Surgical management of non-small-cell lung cancer with ipsilateral mediastinal node metastasis (N2 disease)

True Prevalence of Unforeseen N2 Disease in NSCLC: A Systematic Review + Meta-Analysis

Patients with unforeseen N2 (uN2) disease are traditionally considered to have an unfavorable prognosis. As preoperative and intraoperative mediastinal staging improved over time, the prevalence of uN2 changed. In this review, the current evidence on uN2 disease and its prevalence will be evaluated. A systematic literature search was performed to identify all studies or completed, published trials that included uN2 disease until 6 April 2023, without language restrictions. The Newcastle-Ottawa Scale (NOS) was used to score the included papers. A total of 512 articles were initially identified, of which a total of 22 studies met the predefined inclusion criteria. Despite adequate mediastinal staging, the pooled prevalence of true unforeseen pN2 (9387 patients) was 7.97% (95% CI 6.67-9.27%), with a pooled OS after five years (892 patients) of 44% (95% CI 31-58%). Substantial heterogeneity regarding the characteristics of uN2 disease limited our meta-analysis considerably. However, it seems patients with uN2 disease represent a subcategory with a similar prognosis to stage IIb if complete surgical resection can be achieved, and the contribution of adjuvant therapy is to be further explored.

Survival impact of unexpected N2 in stage IIIB/N2 non-small cell lung cancer patients

BACKGROUND

We investigated the effect of unexpected N2 on survival in stage IIIB/N2 cases.

METHODS

We retrospectively analyzed 1803 non-small cell lung cancer patients between 2010 and 2016. There were 89 patients (4.9%) with unexpected N2 (pathological (p) IIIB/N2 group), whereas 49 patients (2.7%) with cN2 (clinical (c) IIIB/N2 group). Although pIIIB/N2 group underwent surgery followed by adjuvant therapy, the cIIIB/N2 group of patients had multimodality treatment including induction chemotherapy ± radiotherapy followed by surgery.

RESULTS

The five-year overall survival (OS) for all patients was 36.0% [median survival time (MST) 27.9 months], and disease-free survival (DFS) was 28.9% (MST, 18.2 months). The OS was 39.6% (MST: 34.4 months) and the median DFS time was 31.1% (Median: 23.1 months) in the pIIIB/N2 group, whereas it was 29.2% (MST: 23.0 months) for OS and 22% (median: 12.4 months) for DFS in the cIIIB/N2 group. There were no significant OS and DFS differences between the pIIIB/N2 group and the cIIIB/N2 group (p = 0.124 and p = 0.168, respectively).

CONCLUSIONS

In stage IIIB/N2 cases, the fact that N2 could not be detected preoperatively with minimally invasive or invasive methods and was detected in the pathological examination after surgery does not provide a survival advantage.

Management of Early-Stage Resected Non-Small Cell Lung Cancer: Consensus Statement of the Lung cancer Consortium

BACKGROUND

Management of early-stage non-small cell lung cancer (ES-NSCLC) has evolved over the last few years especially in terms of work-up and the use of systemic therapy. This consensus statement was developed to present updated guidelines for the management of this disease.

METHODS

Multidisciplinary team (MDT) of lung cancer experts convened to discuss a set of pertinent questions with importance relevance to the management of ES-NSCLC. ES-NSCLC includes stages I, II and resected stage III. The experts included consultants in chest imaging, thoracic surgery, radiation oncology, and medical oncology. Questions were discussed in virtual meetings and then a written manuscript with supporting evidence was drafted, reviewed, and approved by the team members.

RESULTS

The Consensus Statement included 9 questions addressing work-up and management of ES-NSCLC. Background information and literature review were presented for each question followed by specific recommendations to address the questions by oncology providers. The Statement was endorsed by various oncology societies in the Gulf region.

CONCLUSION

The Consensus Statement serves as a guide for thoracic MDT members in the management of ES-NSCLC. Adaptation of these to the local setting is dictated usually by available resources and expertise, however, all efforts should be excreted to provide the optimal care to all patients whenever possible.

Analysis of clinical features and prognostic factors of lung cancer patients: A population-based cohort study

OBJECTIVES

This paper analyses clinical features of lung cancer patients and discusses factors influencing the lung cancer occurrence and prognosis.

METHODS

Patients diagnosed with lung cancer from 1975 to 2016 are analysed based on SEER database. The samples are divided into groups according to the number of positive lymph nodes of LN > 3 and LN ≤ 3. Univariate and multivariate Cox risk models are performed. After balancing the clinicopathological features of the two groups with the propensity score matching (PSM) method, the survival rates of the two groups are compared.

RESULTS

A total of 30 864 patients are included in this study. Kaplan-Meier curves show that the survival rate of patients with LN ≤ 3 is higher than that of patients with LN > 3 (P < 0.0001). Univariate and multivariate Cox proportional risk model analysis suggests that the number of lymph nodes is an independent prognostic risk factor for lung cancer. LN ≤ 3 group shows better OS (HR2.066; 95% CI 1.941-2.199, P < 0.01) and better CSS (HR 2.461; 95% CI 2.304-2.629, P < 0.01). In addition, age at diagnosis, gender, Laterality, Derived AJCC T, 7th ed (2010-2015), Derived AJCC N, 7th ed (2010-2015) and Derived AJCC M, 7th ed, (2010-2015) have also been proved to be potential prognostic factors. A total of 1,851 pairs of patients are screened after 1:1 PSM matching. Patients with LN ≤ 3 have significant improvements in OS and CSS (HR 1.09; 95% CI 1.001-1.187, P < 0.05 and HR 1.127; 95% CI 1.03-1.232, P < 0.001).

CONCLUSION

The number of lymph nodes is an independent prognostic risk factor for lung cancer. Patients with fewer lymph node positives have a better survival prognosis than patients with more lymph nodes.

Single-station skip-N2 disease: good prognosis in resected non-small-cell lung cancer (long-term results in skip-N2 disease)

OBJECTIVES

Pathological N2 (pN2) involvement has a negative impact on prognosis in patients operated on due to non-small-cell lung cancer (NSCLC). pN2 disease may cause skip (pN0N2) or non-skip (pN1N2) metastases with pathological N1 (pN1) involvement. The effect of pN2 subgroups on prognosis is still controversial. We analysed the effect of pN1 disease and single-station pN2 disease subgroups on survival outcomes.

METHODS

The medical records of patients who underwent anatomical lung resection due to NSCLC at a single centre between January 2007 and January 2017 were prospectively collected and retrospectively analysed. Operative mortality, sublobar resection, Stage IV disease, incomplete resection and carcinoid tumour were considered exclusion criteria. After histopathological examination, the prognosis of patients with pN1, pN0N2 and pN1N2 was compared statistically. Univariable and multivariable analyses were made to define independent risk factors for overall survival rates.

RESULTS

The mean follow-up time for 358 patients with 228 pN1 disease (63.7%), 59 pN0N2 disease (16.5%) and 71 pN1N2 disease (19.8%) was 40.4 ± 30.4 months. Median and 5-year overall survival rates for pN1, pN0N2 and pN1N2 diseases were 73.6 months [95% confidence interval (CI) 55.5-91.7] and 54.1%, 60.3 months (95% CI 26.8-93.8) and 51.2%, 20.8 months (95% CI 16.1-25.5) and 21.5%, respectively. The survival CIs of pN1 and pN0N2 diseases were similar, and the survival rates of these 2 groups were significantly better than those with pN1N2 (P < 0.001, P = 0.001, respectively). In multivariable analysis, patients over the age of 60 [hazard ratio (HR) 2.13, P < 0.001], patients not receiving adjuvant therapy (HR 1.52, P = 0.01) and patients with pN1N2 disease (HR 2.91, P < 0.001) had a poor prognosis.

CONCLUSIONS

Advanced age, not receiving adjuvant therapy and having pN1N2 disease are negative prognostic factors in patients with nodal involvement who underwent curative resection due to NSCLC. The overall survival and recurrence-free survival rates of pN1 disease and single-station pN0N2 disease are similar, and they have significantly better survival rates than pN1N2 disease. Based on these results, surgical treatment may be considered an appropriate choice in patients with histopathologically diagnosed single-station skip-N2 disease.

Multimodality Therapy for N2 Non-Small Cell Lung Cancer: An Evolving Paradigm

BACKGROUND

Induction chemoradiation for resectable N2 non-small cell lung cancer (NSCLC) is used with the intent to optimize locoregional control, whereas induction chemotherapy given in systemic doses is meant to optimally target potential distant disease. However, the optimal preoperative treatment regimen is still unknown and practice patterns continue to vary widely. We compared multiinstitutional oncologic outcomes for N2 NSCLC from 4 experienced lung cancer treatment centers.

METHODS

This collaborative retrospective study unites 4 major thoracic oncology centers. Patients with N2 NSCLC undergoing surgical resection after induction chemotherapy (CxT) or concurrent chemoradiation (CxRT) were included. Primary outcomes were overall and disease-free survival (OS and DFS).

RESULTS

822 patients were identified (CxT = 662 and CxRT = 160). There were no differences in 5-year OS (CxT 39.9% versus CxRT 42.9%, p = 0.250) nor in DFS (CxT 28.7% versus 29.8%, p = 0.207). Recurrence rates (CxT 46.8% versus CxRT 51.6%, p = 0.282) and recurrence patterns were not significantly different (Local: CxT 9.8% versus CxRT 9.7%; and Distant: CxT 30.4% versus CxRT 33.1%, p = 0.764). There was no difference in perioperative mortality. In the analyses of patients who underwent pretreatment invasive mediastinal staging (n = 555), there were still no significant differences in OS (p = 0.341) and DFS (p = 0.455) between the 2 treatment strategies.

CONCLUSIONS

Both treatment strategies produce equivalent and better than expected outcomes compared with historical controls for N2 NSCLC, with no differences in recurrence patterns. How these conventional therapeutic strategies will compare with those involving immunotherapy combined with surgical locoregional disease control for N2 disease remains to be determined.

Risk factors for relapse of resectable pathologic N2 non small lung cancer and prediction model for time-to-progression

Background

Pathologic N2 non-small-cell lung cancer (NSCLC) was demonstrated with poor survival among literature. In this study, we retrospectively reviewed patients with pathologic N2 NSCLC and received anatomic resection (i.e. lobectomy) for further relapse risk factor analysis. The aim of this study is to identify the clinicopathologic factors related to relapse among resectable N2 NSCLC patients and to help clinicians in developing individualized follow up program and treatment plan.

Method

From January 2005 to July 2012, 90 diagnosed pathologic N2 NSCLC patients were enrolled into this study. We retrospectively reviewed medical records, image studies, and pathology reports to collect the patient clinico-pathologic factors.

Result

We identified that patients with visceral pleural invasion (p = 0.001) and skip metastases along mediastinal lymph node (p = 0.01) had a significant relationship to distant and disseminated metastases. Patients who had 2 or more risk factors for relapse demonstrated poor disease free survival than those who had less than 2 risk factors (p = 0.02). The number of involved metastatic area were significantly influential to the period of time-to-progression. The duration of time-to-progression was correlated with square of number of involved metastatic areas. (Pearson correlation coefficient = −0.29; p = 0.036).

Conclusion

Relapse risk factors of resectable pathologic N2 NSCLC patient after anatomic resection were visceral pleural invasion, skip mediastinal lymph node involvement, and the receipt of neoadjuvant therapy. The duration of time-to-progression was correlated with square of number of involved metastatic areas.

Long-term outcomes after lobectomy for non-small cell lung cancer when unsuspected pN2 disease is found: A National Cancer Data Base analysis

OBJECTIVE

There are few studies evaluating whether to proceed with planned resection when a patient with non-small cell lung cancer (NSCLC) unexpectedly is found to have N2 disease at the time of thoracoscopy or thoracotomy. To help guide management of this clinical scenario, we evaluated outcomes for patients who were upstaged to pN2 after lobectomy without induction therapy using the National Cancer Data Base (NCDB).

METHODS

Survival of NSCLC patients treated with lobectomy for clinically unsuspected mediastinal nodal disease (cT1-cT3 cN0-cN1, pN2 disease) from 1998-2006 in the NCDB was compared with "suspected" N2 disease patients (cT1-cT3 cN2) who were treated with chemotherapy with or without radiation followed by lobectomy, using matched analysis based on propensity scores.

RESULTS

Unsuspected pN2 disease was found in 4.4% of patients (2047 out of 46,691) who underwent lobectomy as primary therapy for cT1-cT3 cN0-cN1 NSCLC. The 5-year survival was 42%, 36%, 21%, and 28% for patients who underwent adjuvant chemotherapy (n = 385), chemoradiation (n = 504), radiation (n = 300), and no adjuvant therapy (n = 858), respectively. Five-year survival of the entire unsuspected pN2 cohort was worse than survival of 2302 patients who were treated with lobectomy after induction therapy for clinical N2 disease (30% vs 40%; P < .001), although no significant difference in 5-year survival was found in a matched-analysis of 655 patients from each group (37% vs 37%; P = .95).

CONCLUSIONS

This population-based analysis suggests that, in the setting of unsuspected pN2 NSCLC, proceeding with lobectomy does not appear to compromise outcomes if adjuvant chemotherapy with or without radiation therapy can be administered following surgery.

Outcome of Patients With pN2 "Potentially Resectable" Nonsmall Cell Lung Cancer Who Underwent Surgery After Induction Chemotherapy

Patients with stage IIIA-ipsilateral mediastinal lymph node involvement (N2) non-small cell lung cancer (NSCLC) represent a heterogeneous group with different clinical presentation. The aim of this study was to analyze a series of patients with "potentially resectable" stage IIIA-pathologically proven N2 (pN2) NSCLC undergoing induction chemotherapy followed by surgery to evaluate their long-term outcomes and to identify prognostic factors. Out of 287 patients who underwent induction chemotherapy for NSCLC with ipsilateral mediastinal lymph node involvement pathologically proven, we retrospectively evaluated 141 (49%) patients with no clinical evidence of progression after induction chemotherapy and candidates for surgery. Most of them (73%) underwent at least 3 cycles of cisplatin-based chemotherapy. We used the Kaplan-Meier method to plot survival and the log-rank test to assess the survival difference between groups. Multivariable analysis was performed using Cox proportional hazards regression. A total of 15 (10.6%) patients underwent explorative thoracotomy; 126 patients underwent surgical anatomical resection after a median 27 days (range: 21-30) from the last cycle of chemotherapy. A total of 113 (89.7%) patients had a radical resection. A total of 22 (17.5%) patients had a complete pathologic lymph node downstaging (pN0), and 8 (6.3%) patients had a complete pathological response (pT0N0). The median overall survival was 24 months, with a 5-year overall survival of 30%. At multivariable analysis, downstaging and number of cycles of chemotherapy were independent prognostic factors (P = 0.006); downstaging benefit was mostly because of complete pathological response (hazards ratio = 0.23, 95% CI: 0.07-0.76). In conclusion, more than 3 cycles of chemotherapy and pathological downstaging could significantly improve 5-year survival in selected patients with "potentially resectable" pathologically proven N2 disease.

Selection of proper candidates with resected pathological stage IIIA-N2 non-small cell lung cancer for postoperative radiotherapy

BACKGROUND

To establish a prediction model in selecting fit patients with resected pIIIA-N2 non-small cell lung cancer (NSCLC) for postoperative radiotherapy (PORT), and evaluate the model in clinical practice.

METHODS

Between January 2003 and December 2005, 221 patients with resected pIIIA-N2 NSCLC were retrospectively analyzed. The effect of PORT on overall survival (OS) of patients with different clinicopathological factors was evaluated and the results were used to establish a prediction model to select patients fit for PORT.

RESULTS

Compared with the control, PORT significantly improved the OS of patients with a smoking index ≤400 (P = 0.033), cN2 (P = 0.003), pT3 (P = 0.014), squamous cell carcinoma (SCC) (P = 0.013), or ≥4 positive nodes (P = 0.025). Patients were divided from zero to all five factors into low, middle, and high PORT index (PORT-I) groups (scored 0-1, 2, and 3-5, respectively). PORT did not improve OS (3-year, P = 0.531), disease free survival (DFS) (P = 0.358), or loco-regional recurrence free survival (LRFS) (P = 0.412) in the low PORT-I group. PORT significantly improved OS (P = 0.033), and tended to improve DFS (P = 0.064), but not LRFS (P = 0.287) in the middle PORT-I group. PORT could significantly improve OS (P = 0.000), DFS (P = 0.000), and LRFS (P = 0.006) in the high PORT-I group.

CONCLUSION

The prediction model is valuable in selecting patients with resected pIIIA-N2 NSCLC fit for PORT. PORT is strongly recommended for patients with three or more of the five factors of smoking index ≤400, cN2, pT3, SCC, and ≥4 positive nodes.

Controversies in the management of stage III non-small-cell lung cancer

Lung cancer remains the leading cause of death in the USA and is the most common cancer both in incidence and in mortality globally (1.35 million deaths annually). Non-small-cell lung cancer accounts for >80% of all lung cancers [1] . About 35-45% of non-small-cell lung cancer patients present with locally advanced non-metastatic stage III disease. However, confirmed stage III disease represents a very heterogeneous group ranging from borderline surgical candidate with minimal mediastinal involvement to bulky mediastinal nodes or contralateral nodal involvement with significant controversy regarding optimal management in these various situations. This article specifically addresses the role of surgery, radiotherapy and chemotherapy in multimodal approach to treat stage III patients with N2/N3 involvement and controversies surrounding these recommendations.

Surgical outcomes after initial surgery for clinical single-station N2 non-small-cell lung cancer

OBJECTIVE

Single-station N2 (Stage IIIA) non-small-cell lung cancer has been reported to have a relatively favorable prognosis after surgery. However, most previous studies examined surgical outcomes in N2 disease by pathologic nodal status but not by clinical nodal status. The objective of this study was to clarify the surgical outcomes in clinical single-station N2 non-small-cell lung cancer patients.

METHODS

A total of 125 consecutive patients with clinical single-station N2 non-small-cell lung cancer were treated in our institution between 1992 and 2008. Among them, 97 (78%) patients underwent thoracotomy, and were included in this retrospective study. We defined clinical single-station N2 node as a node measuring 1-2 cm in a single mediastinal station observed on contrast-enhanced computed tomography. The median follow-up period was 5.9 years (range, 1.8-12.6).

RESULTS

Eighty-eight (91%) patients underwent lung resection. Of them, 17 (19%) had true (pathologic) single-station N2 disease. Twenty-eight (32%) had pathologic multistation N2 and 43 (49%) had pN0-1 disease with favorable prognoses. The overall survival of the clinical single-station N2/pathologic N2 patients after initial surgery was unsatisfactory with a 5-year overall survival of 23.6%, but their prognoses were heterogeneous. True single-station pathologic N2 status (hazard ratio = 0.35, P = 0.008) and negative subcarinal node status (hazard ratio = 0.34, P = 0.022) were independent favorable prognostic factors after initial resection for clinical single-station N2/ pathologic N2 patients. The patients with both factors revealed a relatively favorable 5-year overall survival of 43.8%.

CONCLUSION

Clinical single-station N2 status does not always correspond with pathologic true N2 status. From a prognostic point of view, initial surgery for clinical single-station N2 patients is indicated if their true single-station N2 status and negative subcarinal involvement are preoperatively confirmed.

Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines

OBJECTIVES

Stage III non-small cell lung cancer (NSCLC) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky nodal disease. This review updates the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients.

METHODS

Systematic searches were conducted through MEDLINE, Embase, and the Cochrane Database for Systematic Review up to December 2011, focusing primarily on randomized trials, selected meta-analyses, practice guidelines, and reviews.

RESULTS

For individuals with stage IIIA or IIIB disease, good performance scores, and minimal weight loss, treatment with combined chemoradiotherapy results in better survival than radiotherapy alone. Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported. Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation. Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy; however, weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate. The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery. Postoperative radiotherapy improves local control without improving survival.

CONCLUSIONS

Multimodality therapy is preferable in most subsets of patients with stage III lung cancer. Variability in the patients included in randomized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios. Future trials are needed to investigate the roles of individualized chemotherapy, surgery in particular cohorts or settings, prophylactic cranial radiation, and adaptive radiation.

[Resected non-small cell bronchogenic carcinoma stage pIIIA-N2. Which patients will benefit most from adjuvant therapy?]

BACKGROUND

Controversy persists as regards the indications and results of surgery in the treatment of patients with stage pIIIA-N2 non-small cell lung cancer (NSCLC). The objective of this study was to analyze the overall survival of a multicentre series of these patients and the role of adjuvant treatment, looking for factors that may define subgroups of patients with an increased benefit from this treatment.

METHODS

A retrospective study was conducted on 287 patients, with stage pIIIA-N2 NSCLC subjected to complete resection, taken from a multi-institutional database of 2.994 prospectively collected consecutive patients who underwent surgery for lung cancer. Adjuvant treatment was administered in 238 cases (82.9%). Analyses were made of the age, gender, histological type, administration of induction and adjuvant chemotherapy and/or radiation therapy treatments.

RESULTS

The 5-year survival was 24%, with a median survival of 22 months. Survival was 26.5% among patients receiving with adjuvant treatment, versus 10.7% for those without it (P=.069). Age modified the effect of adjuvant treatment on survival (interaction P=.049). In patients under 70 years of age with squamous cell carcinoma, adjuvant treatment reduced the mortality rate by 37% (hazard ratio: 0,63; 95% CI; 0,42-0,95; P=.036).

CONCLUSIONS

Completely resected patients with stage pIIIA-N2 NSCLC receiving adjuvant treatment reached higher survival rates than those who did not. Maximum benefit was achieved by the subgroup of patients under 70 years of age with squamous cell carcinoma.

Size of Stage IIIA Primary Lung Cancers and Survival: A Surveillance, Epidemiology and End Results Database Analysis

Size of early-stage lung cancer is important in the prognosis of patients. We examined the large population-based Surveillance, Epidemiology and End Results database to determine if tumor size was an independent risk factor of survival in patients undergoing lobectomy for N2 positive Stage IIIA nonsmall cell lung cancer (NSCLC). This study identified 1971 patients diagnosed with N2 positive Stage IIIA NSCLC, from 1998 to 2007, and who underwent lobectomy. Five tumor groups based on the seventh edition TNM lung cancer staging system (pathologic T1a 2 cm or less; T1b greater than 2 cm and 3 cm or less; T2a greater than 3 cm and 5 cm or less; T2b greater than 5 cm and 7 cm or less; T3 greater than 7 cm) were analyzed. Survival was reduced in patients with T3, T2a, and T2b tumors compared with patients with T1a and T1b ( P < 0.001). Survival estimates correlated with tumor size with poorer survival in T3 followed by T2b, T2a, and then T1b and T1a. Cohorts with T1a (hazard ratio [HR], 0.53; P = 0.01) and T1b (HR, 0.54; P = 0.01) were both found to have decreased hazard of death. Negative predictors of survival, in addition to increasing tumor size, included age and male gender, whereas positive predictors included tumor Grade I and upper lobe location. Increasing size of tumor is an independent negative risk factor for survival in patients undergoing lobectomy for N2 positive Stage IIIA NSCLC.

Which subgroup of patients with pathologic N2 non-small cell lung cancer benefit from surgery?

OBJECTIVE

Patients with pathologic N2 non-small cell lung cancer comprise a heterogeneous group. The objective of this study was to evaluate which subgroup of patients with pathologic N2 benefit from surgery in terms of survival probability.

METHODS

This retrospective study included 141 patients who had undergone major resection with pathologically proven N2 from 1990 to 2006 (103 with adenocarcinoma, 38 with squamous cell carcinoma). Patients undergoing preoperative induction therapy were excluded. Records were examined for age, gender, tumor size, surgical procedure, surgical side, clinical N status, primary tumor lobe, curative resection, and metastatic N2 stations.

RESULTS

In patients with adenocarcinoma, surgical procedure, clinical N status, curative resection, and metastatic N2 stations were significant prognostic factors in univariate analysis. Age and curative resection were significant factors in patients with squamous cell carcinoma. In multivariate analysis, clinical N2 (P = 0.003), incomplete resection (P = 0.04), and multi-station N2 (P = 0.004) were significant adverse prognostic factors in patients with adenocarcinoma, whereas only incomplete resection (P = 0.002) was significant in patients with squamous cell carcinoma. For adenocarcinoma patients with pathologic N2, the 5-year survival rates were 58.8% for clinical N0-1 and single-station N2, 50% for clinical N2 and single-station N2, 23.9% for clinical N0-1 and multi-station N2, and 0% for clinical N2 and multi-station N2.

CONCLUSIONS

Prognosis of patients with pathologic N2 can be grouped according to clinical N status and metastatic N2 stations in adenocarcinoma, but not in squamous cell carcinoma. Only adenocarcinoma patients with pathologic N2 appear to have heterogeneous subgroups with different prognoses.

Efficacy of convex probe endobronchial ultrasound (CP-EBUS) assisted transbronchial needle aspiration for mediastinal staging in non-small cell lung cancer cases with mediastinal lymphadenopathy

BACKGROUND AND OBJECTIVE

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a sampling method for the patients with non-small cell lung cancer (NSCLC) that have enlarged mediastinal lymph nodes that are detected with computed tomography (CT). We aimed to investigate the value of EBUS-TBNA in sampling enlarged mediastinal lymph nodes in the patient with NSCLC.

PATIENTS AND METHOD

From January 2007 to May 2009, patients were diagnosed NSCLC with CT scans showing enlarged lymph nodes (node >1 cm) or a positron emission tomography (PET/CT) finding of the mediastinum underwent EBUS-TBNA.

RESULTS

EBUS-TBNA was successfully performed in all 52 patients (mean age, 52 years; 45 men) from 93 mediastinal lymph nodes. EBUS detected lymph node metastasis in 40 patients (77%). 12 patients (23%) with negative lymph node samples were underwent mediastinoscopy. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EBUS-TBNA in the detection of mediastinal metastasis were 95 %, 100%, 100%, 83%, and 96%, respectively. EBUS-TBNA was uneventful, and there were no complications.

CONCLUSION

EBUS-TBNA is an effective, safe and minimally invasive procedure following PET/CT or CT scanning in the mediastinal staging of potentially operable NSCLC.

Re-appraisal of N2 disease by lymphatic drainage pattern for non-small-cell lung cancers: by terms of nodal stations, zones, chains, and a composite

PURPOSE

N2 non-small-cell lung cancer (NSCLC) is a heterogeneous disease with an extremely wide range of 5-year survival rates. A composite method of sub-classification for N2 is likely to provide a more accurate method to more finely differentiate prognosis of N2 disease.

METHODS

A total of 720 pN2 (T1-4N2M0) NSCLC cases were enrolled in our retrospective analysis of the proposed composite method. Survival rates were respectively calculated according to the N2 stratification methods: singly by "nodal stations", "nodal zones", or "nodal chains", or by combination of all three. Statistical analysis was carried out by Kaplan-Meier and Cox regression models.

RESULTS

A total of 10,199 lymph nodes (8059 mediastinal; 2140 hilar and intra-lobar) were removed. By nodal station, there were 173 cases of single-station involvement and 547 multi-stations. By nodal zone, there were 413 single-zone involvement and 307 with multiple zones. By nodal chain, there were 311 cases with single-chain and 409 multi-chain involvements. The overall 5-year survival was 20% and median survival time was 27.52 months. The 5-year survival was significantly better for cases of single-zone involvement, as compared to multi-zones (29% vs. 6%, p<0.0001). The 5-year survival rates of single- and multi-chains involvement were 36% and 8%, respectively (p<0.0001). When taking all of the above grouping methods into consideration, the N2 disease state could be further sub-classified into two subgroups with respective survival rates of 36% and 7% (p<0.0001). Subgroup I was composed of individuals with single-chain involvement and having either one or two station metastasis; individuals with any other metastasis combinations formed Subgroup II. Multivariate analysis revealed that the composite sub-classification method, number of positive lymph nodes, ratio of nodal metastasis, and pT information were the most important risk factors of 5-year survival.

CONCLUSIONS

By combining the three N2 stratification methods based on "stations", "zones", and "chains" into one composite method, prognosis prediction was more accurate for N2 NSCLC disease. Single nodal chain involvement, which may be either one or two nodal stations metastasis, is associated with best outcome for pN2 patients.

Prognostic factors for resected non-small cell lung cancer with pN2 status: implications for use of postoperative radiotherapy

BACKGROUND

For non-small cell lung cancer (NSCLC) patients with pN2 status, the use of postoperative radiotherapy (PORT) remains controversial. Here, we investigated the association between different clinicopathological features and postoperative therapy and local control and survival in patients with resected pN2 NSCLC.

METHODS

We retrospectively analyzed 83 patients with pN2 NSCLC who underwent resection at Vanderbilt University Medical Center between 1994 and 2004. The relationship between 10 prognostic factors-gender, age at diagnosis, histology, tumor size, number of nodal stations involved, positive node number, surgical margin, extracapsular extension (ECE), and use of postoperative chemotherapy and PORT-and 2-year local recurrence-free survival (LRFS), distant recurrence-free survival (DRFS), recurrence-free survival (RFS), and overall survival (OS) rates was evaluated. Univariate and multivariate analyses were conducted using the Kaplan-Meier method and Cox proportional hazards ratios, respectively.

RESULTS

On univariate analysis, PORT was significantly associated with greater LRFS, RFS, and OS rates, whereas chemotherapy was associated with a trend toward a higher OS rate. Negative surgical margins were predictive of a higher OS rate, and negative ECE was associated with higher LRFS and RFS rates. On multivariate analysis, only PORT and negative ECE were associated with a higher LRFS rate. On subgroup analysis, in negative ECE patients, PORT was significantly associated with a higher OS rate.

CONCLUSIONS

PORT is associated with a higher OS rate for patients with resected pN2 NSCLC with negative ECE but not with positive ECE. The absence of ECE may serve as a useful prognostic variable in the selection of pN2 NSCLC patients for PORT and warrants further investigation in randomized clinical trials.

Is there a subset of patients with preoperatively diagnosed N2 non-small cell lung cancer who might benefit from surgical resection?

OBJECTIVE

The role of surgery in the treatment of preoperatively diagnosed N2 non-small cell lung cancer remains controversial. This study sought significant prognostic factors to select candidates for surgery and assess prognosis.

METHODS

The study population included 277 patients who underwent primary resection (192) or induction chemotherapy followed by surgery (85) for preoperatively diagnosed, potentially resectable N2 non-small cell lung cancer. N2 descriptors were prospectively recorded. Kaplan-Meier curves were used to evaluate survival, and statistical significance of differences between curves was assessed by log-rank test. Cox regression was used for multivariate analyses.

RESULTS

Preoperative significant prognostic factors were number of mediastinal node levels involved (P < .001), symptom severity (P = .013), clinical T (P = .041), and induction chemotherapy (P = .001). Three groups with different prognoses were based on individual prognostic score. The group that did best had a median survival of 29.6 months. Postoperative predictors of survival were pathologic T (P = .003), tumor residue (P = .034), and number of mediastinal nodes involved (P < .001). Of 3 groups with different prognoses, the most favorable had a median survival as long as 42 months.

CONCLUSION

This study provides a practical tool that uses significant prognostic factors to predict which patients with preoperatively diagnosed N2 non-small cell lung cancer have better prognoses. Because patients with the favorable prognostic factors showed good long-term survival and excellent local disease control, surgery should still play an important role in the multimodality treatment of these patients.

The significance of one-station N2 disease in the prognosis of patients with nonsmall-cell lung cancer

BACKGROUND

A retrospective study was conducted to define the characteristics and the prognosis of N2 disease subgroups according to their patterns of spread.

METHODS

From January 1993 to December 2004, 1,329 patients underwent lung resection for bronchogenic carcinoma The records of all patients with positive mediastinal lymph nodes at the surgical specimen (pIIIA/N2) after radical resection were analyzed, and the pattern of mediastinal lymphatic spread was classified according to regional spread, to skip metastasis, and to one or two or more lymph node stations, in relation to primary tumor location. Age, sex, type of resection, right or left lesion, T status, primary tumor location, tumor size, tumor central or peripheral location, histology, and survival were recorded and analyzed. Survival was analyzed according to regional spread or not, number of mediastinal lymph node stations involved, and skip metastasis status.

RESULTS

Among 302 cases (22.7%) with positive mediastinal lymph nodes pIIIA/N2, 66 (22%) were skip metastases, 72 (24%) had a nonregional mode of spread, and 199 (66%) included two or more stations of mediastinal lymph node invasion. Cox regression analysis of all cases disclosed malignant invasion in only one mediastinal lymph node station as the only favorable factor of survival (p < 0.001, odds ratio 0.57, 95% confidence interval: 0.42 to 0.78).

CONCLUSIONS

The presence of one-station mediastinal lymph node metastasis in patients with nonsmall-cell lung cancer who underwent major lung resection with complete mediastinal lymph node dissection proved to be a good prognostic factor that should be taken into account in the future.

Completely resected non-small cell lung cancer: reconsidering prognostic value and significance of N2 metastases

BACKGROUND

Non-small cell lung cancer (NSCLC) mediastinal (N2) metastases are indicators of poor prognosis. Survival rates decrease with increasing number of N2 stations and involved lymph nodes as well as lymph node size and capsular invasion. Our purpose was to elucidate the impact lymph node-related variables on the outcome after surgical resection.

METHODS

We reviewed data of 2344 NSCLC patients who underwent curative resections with mediastinal lymphadenectomy, and 586 (25%) had N2 metastases. We studied the overall survival of N2 patients according to some important covariates.

RESULTS

Metastases involved single N2 stations in 386 patients (66%) and two or more in 200 (34%). Survival was not related with histology or pathologic tumor (pT), but was better when only one N2 station was involved (5-year overall survival 28.5% [median, 24 months] versus 17.2% [median, 14 months] respectively; p = 0.0002. For single N2 stations, capsular rupture, number, and size of lymph nodes were not significant prognostic factors. When the size of lymph node was analyzed (micrometastases, 53; nonbulky, 207; or bulky metastases, 126), overall survival differences between nonbulky and bulky N2 were significant: 5-year overall survival was 34% (median, 28 months) versus 23% (median, 23 months), respectively (p = 0.026). Presence of micrometastases was associated with a poor prognosis: 5-year overall survival of 21.4% (median, 23 months).

CONCLUSIONS

Prognosis was better for patients with single N2 stations when metastatic lymph nodes were not enlarged. However, the presence of lymph nodes micrometastases does not seems associated with a better outcome.

Treatment of Non-small Cell Lung Cancer-Stage IIIA

STUDY OBJECTIVES

Stage IIIA non-small cell lung cancer represents a relatively heterogeneous group of patients with metastatic disease to the ipsilateral mediastinal (N2) lymph nodes and also includes T3N1 patients. Presentations of disease range from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky multistation nodal disease. This review explores the published clinical trials to make treatment recommendations in this controversial subset of lung cancer.

DESIGN, SETTING, AND PARTICIPANTS

Systematic searches were made of MEDLINE, HealthStar, and Cochrane Library databases up to May 2006, focusing primarily on randomized trials, with inclusion of selected metaanalyses, practice guidelines, and reviews. Study designs and results are summarized in evidence tables.

MEASUREMENT AND RESULTS

The evidence derived from the literature now appears to support routine adjuvant chemotherapy after complete resection of stage IIIA lung cancer encountered unexpectedly at surgery. However, using neoadjuvant therapy followed by surgery for known stage IIIA lung cancer as a routine therapeutic option is not supported by current published randomized trials. Combination chemoradiotherapy, especially delivered concurrently, is still the preferred treatment for prospectively recognized stage IIIA lung cancer with all degrees of mediastinal lymph node involvement. Current and future trials may modify these recommendations.

CONCLUSIONS

Multimodality therapy of some type appears to be preferable in all subsets of stage IIIA patients. However, because of the relative lack of consistent randomized trial data in this subset, the following evidence-based treatment guidelines lack compelling evidence in most scenarios.

The IASLC Lung Cancer Staging Project: Proposals for the Revision of the N Descriptors in the Forthcoming Seventh Edition of the TNM Classification for Lung Cancer

INTRODUCTION

Accurate staging of lymph node involvement is a critical aspect of the initial management of nonmetastatic non-small cell lung cancer (NSCLC). We sought to determine whether the current N descriptors should be maintained or revised for the next edition of the international lung cancer staging system.

METHODS

A retrospective international lung cancer database was developed and analyzed. Anatomical location of lymph node involvement was defined by the Naruke (for Japanese data) and American Thoracic Society (for non-Japanese data) nodal maps. Survival was calculated by the Kaplan-Meier method, and prognostic groups were assessed by Cox regression analysis.

RESULTS

Current N0 to N3 descriptors defined distinct prognostic groups for both clinical and pathologic staging. Exploratory analyses indicated that lymph node stations could be grouped together into six "zones": peripheral or hilar for N1, and upper or lower mediastinal, aortopulmonary, and subcarinal for N2 nodes. Among patients undergoing resection without induction therapy, there were three distinct prognostic groups: single-zone N1, multiple-zone N1 or single N2, and multiple-zone N2 disease. Nevertheless, there were insufficient data to determine whether the N descriptors should be subdivided (e.g., N1a, N1b, N2a, N2b).

CONCLUSIONS

Current N descriptors should be maintained in the NSCLC staging system. Prospective studies are needed to validate amalgamating lymph node stations into zones and subdividing N descriptors.

Lung cancer: New surgical approaches

Over the past two decades, many surgical specialties have seen a dramatic shift from large, open operations with wide incisions towards more-minimal incisions and less-invasive procedures. Surgical techniques for lung cancer are no exception, and today, video-assisted thoracic surgical lobectomies are being performed with increasing frequency in large-volume thoracic practices. Despite these new surgical techniques, however, the most substantial innovations that have changed surgical outcomes occurred away from the operative theatre. In lung cancer, in particular, the last 20 years have witnessed the clinical debut of more sophisticated, more elegant and more accurate imaging modalities for improved screening, diagnostic and staging, such as the spiral CT scan, PET scan, PET/CT and the endobronchial ultrasound machine. This technology has been complimented by more targeted chemotherapeutic regimens, novel methods of administering more accurate and more concentrated doses of radiation therapy, and innovative local excisional methods, such as the Cyberknife and radiofrequency ablation. The result has been that surgical excision, although remaining the most effective local therapeutic modality in early-stage lung cancer, is no longer the 'lone ranger' treatment, but rather is part of a complex mosaic of multimodality therapy. As scientific advances continue to be translated into the clinic, this trend will inexorably continue with the advent of a molecular staging system using molecular markers and tumour profiling, which ultimately could enhance our ability to predict tumour chemosensitivity. In this brave new world, however, complete surgical resection of the lung cancer will continue to be critical.

Clinical Value of Serum Cytokeratin 19 Fragment and Sialyl-Lewis X in Non-Small Cell Lung Cancer

BACKGROUND

This study aimed to establish the clinical significance of preoperative serum cytokeratin 19 fragment (CYFRA21-1) and sialyl-Lewis x (SLex) as prognostic markers.

METHODS

The study involved 272 patients (181 male, 91 female; median age 69 years; range, 32 to 92) with non-small cell lung cancer (NSCLC) who underwent pulmonary resection with mediastinal lymph node dissection. Tumor markers carcinoembryonic antigen (CEA), squamous cell carcinoma antigen (SCC), CYFRA21-1, and SLex were examined.

RESULTS

A log-rank test revealed that age, gender, performance status, CEA, SCC, CYFRA21-1, and SLex were associated with the survival rate. By multivariate analysis, age, gender, performance status, CYFRA21-1 (risk ratio, 2.42) and SLex (risk ratio, 6.18) were independent prognostic factors. For patients positive for both markers, the relative risk was 6.10 compared with patients negative for both markers. The patients were divided into three groups: negative for both CYFRA21-1 and SLex (n = 97); positive for either marker (n = 136); and positive for both markers (n = 39). The 1-, 3-, and 5-year survival rates were the following: 98%, 82%, and 75% in the first group; 90%, 63%, and 49% in the second group; and 62%, 31%, and 25% in the third group (p < 0.001). Sixty-four percent of patients positive for both markers were histologic stage III/IV, and 68% of patients negative for both markers were stage I.

CONCLUSIONS

Serum CYFRA21-1 and SLex were prognostic markers for NSCLC. Their combination should contribute to the classification of NSCLC patients. Preoperative staging should be carefully performed in patients positive for both tumor markers.

The Future in Diagnosis and Staging of Lung Cancer

Surgical techniques remain central to the diagnosis and staging of lung cancer. Clinical situations which invoke the role of surgery include the diagnosis of solitary pulmonary masses, staging of the mediastinum, restaging of the mediastinum and the assessment of resectability. The techniques available include cervical mediastinoscopy, anterior mediastinotomy, video-assisted thoracoscopy and different procedures for intra-operative mediastinal lymph node assessment including systematic nodal dissection, lobe-specific nodal dissection and sentinel node mapping. The staging of lung cancer is continuously evolving as technological advances combine with clinical advances to better stratify patients into treatment and prognostic categories and alter pre-operative investigation algorithms. Although most of the surgical techniques have been around for many years, it is their application in future which is likely to change. The increasing use of positron emission tomography/computed tomography fusion imaging is raising the proportion of patients being shown to have additional lesions that could contraindicate surgical treatment but which require tissue confirmation to exclude a false-positive examination. Many such lesions are amenable to the expanding techniques available to the interventional endoscopist. The relationship between the surgeon and the endoscopist must become closer to ensure that the appropriate technique is used at each point in the patient's pathway. The future of surgical techniques will be driven by: (1) developments in screening and imaging, with a likelihood that more early stage cancers will present and may be amenable to minimally invasive surgical approaches with the possibility of a role for robotics and nanotechnology; (2) improvements in neoadjuvant therapies which will demand flawless mediastinal staging and restaging; (3) advances in molecular biology which, whilst currently requiring that surgery provide samples of tumour and lymph node tissue to fully characterize the disease, do hold the promise that ever smaller amounts of tissue will be required and that eventually the genetic fingerprint will provide a biological ultrastaging to perhaps supersede anatomical staging.

High serum concentrations of Sialyl Lewisx predict multilevel N2 disease in non-small-cell lung cancer

BACKGROUND

The purpose of this study was to analyze the clinical significance of serum Sialyl Lewisx (SLX) concentrations as a predictor of N2 disease in patients with non-small-cell lung cancer.

METHODS

The study included 272 patients with non-small-cell lung cancer who underwent pulmonary resection in our institution between January 1998 and December 2003. Of 272 patients, the serum concentrations of SLX were measured by using a commercially available radioimmunoassay kit.

RESULTS

The 5-year survival rates of patients with concentrations of SLX > 38 U/mL and those with lower concentrations were 32% and 69%, respectively (P < .0001). The median serum concentration of SLX in patients with multilevel N2 or N3, single-level N2, and N0/1 disease were 44, 30, and 27 U/mL, respectively. The concentrations of serum SLX in patients with multilevel N2 disease were significantly higher than those in patients with single-level N2 or those with N0/1 disease (Mann-Whitney U-test; P < .0001). Although the sensitivity of SLX for identifying patients with non-small-cell lung cancer was only 24% in all patients, the sensitivity of SLX increased as the N-factor increased; the sensitivity of N0/1 disease was 15%, that of single-level N2 disease was 22%, and that of multilevel N2 or N3 disease was 71%.

CONCLUSIONS

High serum concentrations of SLX predicted multilevel N2 disease and the associated poor outcome. Although the sensitivity of serum SLX is not acceptable for use as a screening tumor marker, we suggest that the serum concentration of SLX is useful as a staging marker to determine the strategy of treatment.

Complete resection via medial sternotomy for non-small cell lung cancer in the right upper lobe

BACKGROUND

Right upper lobectomy with right cervical and bilateral mediastinal lymph node dissection via a median approach was performed for non-small cell lung cancer.

METHODS

From 1995 to 2003, 48 patients aged < or = 70 years underwent resection of cancer in the right upper lobe, including 26 with N0, four with N1 and 18 with N2 disease.

RESULTS

Metastases to the right cervical, highest mediastinal, pretracheal and bilateral tracheobronchial lymph nodes were frequent. There were no operative or hospital deaths. Preoperative accuracy of N-factor diagnosis was only 35.4%. The overall 5-year survival rate was 58.8%. The rate for C-N2 disease (n = 18) was 42.6%, and the rate for p-N2 disease (n = 7) and p-N3 disease (n = 13) was 57.1% and 0%, respectively, using the Kaplan-Meier method.

CONCLUSIONS

Patients without N3 disease have a good prognosis, and extended and systematic radical lymphadenectomy via median sternotomy improves the staging, and possibly the prognosis of pure N2 disease.

Combined Video-Assisted Mediastinoscopy and Thoracoscopy in the Management of Lung Cancer: A Five-Year Experience

OBJECTIVE

The aim of this study was to assess the usefulness of combined video-assisted mediastinoscopy (VM) and video-assisted thoracoscopy (VT) in the management of patients with lung cancer.

METHODS

A prospective observational study was performed over a 5-year period. Indications for combined VM and VT included inconclusive findings from imaging techniques concerning locoregional extension and resectability; possible involvement of different structures not accessible to a single procedure; and failure to obtain a histologic diagnosis with a single technique.

RESULTS

An indication for combined exploration was established in 30 patients, representing 2.6% of all the patients referred to us for diagnosis, staging, and/or resection of lung cancer. Combined VM and VT was completed in 28 patients, as pleural carcinosis was found at VT in 2 cases. There was no mortality or morbidity in our series. Histologic diagnosis was obtained in 12/13 patients without preoperative histologic typing. In all the evaluated patients, combined VM and VT was useful in clinical decision-making, leading to immediate surgery (n=10), induction treatments (n=8), or nonsurgical therapy (n=12). Among the patients who underwent immediate surgery, combined VM and VT never failed to assess the T factor. The N factor was correctly evaluated in 8/10 patients, and in 2 patients it failed to recognize a minimal N2 disease.

CONCLUSION

Combined VM and VT is a safe and useful tool in the management of selected patients with lung neoplasms. Both the extent of primary tumor and the possible intrathoracic spread can be thoroughly evaluated.

Mediastinal Staging 2005: Pictures, Scopes, and Scalpels

Staging of the mediastinum for lung cancer has matured dramatically with the advent of newer technologies in imaging and endoscopic surveillance. Some of these technologies such as positron emission tomography (PET) scanning are becoming mainstream in the evaluation of patients with clinically suspicious mediastinal disease as seen on computed tomography (CT), while others such as endobronchial ultrasound are reserved for specialty expertise and await validation. While much improvement has been made in the accurate preoperative staging of patients having surgery as the primary modality in lung cancer, controversy exists regarding the restaging of locally advanced cases after induction chemotherapy or chemoradiotherapy. A major concentration on these restaging issues is warranted since it is now generally agreed that sterilization of the mediastinum after induction therapy has an impact on the prognosis of patients with stage IIIA disease, and accurate staging after therapy may rationally guide diverse therapeutic interventions in these patients.

Vascular endothelial growth factor expression in pN2 non-small cell lung cancer: Lack of prognostic value

OBJECTIVE

Although several previous studies have investigated the prognostic significance of vascular endothelial growth factor (VEGF) expression in non-small cell lung (NSCL) cancer, no previous study has concentrated on NSCL cancer with pathologically abnormal mediastinal nodes (pN2).

METHODOLOGY

A total of 60 patients with pN2 NSCL cancer who had undergone a complete resection with a systematic mediastinal lymph node dissection were reviewed retrospectively. Immunohistochemical examination, using antibodies against VEGF, was conducted. The prognostic significance of VEGF expression and clinicopathological factors were analysed.

RESULTS

The overall 5-year survival rate was 21.7%. With respect to clinicopathological factors, single N2 involvement and skip metastasis were significantly associated with patients' survival. Expression of VEGF was found in 35/60 (58.3%) patients. VEGF expression was not related to the clinicopathological parameters examined. There was no relationship between survival rates and patients positive and negative for VEGF. Multivariate analysis showed that single N2 disease was an independent prognostic factor, while VEGF expression was not.

CONCLUSIONS

Although VEGF expression might be important for tumour development and maintenance, no prognostic significance of VEGF expression in pN2 NSCL cancer was found.

Prolonged survival in patients with resected non-small cell lung cancer and single-level N2 disease

OBJECTIVES

To test the hypothesis that patients with non-small cell lung cancer and single-level N2 metastases constitute a favorable subgroup of patients with mediastinal metastases, we analyzed the results of the Eastern Cooperative Oncology Group 3590 (a randomized prospective trial of adjuvant therapy in patients with resected stages II and IIIa non-small cell lung cancer) by site of primary tumor and pattern of lymph node metastases.

METHODS

Accurate staging was ensured by mandating either systematic sampling or complete dissection of the ipsilateral mediastinal lymph nodes. The overall survival of patients with left lung non-small cell lung cancer and metastases in only 1 of lymph node levels 5, 6, or 7 and right lung non-small cell lung cancer with metastases in only 1 of levels 4 or 7 was compared with that of patients with N1 disease originating in the same lobe.

RESULTS

The median survival of the 172 patients with single-level N2 disease was 35 months (95% confidence interval: 27-40 months) versus 65 months (95% confidence interval: 45-84 months) for the 150 patients with N1 disease (median follow-up 84 months, P =.01). However, among patients with left upper lobe tumors, survival was not significantly different between patients with N1 disease and patients with single-level N2 disease (49 vs 51 months, P =.63). The median survival of the 71 patients with single-level N2 metastases without concomitant N1 disease (skip metastases) was 59 months (95% confidence interval: 36-107 months) versus 26 months (95% confidence interval: 16-36 months) for the 145 patients with both N1 and N2 metastases (P =.001).

CONCLUSIONS

Survival of patients with left upper lobe non-small cell lung cancer and metastases to single-level N2 lymph nodes is not significantly different from that of patients with N1 disease. The presence of isolate N2 skip metastases is associated with improved survival when compared with patients with both N1 and N2 disease. Survival should be reported by the lobe of primary tumor and metastatic pattern to guide future clinical trial development, treatment strategies, and revisions of the TNM staging system.

Prognosis in N2 NSCLC

The prognosis of bronchogenic carcinoma in stage III N2 is poor. Five-year survival ranges between 0 and 5%. Lymph-node involvement itself still is the main prognostic factor. Complete lymphadenectomy improves long-term survival in contrast to lymph-node sampling. Recent studies have indicated that the number of involved lymph nodes could be another prognostic factor. It has also been proved that complete lymphadenectomy is necessary for correct staging. This also applies to preoperative staging prior to neoadjuvant treatment. For this reason exact knowledge of lymph-node anatomy and drainage is required. To achieve assessment and comparison of mediastinal staging and of lymphadenectomy, the number of pathologically examined lymph nodes should be documented. Other prognostic factors within N2 stages are age and T stage. Molecular markers are subject to major investigation. A definite clinical relevance, however, could so far not be verified for any of them.

Results of surgical intervention for p-stage IIIA (N2) non-small cell lung cancer: acceptable prognosis predicted by complete resection in patients with single N2 disease with primary tumor in the upper lobe

OBJECTIVES

Non-small cell lung cancer with mediastinal lymph node involvement is a heterogeneous entity different from single mediastinal lymph node metastasis to multiple nodes or extranodal disease. The objective of this study was to identify the subpopulation of patients with N2 disease who can benefit from surgical intervention.

METHODS

We reviewed 219 consecutive patients with N2 non-small cell lung cancer treated with a thoracotomy between November 1980 and June 2002 and retrospectively analyzed 154 of those who had p-stage IIIA disease and underwent a complete resection. Age, sex, side (right or left), histology, location (upper or middle-lower lobe), tumor size, c-N factor, and N2 level (single or multiple) were used as prognostic variables.

RESULTS

The 3- and 5-year survivals were 45.3% and 28.1%, respectively, in patients with p-stage IIIA (N2) disease. Survival for those with single N2 non-small cell lung cancer was significantly better than in those with multiple N2 disease (P =.0001), and patients with a tumor in the upper lobe showed a significantly longer survival than those with middle-lower lobe involvement (P =.0467). The 3- and 5-year survivals for patients with single N2 disease with a primary tumor in the upper lobe were 74.9% and 53.5%, respectively. A multivariate analysis with Cox regression identified 5 predictors of better prognosis: younger age, squamous cell carcinoma as determined by histology, primary tumor location in the upper lobe, c-N0 status, and a single station of mediastinal node metastasis.

CONCLUSION

Our results suggest that of the heterogeneity of N2 diseases, patients with single N2 disease with non-small cell lung cancer in the upper lobe are good candidates for pulmonary resection.

Equivalent outcome of patients with clinical Stage IIIA non–small-cell lung cancer treated with concurrent chemoradiation compared with induction chemotherapy followed by surgical resection

PURPOSE

To compare the outcome of induction chemotherapy followed by surgery (C/S) and concurrent chemoradiotherapy (CRT) for clinical Stage IIIA non-small-cell lung cancer (NSCLC).

METHODS AND MATERIALS

Between 1990 and 2000, 107 patients underwent either induction C/S (n = 55) or concurrent CRT (n = 52) for clinical Stage IIIA NSCLC at The University of Texas M. D. Anderson Cancer Center. Patient and tumor characteristics were balanced in the two treatment groups with respect to T and N stage, race, median age, performance status, weight loss, and histologic findings. In the C/S group, induction chemotherapy included two to four cycles of cisplatin-based chemotherapy followed by lobectomy and mediastinal lymph node dissection. Postoperative RT was delivered in 35 patients, with referral for RT made at the discretion of the treating physician. CRT consisted of three cycles of cisplatin-based chemotherapy given every 3 weeks concurrent with RT to 60-63 Gy in 30-35 fractions in 27 patients and 69.6 Gy in 58 fractions (b.i.d.) in 25 patients. Local control, overall disease-free survival, and distant metastasis-free survival rates were calculated using the Kaplan-Meier method. The median follow-up duration was 20 months in all patients and 32 months in surviving patients.

RESULTS

No statistically significant differences were found in the end points measured in the two treatment groups. Specifically, the median survival time was 31 and 27 months and the 5-year overall survival rate was 33% and 30% in the C/S and CRT groups, respectively. Likewise, the 5-year local control (58% vs. 61%), disease-free (24% vs. 23%), and distant metastasis-free (44% vs. 36%) survival rates in the two groups were not significantly different. In the C/S group, postoperative RT significantly improved the 5-year local control rate from 33.8% to 81.5% (p = 0.007) but did not significantly improve overall survival. Additionally, patients in the C/S group whose disease responded to induction chemotherapy had a significantly improved 5-year overall survival rate (50%) compared with those who had stable or progressive disease (16%, p = 0001).

CONCLUSION

Treatment of Stage IIIA NSCLC using either induction C/S or CRT resulted in similar outcomes in terms of local control and median overall, 5-year overall, distant metastasis-free, and disease-free survival. However, patients undergoing induction C/S often needed postoperative RT to achieve local control equivalent to that achieved with concurrent CRT. Advances in radiation-based treatment as reflected in this study have resulted in similar outcomes compared with modern induction C/S. To improve survival, however, newer systemic agents that reduce and control distant metastasis are required.