OBJECTIVE: Stage M1a-IVA non-small cell lung cancer (NSCLC) has traditionally been regarded as an advanced disease primarily managed with systemic therapy, and the role of surgical intervention remains controversial. This study aimed to evaluate the safety of primary tumor resection in patients with stage M1a-IVA NSCLC and its association with survival outcomes, as well as to explore its potential implications for real-world clinical decision-making. METHODS: This retrospective cohort study included patients with stage M1a-IVA NSCLC treated at Peking University Cancer Hospital between February 2007 and April 2024. Both medically and surgically managed patients were drawn from the same treatment era. Clinicopathologic data were collected, and inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics. Survival differences were assessed using the Kaplan-Meier method, and independent prognostic factors were evaluated with Cox proportional hazards models. RESULTS: A total of 145 patients were included, with a mean age of 59.1 years. Adenocarcinoma accounted for 77.9% (113/145) of cases, and 31.7% (46/145) harbored classic EGFR mutations (19del/L858R) or ALK fusion. Fifty-six patients underwent primary tumor resection, including 12 who received systemic therapy before surgery. Surgical procedures consisted of lobectomy in 27 patients, sublobectomy in 25 patients, and pneumonectomy in 1 patient. The mean operative time was 104.49 minutes, with an average blood loss of 75.66 mL and a mean postoperative hospital stay of 5.25 days. Postoperative complications occurred in 12.5% (7/56) of patients, with no grade 3 or higher events observed. Subgroup analysis demonstrated no additional survival benefit associated with more extensive lung resection or systematic lymph node dissection. The 5-year overall survival rate was significantly higher in the primary tumor resection group than in the nonresection group (51.3% vs 32.6%, P = 0.003). Multivariable analysis identified several factors associated with worse overall survival. These included absence of classic EGFR mutations (19del/L858R) or ALK fusion, diagnosis before 2018, and no primary tumor resection. CONCLUSIONS: By comparing outcomes between patients managed with systemic therapy alone and those undergoing surgical intervention during treatment, this study suggests that primary tumor resection is feasible and may be associated with favorable survival outcomes in highly selected patients with stage M1a-IVA NSCLC.
Fang et al. (Sat,) studied this question.