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Surgical multimodality treatment for baseline resectable stage IIIA-N2 non-small cell lung cancer. Degree of mediastinal lymph node involvement and impact on survival

^a Leuven Lung Cancer Group, Department of Thoracic Surgery, University Hospital Leuven, Leuven, Belgium
^b Leuven Lung Cancer Group, Department of Pneumology, University Hospital Leuven, Leuven, Belgium

Received 12 November 2008; received in revised form 23 March 2009; accepted 6 April 2009.

^_* Corresponding author. Address: Department of Thoracic Surgery, University Hospital Leuven, Herestraat 49, B-3000 Leuven, Belgium. Tel.: +32 16 346820; fax: +32 16 346821. (Email: Herbert.decaluwe{at}uzleuven.be).

Objective: Analysis of single centre results and identification of prognostic factors of surgical combined modality treatment in pathological proven stage IIIA-N2 non-small cell lung cancer (NSCLC). Methods: Out of a total of 996 resections for NSCLC between 2000 and 2006, 92 patients with radiological response or stable disease after induction chemotherapy for pathologically proven ipsilateral positive lymph nodes (N2-disease) underwent surgical exploration with the aim of complete resection. Adenocarcinoma and squamous cell carcinomas were equally present (48% vs 43%). Median follow-up of surviving patients (n = 36) was 51 (10–94) months. Results: Complete resection (i.e., tumour with free margins and negative highest mediastinal lymph nodes, R0) was achieved in 68% (n = 63), resection was uncertain or incomplete in 24% (n = 22), while surgery was explorative in 8% (n = 7). Pneumonectomy was performed in 24%, (bi)lobectomy in 62%, and sleeve lobectomy in 13% of patients. In-hospital mortality was 2.3%. Overall need for ICU stay was 18% (30% after pneumonectomy). Median hospital stay was 10 days (6–157). Downstaging of mediastinal lymph nodes (ypN0-1) was found in 43% (n = 40). Overall survival at 5 years (5YS) was 33% (n = 92), and after complete resection 43% (n = 63). Detection of multilevel compared to single level positive nodes at initial mediastinoscopy was related to lower 5YS (17% vs 39%; p < 0.005), and this was identified as an independent prognostic factor in a multivariate analysis of the examined presurgical variables. We found a trend for a better 5YS in patients with mediastinal nodal downstaging compared to patients with persistent N2 disease (49% vs 27%; p = 0.095). In the subgroup with persistent N2 disease, single level disease has a significantly better survival (37% vs 7% 5YS, p < 0.005). Multivariate survival analysis of the examined surgical variables identified completeness of resection and classification of ypN category (ypN0-1 and ypN2-single level vs multilevel-ypN2 and ypN3) as independent prognostic factors. Conclusions: Surgery after induction chemotherapy for stage IIIA-N2 NSCLC can be performed with an acceptable mortality and morbidity. Baseline single level N2 disease is an independent prognostic factor for long-term survival. Patients with mediastinal downstaging, but also a subgroup of patients with single level persistent N2 disease, after induction therapy have a rewarding survival.

Key Words: Non-small-cell lung cancer • Positive mediastinal lymph nodes • Stage IIIA-N2 • Induction therapy • Pneumonectomy • Lobectomy

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				P. A. Thomas Stage IIIA N2 non-small-cell lung cancer: current controversies in combined-modality therapy Eur. J. Cardiothorac. Surg., September 1, 2009; 36(3): 431 - 432. [Full Text] [PDF]