Current Surgical Therapy for Stage IIIA (N2) Non-Small Cell Lung Cancer

Multimodality therapy in subclassified stage IIIA-N2 non-small cell lung cancer patients according to the Robinson classification: heterogeneity and management

Background

Non-small cell lung cancer (NSCLC) with mediastinal lymph node involvement (N2) is a heterogeneous entity. The objective of this analysis is to investigate the results of treatment strategies for N2-positive patients.

Methods

Retrospective study (2009-2014) of 104 consecutive patients with stage IIIA-N2 NSCLC classified according to the Robinson classification (IIIA1-IIIA4) and treated within a multimodality treatment regime.

Results

The Robinson subgroups were: IIIA1 (n=27), IIIA3 (n=60) and IIIA4 (n=17). We had no stage IIIA2 samples because we did not perform an intraoperative frozen section of lymph nodes. Surgical resection with systematic lymph node dissection was performed in all patients with stage IIIA1 (n=27). After chemotherapy or chemo-/radiotherapy, 53.3% of patients in stage IIIA3 (n=32) and 11.7% of patients in stage IIIA4 (n=2) underwent surgery with curative intention. R0 was achieved in 92.6% in stage IIIA1, 93.8% in stage IIIA3 and 100% in stage IIIA4. The 30-day mortality was 3.2%. The overall median survival was 31.7 months (5-year survival was 30.5%). There were no significant differences (P=0.583) in survival regarding the Robinson subgroups. Patients who underwent tumour resection had significantly better median survival (39.8 vs. 19.6 months; P=0.014) compared to patients treated conservatively. Deviation from the interdisciplinary recommended therapy (12%) led to a reduced median survival (11.4 vs. 31.8 months; P=0.137).

Conclusions

N2-patients should be subclassified according to the Robinson classification and discussed in the tumour board. Surgical resection should be recommended in specific cases of N2-disease (non-bulky, sensitivity to systemic treatment).

From Diagnosis to Treatment: Clinical Applications of Nanotechnology in Thoracic Surgery

Nanotechnology is an emerging field with potential as an adjunct to cancer therapy, particularly thoracic surgery. Therapy can be delivered to tumors in a more targeted fashion, with less systemic toxicity. Nanoparticles may aid in diagnosis, preoperative characterization, and intraoperative localization of thoracic tumors and their lymphatics. Focused research into nanotechnology's ability to deliver both diagnostics and therapeutics has led to the development of nanotheranostics, which promises to improve the treatment of thoracic malignancies through enhanced tumor targeting, controlled drug delivery, and therapeutic monitoring. This article reviews nanoplatforms, their unique properties, and the potential for clinical application in thoracic surgery.

Modern outcome and risk analysis of surgically resected occult N2 non-small cell lung cancer

BACKGROUND

This study was performed to assess the incidence, survival, and risk factors associated with unsuspected pathologic N2 disease in patients with resectable clinical N0-1 non-small cell lung cancer.

METHODS

Between January 2002 and December 2010, 1,821 patients with clinical N0-1 non-small cell lung cancer underwent pulmonary resection and mediastinal lymph node dissection. Clinical outcomes and risk factors for pathologic N2 disease were retrospectively analyzed for this cohort.

RESULTS

Unsuspected pathologic N2 disease was identified in 196 patients (10.8%). The most common type of resection was lobectomy (81.6%). Adjuvant therapy was administered in 177 patients (90.3%). The median follow-up time was 28 months (range, 1 to 101 months). N2 involvement was single-station in 121 (66.8%) and multiple-station in 65 (33.2%). The 5-year overall and disease-free survival rates were 56.1% and 35.0%, respectively. The 5-year survival rates of single-station and multiple-station N2 were 66.6% and 36.4%, respectively (p < 0.001). Adenocarcinoma, clinical N1, tumor size (>3 cm), and a right middle lobe tumor were identified as independent risk factors for unsuspected multiple-station N2 disease by multivariate analysis. Incidence of unsuspected multiple-station N2 disease in low-risk classes (aggregate score, 0 to ≤2) was only 5.5%.

CONCLUSIONS

The incidence of unsuspected N2 disease in our cohort was similar to that of previous reports. Survival outcomes were favorable for unsuspected single-station N2 disease but were poor for unsuspected multiple-station N2 disease. Clinical N0-1 non-small cell lung cancer patients with risk class of low score for unsuspected multiple-station N2 disease can be exempted from aggressive mediastinal staging.