[],"technologies":["robotic-surgery","sbrt","checkpoint-inhibitor","kinase-inhibitors","pet-ct","mri","low-dose-ct-screening","robotic-bronchoscopy","mrd-testing","cytotoxic-chemotherapy","platinum"],"targets":["pd1","pdl1","egfr","alk"],"drugs":["nivolumab","pembrolizumab","durvalumab","atezolizumab","osimertinib","alectinib","cisplatin","carboplatin","pemetrexed","paclitaxel","vinorelbine"],"companies":["bms","merck","astrazeneca","roche-genentech"],"institutions":["alliance-oncology","jcog","iaslc"],"pathways":["pd1-checkpoint"],"terms":["lobectomy","segmentectomy","pneumonectomy","minimally-invasive-surgery","neoadjuvant-adjuvant","pcr","major-pathological-response","efs","tnm-staging","cancer-stage","bronchoscopy","ctdna"],"trials":["checkmate-816","keynote-671","nct03800134","nct04025879","nct02486718","adaura","alina","calgb-140503","chisel","jcog0403","nlst-nelson","alchemist"],"people":["patrick-forde","jonathan-spicer","tina-cascone","heather-wakelee","john-heymach","enriqueta-felip","roy-herbst","wu-yi-long"],"bottlenecks":[],"keyPapers":["paper-checkmate-816-nejm-2022","paper-adaura-nejm-2020","paper-nlst-nejm-2011"],"journals":[],"dependsOn":[],"notes":[],"group":"lung","burden":"About a quarter to a third of non-small-cell lung cancers are found while still resectable, a share rising with low-dose CT screening; five-year survival ranges from over 80 percent for screen-detected stage IA tumours to about 40 percent for stage IIIA.","subtypes":["Stage IA peripheral adenocarcinoma 2 cm or less (sublobar resection or lobectomy)","Stage IB to IIIA adenocarcinoma or squamous cell carcinoma without a driver (perioperative or neoadjuvant chemoimmunotherapy)","Resected EGFR-mutated adenocarcinoma (adjuvant osimertinib)","Resected ALK-positive adenocarcinoma (adjuvant alectinib)","Medically inoperable stage I (stereotactic radiotherapy)","Superior sulcus (Pancoast) tumour (chemoradiation then surgery)"],"biomarkers":["TNM stage by PET-CT, brain MRI (stage II and above) and mediastinal sampling by endobronchial ultrasound or mediastinoscopy","EGFR and ALK status before any systemic treatment (targeted adjuvant therapy; neoadjuvant immunotherapy avoided)","PD-L1 tumour proportion score (adjuvant atezolizumab and pembrolizumab eligibility)","Pathological complete and major pathological response after neoadjuvant therapy","Circulating tumour DNA after surgery (molecular residual disease; under study)","Pulmonary function and cardiac fitness for surgery"],"standardOfCare":[{"setting":"Stage IA, peripheral, 2 cm or less","approach":"Segmentectomy or lobectomy by video-assisted or robotic thoracoscopy with node dissection (CALGB 140503, JCOG0802); no systemic therapy; stereotactic radiotherapy if not fit for surgery.","refs":["calgb-140503","lobectomy","segmentectomy","robotic-surgery","minimally-invasive-surgery","sbrt","chisel","jcog0403"],"guideline":{"version":"NCCN Guidelines: Non-Small Cell Lung Cancer","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1450"}},{"setting":"Stage IB to IIIA without EGFR or ALK alteration","approach":"Neoadjuvant nivolumab plus platinum chemotherapy for three cycles (CheckMate 816) or perioperative pembrolizumab (KEYNOTE-671), durvalumab (AEGEAN) or nivolumab (CheckMate 77T) with chemotherapy before and immunotherapy for a year after surgery; or surgery first then adjuvant cisplatin doublet and atezolizumab or pembrolizumab if PD-L1-positive (IMpower010).","refs":["checkmate-816","nivolumab","keynote-671","pembrolizumab","nct03800134","durvalumab","nct04025879","nct02486718","atezolizumab","cisplatin","carboplatin","pemetrexed","neoadjuvant-adjuvant","pcr","major-pathological-response"],"guideline":{"version":"NCCN Guidelines: Non-Small Cell Lung Cancer","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1450"}},{"setting":"Resected EGFR-mutated stage IB to IIIA","approach":"Adjuvant platinum chemotherapy where indicated, then three years of osimertinib (ADAURA).","refs":["adaura","osimertinib","egfr-exon19-l858r"],"guideline":{"version":"NCCN Guidelines: Non-Small Cell Lung Cancer","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1450"}},{"setting":"Resected ALK-positive stage IB to IIIA","approach":"Two years of adjuvant alectinib in place of chemotherapy (ALINA).","refs":["alina","alectinib"],"guideline":{"version":"NCCN Guidelines: Non-Small Cell Lung Cancer","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1450"}},{"setting":"Staging and surveillance","approach":"PET-CT and mediastinal sampling before surgery; CT every six months for two years then yearly; circulating tumour DNA surveillance in trials.","refs":["pet-ct","bronchoscopy","ct","mrd-testing","ctdna","tnm-staging"],"guideline":{"version":"NCCN Guidelines: Non-Small Cell Lung Cancer","url":"https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1450"}}],"stateOfArt":["Perioperative chemoimmunotherapy (CheckMate 816, KEYNOTE-671, AEGEAN, CheckMate 77T) cuts recurrence by about 40 percent and improves survival in driver-negative disease.","Targeted adjuvant therapy for EGFR (ADAURA) and ALK (ALINA) tumours with hazard ratios of 0.17 and 0.24 for recurrence.","Sublobar resection is an accepted standard for small peripheral tumours.","Low-dose CT screening is shifting diagnoses toward stage I."],"history":[{"year":1933,"title":"Evarts Graham performs the first successful pneumonectomy for lung cancer","refs":["pneumonectomy"]},{"year":1995,"title":"Lung Cancer Study Group: lobectomy beats limited resection, setting the standard for 30 years","refs":["lobectomy"]},{"year":2008,"title":"LACE meta-analysis: adjuvant cisplatin chemotherapy adds about 5 percent to five-year survival","refs":["cisplatin","vinorelbine"]},{"year":2011,"title":"NLST: low-dose CT screening cuts lung cancer mortality by 20 percent, finding more early-stage tumours","refs":["nlst-nelson","low-dose-ct-screening","paper-nlst-nejm-2011"]},{"year":2020,"title":"ADAURA: adjuvant osimertinib for EGFR-mutated disease","refs":["adaura","osimertinib","roy-herbst","wu-yi-long"]},{"year":2021,"title":"IMpower010: adjuvant atezolizumab improves disease-free survival in PD-L1-positive stage II to IIIA","refs":["nct02486718","atezolizumab","enriqueta-felip","heather-wakelee"]},{"year":2022,"title":"CheckMate 816: neoadjuvant nivolumab plus chemotherapy raises pathological complete response from 2 to 24 percent","refs":["checkmate-816","nivolumab","patrick-forde","jonathan-spicer","paper-checkmate-816-nejm-2022"]},{"year":2023,"title":"KEYNOTE-671 and AEGEAN: perioperative pembrolizumab and durvalumab; CALGB 140503: sublobar resection non-inferior","refs":["keynote-671","nct03800134","calgb-140503","heather-wakelee","john-heymach"]},{"year":2024,"title":"ALINA: adjuvant alectinib for ALK-positive disease; CheckMate 77T perioperative nivolumab approved","refs":["alina","alectinib","nct04025879","tina-cascone"]}],"pipeline":["mrd-testing","ctdna","nct04025879","idea-tr2-ctdna-mrd-qualification","idea-tr2-neoadjuvant-combo-platform","idea-bio2-neoadjuvant-biomarker-engine","low-dose-ct-screening","robotic-bronchoscopy"],"openProblems":["Whether adjuvant immunotherapy adds anything after neoadjuvant treatment and surgery, especially for complete pathological responders, has not been tested directly.","Circulating tumour DNA after surgery identifies high-risk patients but no trial yet shows that acting on it improves survival.","About a fifth of patients given neoadjuvant therapy never reach surgery, from progression, toxicity or decline.","Screening uptake is low in most countries, so most lung cancers are still found late."],"parent":"nsclc"},"route":"/cancers/resectable-nsclc/","neighbours":{"technology":[{"id":"ct","kind":"technology","name":"CT (computed tomography)","route":"/technologies/ct/"},{"id":"cytotoxic-chemotherapy","kind":"technology","name":"Cytotoxic chemotherapy","route":"/technologies/cytotoxic-chemotherapy/"},{"id":"checkpoint-inhibitor","kind":"technology","name":"Immune checkpoint inhibitors","route":"/technologies/checkpoint-inhibitor/"},{"id":"low-dose-ct-screening","kind":"technology","name":"Low-dose CT lung screening","route":"/technologies/low-dose-ct-screening/"},{"id":"mrd-testing","kind":"technology","name":"MRD / molecular residual disease testing","route":"/technologies/mrd-testing/"},{"id":"mri","kind":"technology","name":"MRI","route":"/technologies/mri/"},{"id":"pet-ct","kind":"technology","name":"PET/CT","route":"/technologies/pet-ct/"},{"id":"platinum","kind":"technology","name":"Platinum agents","route":"/technologies/platinum/"},{"id":"robotic-surgery","kind":"technology","name":"Robotic & minimally invasive surgery","route":"/technologies/robotic-surgery/"},{"id":"robotic-bronchoscopy","kind":"technology","name":"Robotic and navigational bronchoscopy","route":"/technologies/robotic-bronchoscopy/"},{"id":"sbrt","kind":"technology","name":"SBRT / SABR (stereotactic radiotherapy)","route":"/technologies/sbrt/"},{"id":"kinase-inhibitors","kind":"technology","name":"Small-molecule kinase inhibitors","route":"/technologies/kinase-inhibitors/"}],"target":[{"id":"alk","kind":"target","name":"ALK","route":"/targets/alk/"},{"id":"egfr","kind":"target","name":"EGFR","route":"/targets/egfr/"},{"id":"pd1","kind":"target","name":"PD-1","route":"/targets/pd1/"},{"id":"pdl1","kind":"target","name":"PD-L1","route":"/targets/pdl1/"}],"drug":[{"id":"alectinib","kind":"drug","name":"Alectinib","route":"/drugs/alectinib/"},{"id":"atezolizumab","kind":"drug","name":"Atezolizumab","route":"/drugs/atezolizumab/"},{"id":"carboplatin","kind":"drug","name":"Carboplatin","route":"/drugs/carboplatin/"},{"id":"cisplatin","kind":"drug","name":"Cisplatin","route":"/drugs/cisplatin/"},{"id":"durvalumab","kind":"drug","name":"Durvalumab","route":"/drugs/durvalumab/"},{"id":"nivolumab","kind":"drug","name":"Nivolumab","route":"/drugs/nivolumab/"},{"id":"osimertinib","kind":"drug","name":"Osimertinib","route":"/drugs/osimertinib/"},{"id":"paclitaxel","kind":"drug","name":"Paclitaxel / nab-paclitaxel","route":"/drugs/paclitaxel/"},{"id":"pembrolizumab","kind":"drug","name":"Pembrolizumab","route":"/drugs/pembrolizumab/"},{"id":"pemetrexed","kind":"drug","name":"Pemetrexed","route":"/drugs/pemetrexed/"},{"id":"vinorelbine","kind":"drug","name":"Vinorelbine","route":"/drugs/vinorelbine/"}],"company":[{"id":"astrazeneca","kind":"company","name":"AstraZeneca","route":"/companies/astrazeneca/"},{"id":"bms","kind":"company","name":"Bristol Myers Squibb","route":"/companies/bms/"},{"id":"merck","kind":"company","name":"Merck & Co. (MSD)","route":"/companies/merck/"},{"id":"roche-genentech","kind":"company","name":"Roche / Genentech","route":"/companies/roche-genentech/"}],"institution":[{"id":"alliance-oncology","kind":"institution","name":"Alliance for Clinical Trials in Oncology","route":"/institutions/alliance-oncology/"},{"id":"iaslc","kind":"institution","name":"International Association for the Study of Lung Cancer","route":"/institutions/iaslc/"},{"id":"jcog","kind":"institution","name":"Japan Clinical Oncology Group (JCOG)","route":"/institutions/jcog/"}],"pathway":[{"id":"pd1-checkpoint","kind":"pathway","name":"PD-1 / PD-L1 immune checkpoint & T-cell activation","route":"/pathways/pd1-checkpoint/"}],"term":[{"id":"bronchoscopy","kind":"term","name":"Bronchoscopy (EBUS, robotic navigation)","route":"/terms/bronchoscopy/"},{"id":"ctdna","kind":"term","name":"Circulating tumour DNA (ctDNA)","route":"/terms/ctdna/"},{"id":"egfr-exon19-l858r","kind":"term","name":"EGFR exon 19 deletion & L858R","route":"/terms/egfr-exon19-l858r/"},{"id":"efs","kind":"term","name":"Event-free / disease-free survival (EFS, DFS, iDFS, RFS)","route":"/terms/efs/"},{"id":"lobectomy","kind":"term","name":"Lobectomy","route":"/terms/lobectomy/"},{"id":"major-pathological-response","kind":"term","name":"Major pathological response (MPR)","route":"/terms/major-pathological-response/"},{"id":"minimally-invasive-surgery","kind":"term","name":"Minimally invasive surgery (laparoscopic, robotic, VATS)","route":"/terms/minimally-invasive-surgery/"},{"id":"neoadjuvant-adjuvant","kind":"term","name":"Neoadjuvant / adjuvant / perioperative","route":"/terms/neoadjuvant-adjuvant/"},{"id":"pcr","kind":"term","name":"Pathologic complete response (pCR)","route":"/terms/pcr/"},{"id":"pneumonectomy","kind":"term","name":"Pneumonectomy","route":"/terms/pneumonectomy/"},{"id":"segmentectomy","kind":"term","name":"Segmentectomy (sublobar resection)","route":"/terms/segmentectomy/"},{"id":"cancer-stage","kind":"term","name":"Stage","route":"/terms/cancer-stage/"},{"id":"tnm-staging","kind":"term","name":"TNM staging","route":"/terms/tnm-staging/"}],"trial":[{"id":"nct04025879","kind":"trial","name":"A Study of Neoadjuvant Chemotherapy Plus Nivolumab Versus Neoadjuvant Chemotherapy Plus Placebo, Followed by Surgical Removal and Adjuvant Treatment With Nivolumab or Placebo for Participants With Surgically Removable Early Stage Non-small Cell Lung Cancer","route":"/trials/nct04025879/"},{"id":"nct03800134","kind":"trial","name":"A Study of Neoadjuvant/Adjuvant Durvalumab for the Treatment of Patients With Resectable Non-small Cell Lung Cancer","route":"/trials/nct03800134/"},{"id":"adaura","kind":"trial","name":"ADAURA","route":"/trials/adaura/"},{"id":"alchemist","kind":"trial","name":"ALCHEMIST (Adjuvant Lung Cancer Enrichment Marker Identification and Sequencing Trials)","route":"/trials/alchemist/"},{"id":"alina","kind":"trial","name":"ALINA","route":"/trials/alina/"},{"id":"calgb-140503","kind":"trial","name":"CALGB 140503 (Alliance)","route":"/trials/calgb-140503/"},{"id":"checkmate-816","kind":"trial","name":"CheckMate 816","route":"/trials/checkmate-816/"},{"id":"chisel","kind":"trial","name":"CHISEL (TROG 09.02)","route":"/trials/chisel/"},{"id":"jcog0403","kind":"trial","name":"JCOG0403","route":"/trials/jcog0403/"},{"id":"keynote-671","kind":"trial","name":"KEYNOTE-671","route":"/trials/keynote-671/"},{"id":"nlst-nelson","kind":"trial","name":"NLST & NELSON (low-dose CT screening)","route":"/trials/nlst-nelson/"},{"id":"nct02486718","kind":"trial","name":"Study to Assess Safety and Efficacy of Atezolizumab (MPDL3280A) Compared to Best Supportive Care Following Chemotherapy in Patients With Lung Cancer [","route":"/trials/nct02486718/"}],"person":[{"id":"enriqueta-felip","kind":"person","name":"Enriqueta Felip","route":"/people/enriqueta-felip/"},{"id":"heather-wakelee","kind":"person","name":"Heather A. Wakelee","route":"/people/heather-wakelee/"},{"id":"john-heymach","kind":"person","name":"John V. Heymach","route":"/people/john-heymach/"},{"id":"jonathan-spicer","kind":"person","name":"Jonathan Spicer","route":"/people/jonathan-spicer/"},{"id":"patrick-forde","kind":"person","name":"Patrick M. Forde","route":"/people/patrick-forde/"},{"id":"roy-herbst","kind":"person","name":"Roy S. Herbst","route":"/people/roy-herbst/"},{"id":"tina-cascone","kind":"person","name":"Tina Cascone","route":"/people/tina-cascone/"},{"id":"wu-yi-long","kind":"person","name":"Yi-Long Wu","route":"/people/wu-yi-long/"}],"paper":[{"id":"paper-adaura-nejm-2020","kind":"paper","name":"ADAURA: three years of osimertinib after surgery for EGFR-mutated lung cancer","route":"/key-papers/paper-adaura-nejm-2020/"},{"id":"paper-checkmate-816-nejm-2022","kind":"paper","name":"CheckMate 816: three cycles of nivolumab plus chemotherapy before lung cancer surgery","route":"/key-papers/paper-checkmate-816-nejm-2022/"},{"id":"paper-nlst-nejm-2011","kind":"paper","name":"NLST: yearly low-dose CT scans cut lung cancer deaths in heavy smokers","route":"/key-papers/paper-nlst-nejm-2011/"}],"idea":[{"id":"idea-tr2-ctdna-mrd-qualification","kind":"idea","name":"Formally qualify tumour-DNA blood tests as a surrogate endpoint for adjuvant trials","route":"/ideas/idea-tr2-ctdna-mrd-qualification/"},{"id":"idea-tr2-neoadjuvant-combo-platform","kind":"idea","name":"Pre-surgery platform trials that test combinations on pathological response in months","route":"/ideas/idea-tr2-neoadjuvant-combo-platform/"},{"id":"idea-bio2-neoadjuvant-biomarker-engine","kind":"idea","name":"Use pre-surgery immunotherapy windows as the field's biomarker engine","route":"/ideas/idea-bio2-neoadjuvant-biomarker-engine/"}],"cancer":[{"id":"nsclc","kind":"cancer","name":"Non-small-cell lung cancer","route":"/cancers/nsclc/"}]}}