Stage 3 lung cancer (also written stage III) is cancer that has grown beyond the lung but has not spread to distant organs. The first decision is whether surgery is possible. For most patients today the answer is yes — through chemotherapy combined with immunotherapy before surgery. For those who cannot have surgery, chemoradiotherapy followed by immunotherapy is the alternative. Both pathways are delivered privately at London Bridge Hospital and The Lister Hospital Chelsea.
Last reviewed: May 2026 · Dr Lawrence Okiror FRCS(CTh) FRCSEd(CTh) · GMC 6150382
Why This Page Exists
The most important question in stage 3 lung cancer is not which drug regimen you will receive. It is whether surgery is on your treatment plan.
For most patients diagnosed today, the answer is yes — including many whose disease would have been called inoperable five years ago. The route to that answer, and what follows it, has changed substantially since 2022. This page sets out the modern stage 3 (stage III, locally advanced) lung cancer pathway as it currently stands — the decision-tree first, the treatments second.
Five core points for patients and families newly facing a diagnosis of stage 3 (stage III, locally advanced) lung cancer.
Detailed explanation of each point follows below. Reviewed by Dr Lawrence Okiror, Consultant Thoracic Surgeon, May 2026.
Stage 3 lung cancer (medically written stage III) is the term used when non-small cell lung cancer — the type that accounts for around 85% of lung cancers — has grown beyond the lung itself, but has not spread to distant organs such as the liver, brain, or bones.
This middle position matters. It is what makes stage 3 different from stage 4: the cancer is still in one region of the body, and curative-intent treatment remains possible. Patients sometimes arrive at clinic having been told there is "no cure" — when what is actually true is that cure is harder, not impossible.
The system used to describe lung cancer stage is called TNM, with three letters:
For stage 3 disease, the M is always zero. The T and N numbers are higher, in various combinations — which is why stage 3 is divided into three substages.
Stage 3 Substages
| Substage | Surgical pathway? |
|---|---|
| Stage IIIA Tumour with limited nearby lymph node involvement, or smaller tumour with same-side mediastinal nodes (N2) |
Usually yes, after chemoimmunotherapy |
| Stage IIIB Larger or invasive tumour (T4) with significant lymph node involvement |
Sometimes yes — decided by the MDT after restaging |
| Stage IIIC Tumour with lymph nodes spread to the opposite side of the chest or above the collarbone |
Usually no — chemoradiotherapy + immunotherapy is the route |
A note on small cell lung cancer. This page covers non-small cell lung cancer (NSCLC). Small cell lung cancer (SCLC) is biologically different and is treated primarily with chemotherapy and radiotherapy — it is rarely a surgical disease. Patients with SCLC should discuss treatment with a medical oncologist.
Stage 3 lung cancer is treated through one of two modern pathways. The decision between them — made by the multidisciplinary team after staging is complete — depends on whether the tumour and lymph nodes can be safely removed by surgery.
| Aspect | Resectable Stage 3 Pathway | Unresectable Stage 3 Pathway |
|---|---|---|
| Common name | Perioperative chemoimmunotherapy | The PACIFIC pathway |
| Treatment sequence | Chemotherapy + immunotherapy → Surgery → Immunotherapy (up to 1 year) | Chemotherapy + radiotherapy together → Immunotherapy (up to 1 year) |
| Goal | Cure through removal of all visible and microscopic cancer | Cure through chemoradiation, with consolidation immunotherapy reducing the risk of recurrence |
| Evidence base | Six positive phase 3 trials since 2022: CheckMate 816, KEYNOTE-671, AEGEAN, CheckMate 77T, Neotorch, RATIONALE-315 | PACIFIC trial (Antonia, NEJM 2017); LAURA trial (Lu, NEJM 2024) for EGFR-mutated patients |
| Approximate duration | 4–5 months before surgery; up to 1 year of immunotherapy afterwards | 6–7 weeks of chemoradiotherapy; up to 1 year of consolidation immunotherapy |
| Who decides this is for you | Thoracic MDT — based on tumour pattern, lymph node involvement, lung function, and fitness for surgery | The same MDT — based on extensive lymph node spread, tumour location making safe resection impossible, or significant comorbidities ruling out surgery |
An important clarification
Both pathways are valid. Each treats a different patient. A common misconception — repeated even by some AI-generated medical summaries — is that chemoradiotherapy followed by immunotherapy is the universal "gold standard" for stage 3 lung cancer.
That is true for unresectable disease. For resectable disease, the modern standard is the perioperative pathway, supported by six phase 3 trials. And the criteria for "resectable" have widened substantially since 2022.
The crucial step is therefore not which pathway sounds best in general — it is identifying which pathway is the right one for the specific disease you have, decided by a thoracic surgical opinion alongside oncology input, not by either in isolation.
Whether stage 3 lung cancer is "resectable" is judged on four factors, weighed together by the multidisciplinary team:
Factor 1
Tumour location and extent (the T)Where the tumour sits, what structures it touches, and whether it can be removed with clear margins around the edges.
Factor 2
Lymph node pattern (the N)Which nodes contain cancer, on which side of the chest, and across how many anatomical stations.
Factor 3
Lung functionWhether you have enough lung capacity to tolerate the planned resection without becoming significantly short of breath.
Factor 4
General fitnessYour overall health and ability to recover from a major operation, including heart function and other medical conditions.
The first two are about the cancer. The second two are about you.
Five years ago, the line between resectable and unresectable was drawn relatively tightly. Patients with T4 tumours (invading major structures), bulky or multistation N2 disease, or borderline lung function were often routed to chemoradiotherapy without surgery being seriously considered.
That has shifted. Three things have changed in clinical practice:
The practical result: patients with T4N1 disease, T4N2 disease, and multistation N2 disease who would once have been told surgery was "off the table" are now increasingly being considered for the surgical pathway after induction chemoimmunotherapy. The decision is more individual, and more dynamic, than it used to be.
A Recent Case · London Bridge Hospital
A recent patient at London Bridge Hospital illustrates how the surgical indication has expanded. He presented with a T4N1 adenocarcinoma of the middle lobe — a central tumour that, a few years ago, would most likely have been routed to chemoradiotherapy with consolidation immunotherapy rather than surgery.
Under the perioperative pembrolizumab regimen, he completed three months of chemoimmunotherapy. Restaging confirmed significant tumour response. He underwent a robotic middle lobectomy — keyhole surgery despite the central location of the tumour and the treatment-induced fibrosis that makes these operations technically demanding.
Final pathology showed no residual cancer cells: a complete pathological response. He recovered through the standard three-to-five-day inpatient pathway, not the prolonged stay an open thoracotomy would have required.
This outcome is not as unusual as it once would have been. Across the perioperative trials, between 16% and 25% of patients achieve a complete pathological response. What is changing year on year is which patients enter the pathway in the first place. The implication for anyone newly diagnosed with stage 3 lung cancer — and particularly anyone told their disease is "borderline" or "probably not operable" — is that a second opinion at an experienced centre is worth seeking, before the treatment plan is finalised.
Between 2022 and 2025, six large phase 3 randomised trials established that adding immunotherapy to chemotherapy — given before surgery, or both before and after — significantly improves survival in resectable stage 3 lung cancer. The findings have been consistent across different immunotherapy drugs, different populations, and different countries. CheckMate 77T, the most recent, carries the most striking signal for what perioperative immunotherapy does to the surgery itself.
| Trial | Immunotherapy | Design | N | Headline result | What it means for surgery |
|---|---|---|---|---|---|
| CheckMate 816 Forde et al. NEJM 2022 · 5-yr OS ASCO 2025 |
Nivolumab | Neoadjuvant only (3 cycles) | 358 | 5-year OS 65% vs 55%; pCR 24% vs 2.2% | Established that immunotherapy before surgery does not delay or compromise the operation. |
| KEYNOTE-671 Wakelee et al. NEJM 2023 · 5-yr ESMO 2025 |
Pembrolizumab | Perioperative (4 cycles pre-op + 13 cycles post-op) | 797 | 5-year OS 64.6% vs 53.6%; 5-year EFS 49.9% vs 26.5% | Largest of the six trials. Survival benefit holds at five years, in both node-positive and node-negative groups. |
| AEGEAN Heymach et al. NEJM 2023 |
Durvalumab | Perioperative (4 cycles pre-op + 12 months post-op) | 802 | 32% reduction in risk of recurrence, progression or death; pCR 17.2% vs 4.3% | Confirmed the perioperative signal with a different immunotherapy drug; ~70% of trial population had stage 3 disease. |
| CheckMate 77T Cascone et al. NEJM 2024 · N2 update Nature Cancer 2026 |
Nivolumab | Perioperative (4 cycles pre-op + 13 cycles post-op) | 461 | EFS HR 0.58 overall; pCR 25.3% vs 4.7% | Pneumonectomy rate 1% vs 14% in the N2 subgroup — the strongest surgical-deintensification signal in the field. Detail below. |
| Neotorch Lu et al. JAMA 2024 |
Toripalimab | Perioperative (3 cycles pre-op + 1 cycle post-op + 13 cycles maintenance) | 404 (stage III) | EFS HR 0.40; MPR 48.5% vs 8.4% | Pure stage IIIA/IIIB population; consistent with the global trials. |
| RATIONALE-315 Yue et al. Lancet Respir Med 2025 |
Tislelizumab | Perioperative (3–4 cycles pre-op + 8 cycles post-op) | 453 | EFS HR 0.56; pCR 40.7% vs 5.7% | A sixth positive trial — the question is no longer whether perioperative immunotherapy works, but how it should be sequenced. |
Across all six trials, between 16% and 41% of patients achieve a complete pathological response — meaning no living cancer cells found in the surgical specimen. Five years ago this outcome was rare. It is now expected in a meaningful minority of every clinic.
N2 disease means the cancer has reached lymph nodes in the centre of the chest, between the lungs — on the same side as the original tumour. It is the most contested category in stage 3 lung cancer, because the decision to operate or not operate carries the biggest consequences either way.
Historically, N2 disease — particularly when it involved multiple lymph node stations, or when the nodes were enlarged ("bulky") — was often treated with chemoradiotherapy rather than surgery. Surgery in this setting frequently meant removal of the whole lung (pneumonectomy), with significant impact on lung function for life.
The most informative data on what perioperative immunotherapy has changed in N2 disease comes from CheckMate 77T, with supporting evidence from AEGEAN and KEYNOTE-671. All three trials have published subgroup analyses focused specifically on patients with N2 involvement.
| Outcome (N2 patients) | CheckMate 77T | AEGEAN | KEYNOTE-671 |
|---|---|---|---|
| Event-free survival benefit | HR 0.46 (54% reduction in risk) | HR 0.63 (37% reduction) | Favourable trend in node-positive subgroup |
| Complete pathological response (pCR) | 22% vs 5.6% | 16.6% vs 4.9% | Not separately reported in N2 subgroup |
| Lymph nodes cleared by treatment (downstaging to ypN0) | 57% vs 44% | 47% vs 40% | Not separately reported in N2 subgroup |
| Pneumonectomy rate | 1% vs 14% | 9.2% vs 11.1% | Not separately reported in N2 subgroup |
Three findings stand out for any patient told they have N2 disease.
N2 disease is the subgroup where a second opinion at a thoracic surgical centre changes things most often. If you have been told you have N2 lung cancer and chemoradiotherapy is the only pathway being discussed, ask whether your case has been reviewed by a thoracic surgeon — not only by an oncologist.
For about one in five patients with stage 3 non-small cell lung cancer, the tumour carries a specific genetic change that opens an entirely different treatment route — oral targeted therapy. The two most important are EGFR mutations and ALK rearrangements. Patients with these were specifically excluded from the chemoimmunotherapy trials above, because their cancers respond less well to immunotherapy and more strongly to targeted tablets.
EGFR-Mutated NSCLC
EGFR mutations are found in around 10–15% of patients with NSCLC, more commonly in never-smokers and patients of East Asian background. Three landmark trials have shaped the modern pathway:
Herbst et al., NEJM 2023. Osimertinib tablets for three years after surgery achieved 5-year survival of 85% vs 73% — a 51% reduction in risk of death. This is the established UK pathway.
Chaft et al., JCO 2025. Osimertinib before surgery (alone or with chemotherapy) produced major pathological responses in 25–26% of patients, vs 2% with chemotherapy alone. Not yet UK-licensed for pre-surgery use, but it suggests neoadjuvant osimertinib will join the pathway in the coming years.
Lu et al., NEJM 2024. For patients with unresectable EGFR-mutated stage 3 disease, osimertinib after chemoradiotherapy reduced the risk of disease progression by 84%. This has changed the unresectable EGFR pathway from PACIFIC-style consolidation immunotherapy to osimertinib instead.
ALK-Rearranged NSCLC
ALK rearrangements are found in around 3–7% of patients with NSCLC, again more commonly in never-smokers and at younger ages. ALK-positive lung cancer is its own clinical category — biologically distinct, and now treated with a chemotherapy-free post-surgical pathway:
Wu et al., NEJM 2024. Two years of alectinib tablets after surgery achieved 3-year disease-free survival of 88.3% vs 53.3% compared to chemotherapy — a 76% reduction in risk of recurrence. The established pathway for resected ALK-positive stage IB–IIIA disease.
A single-centre phase 2 study presented at ASCO 2026 reported that lorlatinib given before surgery in stage 3 ALK-positive disease produced complete pathological responses in 47% of patients and converted 75% of initially inoperable cases to surgery. These are early results from a small study (25 patients) — intriguing, not yet practice-changing.
For both EGFR and ALK pathways, the principle is the same: test the tumour first. Without these results, the wrong drug can be given to the wrong patient.
The Single Most Important Question Before Treatment Starts
Has my tumour been tested for EGFR mutation, ALK rearrangement, and PD-L1 expression?
If the answer is no or "not yet", systemic treatment should not start until results are available. Testing typically takes one to two weeks and changes the treatment plan in about a quarter of stage 3 patients. Patients sometimes find themselves several cycles into chemoimmunotherapy before discovering their tumour carried a targetable mutation that would have led to a different, more effective pathway.
The National Institute for Health and Care Excellence (NICE) independently reviews the evidence before any new cancer treatment is approved for use in the UK. The trial data above has already translated into national recommendations. NICE approval also informs private medical insurance coverage — treatments with NICE recommendations are generally included within mainstream PMI cancer benefits.
| Reference | Treatment | Who it is for | Based on |
|---|---|---|---|
| NICE TA876 March 2023 |
Neoadjuvant nivolumab with chemotherapy | Resectable NSCLC, 4 cm or larger or with involved lymph nodes — before surgery only | CheckMate 816 |
| NICE TA1017 November 2024 |
Perioperative pembrolizumab | Resectable NSCLC with high risk of recurrence — given before surgery and continued for up to one year afterwards | KEYNOTE-671 |
| NICE TA1127 February 2026 |
Perioperative nivolumab | Resectable NSCLC with high risk of recurrence — alternative to perioperative pembrolizumab | CheckMate 77T |
| NICE TA1037 February 2025 |
Adjuvant osimertinib | EGFR-mutated NSCLC after complete surgical resection — three years of tablets after surgery | ADAURA |
| NICE TA1010 January 2025 |
Osimertinib after chemoradiotherapy | EGFR-mutated unresectable stage 3 NSCLC — after concurrent chemoradiotherapy | LAURA |
| NICE TA1071 June 2025 |
Adjuvant atezolizumab | PD-L1 positive NSCLC after surgery and adjuvant chemotherapy | IMpower010 |
| NICE TA823 August 2022 |
Consolidation durvalumab | Unresectable stage 3 NSCLC — after concurrent chemoradiotherapy (the PACIFIC pathway) | PACIFIC |
| NICE NG122 Last update 2024 |
Lung cancer: diagnosis and management guideline | The national framework requiring MDT review, biomarker testing, and multi-modality treatment planning for every resectable lung cancer | Guideline |
Eight NICE recommendations in three years — the entire modern stage 3 lung cancer pathway is now formally approved for UK patients and reimbursable under private medical insurance.
The decisions on staging, biomarker testing, the choice between the two pathways, and the sequencing of treatments require input from multiple specialists reviewing the same case together. National guidance (NICE NG122) requires this for every patient with resectable lung cancer in the UK. The forum where it happens is the lung cancer multidisciplinary team meeting — the MDT.
Dr Okiror is part of the lung cancer MDT at London Bridge Hospital, attending regularly as one of the thoracic surgeons in the meeting. Every private patient under his care is discussed at this MDT before a treatment plan is finalised.
The team brings together six specialties:
Assess resectability and surgical approach
Prescribe chemotherapy, immunotherapy, and targeted therapy
Plan and deliver radiotherapy
Interpret CT, PET-CT, and restaging scans
Perform diagnostic bronchoscopy, lymph node biopsy, and lung function assessment
Analyse biopsy and resection specimens and perform biomarker testing
Each case is reviewed collectively. Imaging is displayed on the screen. The pathologist confirms tumour type and biomarker status. The thoracic surgeon assesses resectability. The oncologists discuss systemic options. A plan is agreed before anyone speaks to the patient.
If a patient with stage 3 lung cancer has not been formally discussed at a thoracic MDT before treatment starts, the most important thing they can do is ask the question.
Published experience. Dr Okiror co-authored the 2025 Guy's Cancer Centre real-world series on neoadjuvant chemoimmunotherapy in operable lung cancer. Toki M, Elkhalifa M, Bille A, Tan C, Ashrafian L, Okiror L, et al. Lung Cancer 2025;200(Suppl 1):108200. doi: 10.1016/j.lungcan.2025.108200.
Surgery after three or four cycles of chemoimmunotherapy is more technically demanding than surgery on an untreated tumour. The tissues develop fibrosis — a form of scarring. The natural anatomical planes between structures that normally make keyhole surgery feasible can become obliterated.
Many centres respond to this difficulty by converting the operation to open thoracotomy — a larger incision that requires the ribs to be spread apart, significantly longer hospital stay, and markedly slower recovery.
This matters clinically because patients who have just completed four months of systemic therapy are the least able to tolerate a large open operation. The robotic approach — where it remains feasible — preserves their recovery, shortens their hospital stay, and returns them to daily life sooner.
Why the robotic platform handles these cases
Most of Dr Okiror's private patients having surgery after chemoimmunotherapy at London Bridge Hospital have keyhole robotic surgery. A minority require conversion to open thoracotomy during the operation if the anatomy is too distorted to continue safely — this decision is always made in the interests of safe and complete cancer clearance.
For a detailed walk-through of the surgical journey week by week — from the first scan through to discharge home — see the patient guide on surgery after chemotherapy and immunotherapy.
Dr Okiror's NHS base is Guy's and St Thomas' — one of the largest thoracic surgery centres in the UK. The unit's audited results for 2024–25, published in the Society for Cardiothoracic Surgery national audit, set the operative standards Dr Okiror brings to his private practice at London Bridge Hospital and The Lister Chelsea.
1.5%
Pneumonectomy rateAmong the lowest nationally, without compromising survival. Lung-sparing surgery is the default; whole-lung removal is the exception.
99.59%
Operative survival rateFor primary lung cancer surgery in 2024–25 across 969 cases — four perioperative deaths in the cohort.
71.3%
Robotic rate for anatomic resectionsVersus a UK national average of 39.4%. Robotic is the default approach, not a specialised exception.
88.9%
Robotic segmentectomy rateLung-sparing segmentectomy — the smaller, more anatomically precise resection — performed robotically in nearly nine out of ten cases.
The 1.5% pneumonectomy rate is the most important figure here. It means that at the centre where Dr Okiror trains his private practice standards, whole-lung removal is the exception even in locally advanced cases. Source: Society for Cardiothoracic Surgery National Thoracic Audit 2024–25.
The treatment landscape has changed so quickly that advice given even twelve months ago may no longer reflect current options. Three scenarios in particular warrant a fresh look from a thoracic surgical perspective.
Scenario One
The definition of "inoperable" has changed meaningfully in the last three years. Chemoimmunotherapy given before surgery can shrink tumours, clear involved lymph nodes, and convert previously inoperable cancers into operable ones. Patients with T4 tumours and bulky N2 disease who were ruled out a few years ago now routinely come up the surgical route.
When to seek a second opinion: if the advice was given more than twelve months ago, or if biomarker testing was not done before the decision, or if a thoracic surgeon was not part of the team that decided.
Request Second Opinion →Scenario Two
Pneumonectomy — removal of an entire lung — remains the correct operation for some patients. For many others, particularly after chemoimmunotherapy has shrunk the tumour, a lobectomy preserves more lung and delivers equivalent cancer control. Pneumonectomy rates vary significantly between centres — at Dr Okiror's NHS base, it is 1.5% of primary lung cancer operations, one of the lowest rates nationally.
When to seek a second opinion: before agreeing to a pneumonectomy, particularly if you have not yet had chemoimmunotherapy or if your surgeon does not routinely perform sleeve resections or robotic anatomic surgery.
Request Second Opinion →Scenario Three
For some patients with stage 3 lung cancer, chemoradiotherapy followed by immunotherapy is the right pathway. For others — particularly those with N2 disease or T4 tumours who could be converted to resectable disease by chemoimmunotherapy — surgery is now part of the modern standard. A patient routed straight to chemoradiotherapy without a thoracic surgical assessment may not have had the full pathway considered.
When to seek a second opinion: if your case has not been reviewed by a thoracic surgeon as part of the MDT, or if you have not been told why surgery is not being considered.
Request Second Opinion →Private second opinion consultations with Dr Okiror are typically available within 2–3 working days. Self-referrals welcome.
Dr Okiror consults and operates at both London Bridge Hospital and The Lister Hospital Chelsea.
For straightforward lung cancer surgery, either hospital offers full robotic capability and excellent private care.
For more complex cases — for instance, surgery forming part of multi-modality treatment for stage 3 disease — Dr Okiror typically recommends London Bridge Hospital, which has greater experience and deeper infrastructure for these operations.
Patients first seen at The Lister who are found to have more complex disease are not turned away. The surgical episode transfers to LBH, while consultations and follow-up can continue at whichever hospital is more convenient for the patient.
A note on insurance
Multi-modality treatment for stage 3 lung cancer — neoadjuvant chemoimmunotherapy, biomarker testing, robotic surgery, and adjuvant therapy — involves several components and hospital episodes. Some insurance policies require prior authorisation for specialist cancer treatments. Patients are advised to check with their private medical insurer early in the pathway. Self-pay options are available for all elements of treatment; Jo Mitchelson, PA, can provide an estimate on request.
Common questions from patients and families newly facing a diagnosis of stage 3 (stage III, locally advanced) lung cancer.
Stage 3 lung cancer (also written stage III) is locally advanced non-small cell lung cancer. The cancer has grown beyond the lung itself but has not spread to distant organs such as the liver, brain, or bones. It is divided into three substages — stage IIIA, stage IIIB, and stage IIIC — based on how far the tumour has grown and which lymph nodes are involved. Curative-intent treatment remains possible for the great majority of patients with stage 3 disease.
Yes — stage 3 lung cancer is treated with curative intent in most patients. The cure depends on the substage, biomarker testing results, lung function, fitness, and whether the cancer can be surgically removed. The modern combined approach — chemotherapy with immunotherapy followed by surgery, with further immunotherapy afterwards — has substantially improved survival over the past four years across six large international trials. For patients whose disease cannot be surgically removed, chemoradiotherapy followed by consolidation immunotherapy is also a curative pathway.
There is no single gold standard for all stage 3 lung cancer — there are two pathways, and which one is right depends on whether the cancer is surgically removable. For resectable stage 3 disease, the modern standard is chemotherapy combined with immunotherapy before surgery (perioperative chemoimmunotherapy), supported by six positive phase 3 trials since 2022. For unresectable stage 3 disease, the standard is chemoradiotherapy followed by up to one year of consolidation durvalumab — known as the PACIFIC pathway. For EGFR-mutated unresectable disease, osimertinib after chemoradiotherapy is now the standard. The first decision is therefore whether the cancer is resectable, made by a thoracic multidisciplinary team.
Stage IIIA includes tumours with limited nearby lymph node involvement, or smaller tumours with mediastinal lymph nodes on the same side as the tumour (N2 disease). Surgery is usually possible after chemoimmunotherapy. Stage IIIB describes larger or more invasive tumours (T4) with significant lymph node involvement; surgery is sometimes possible after the MDT reviews the response to treatment. Stage IIIC describes cancer that has spread to lymph nodes on the opposite side of the chest or above the collarbone; surgery is uncommon in IIIC, and chemoradiotherapy with consolidation immunotherapy is usually the route.
Neoadjuvant chemoimmunotherapy is platinum-based chemotherapy combined with immunotherapy given before surgery, usually for three or four cycles over nine to twelve weeks. It shrinks the tumour, treats microscopic cancer cells already spread beyond the lung, and helps the body mount a lasting immune response. Surgery is planned four to eight weeks after the final cycle. After surgery, immunotherapy is sometimes continued for up to one year — this combined approach is called perioperative chemoimmunotherapy and is supported by the KEYNOTE-671, AEGEAN, CheckMate 77T, Neotorch, and RATIONALE-315 phase 3 trials.
Three tests on the tumour tissue are essential before systemic treatment for stage 3 lung cancer: EGFR mutation testing, ALK rearrangement testing, and PD-L1 expression. EGFR and ALK mutations identify cancers that respond better to targeted oral tablets than to chemoimmunotherapy — these patients were excluded from the chemoimmunotherapy trials. PD-L1 expression predicts how strongly the cancer will respond to immunotherapy. Testing typically takes one to two weeks and changes the treatment plan in about a quarter of stage 3 patients. If you have been offered systemic treatment without these results, this is the single most important question to ask before starting.
N2 disease means the cancer has reached lymph nodes in the centre of the chest, between the lungs, on the same side as the original tumour. Historically, N2 disease — particularly when bulky or involving multiple lymph node stations — was usually treated without surgery. That has changed. In CheckMate 77T, perioperative immunotherapy in N2 patients cleared mediastinal lymph nodes of cancer in 57% of cases at surgery, achieved complete pathological responses in 22%, and reduced pneumonectomy rates from 14% to 1%. Patients with N2 disease are now routinely operated on at experienced centres after chemoimmunotherapy. A second opinion at a thoracic surgical centre is particularly important if your N2 case has not been reviewed by a thoracic surgeon.
T4 lung cancer means the tumour has grown into major structures in the chest — large blood vessels, the windpipe, the heart sac, the spine, the diaphragm, or there are tumour nodules in a different lobe of the same lung. Historically, T4 disease was often considered too advanced for surgery. The position has shifted. Chemoimmunotherapy given before surgery can shrink T4 tumours sufficiently that resection becomes safely possible, particularly when the cancer responds well to the systemic treatment. At experienced robotic centres, patients with T4N1 and selected T4N2 disease are increasingly being operated on after chemoimmunotherapy. The decision is made by the multidisciplinary team after restaging scans.
Yes, in experienced hands. Surgery after chemoimmunotherapy is more technically demanding because the tissues develop fibrosis and the natural anatomical planes can become obliterated. Many centres respond by converting to open thoracotomy. At high-volume robotic centres, surgeons encounter these fibrotic cases regularly and develop the technique to dissect through them robotically. This matters because patients who have just completed four months of systemic therapy recover significantly faster from keyhole surgery than from thoracotomy. Most of Dr Okiror's private patients having surgery after chemoimmunotherapy at London Bridge Hospital have keyhole robotic surgery, with conversion to open only when anatomy demands it for safe cancer clearance.
Pneumonectomy — removal of an entire lung — remains the right operation for some patients with central tumours or major vascular involvement. For many others, particularly after chemoimmunotherapy has shrunk the tumour, a lobectomy preserves more lung and delivers equivalent cancer control. Pneumonectomy rates vary significantly between centres. At Dr Okiror's NHS base — Guy's and St Thomas' — only 1.5% of primary lung cancer operations are pneumonectomies, one of the lowest rates nationally. If you have been offered a pneumonectomy elsewhere, a second opinion at a robotic surgical centre may identify a lung-sparing alternative.
pCR stands for complete pathological response. It means that when the surgical specimen is examined under the microscope after chemoimmunotherapy and surgery, no living cancer cells are found anywhere in the removed tumour or lymph nodes. pCR is the strongest single predictor of long-term survival after combined treatment. Across the phase 3 perioperative trials, pCR rates range from 16% to 41% — meaning a meaningful minority of patients achieve this outcome with modern multi-modality treatment. Five years ago, pCR in stage 3 lung cancer was rare. It is now expected in roughly one in four to one in five patients in clinic.
Yes — particularly in three situations. First, if you were told your cancer is inoperable, especially if that advice was given more than twelve months ago or before biomarker testing was done. Second, if you have been offered a pneumonectomy. Third, if chemoradiotherapy is the only plan being discussed and you have not been formally reviewed by a thoracic surgeon as part of the MDT. The treatment landscape has changed so quickly that advice given even a year ago may no longer reflect current options. Private second opinion consultations with Dr Okiror are typically available within 2–3 working days. Bring imaging, the pathology report, and any prior treatment recommendations.
Appointments within 2–3 working days. Self-referrals welcome. Multi-modality treatment for stage 3 lung cancer at London Bridge Hospital (complex cases) and The Lister Hospital Chelsea.
Jo Mitchelson, PA · 020 7952 2882 · pa@lungsurgeon.co.uk
St Thomas' Hospital #1 UK · Guy's Hospital #2 UK · London Bridge Hospital #10 UK · Newsweek World’s Best Hospitals 2026
The full private lung cancer surgery service — all stages, robotic and keyhole resection
Your Treatment JourneyPatient guide to multi-modality treatment week by week — what happens, when, and why
Second Opinion ServicePrivate second opinion appointments within 2–3 days — how to prepare and what to bring
Robotic Lung SurgeryRobotic lobectomy, segmentectomy, and complex resection — including post-chemoimmunotherapy cases
Robotic SegmentectomyLung-sparing resection — relevant for patients downstaged by chemoimmunotherapy
Lung Nodule PathwayCombined biopsy-and-resection pathway for indeterminate nodules — same anaesthetic