Results of surgical treatment in N2 lung cancer

Upfront surgery in patients with clinical skip N2 lung cancer based on results of modern radiological examinations

Background

Direct lymphatic drainage from a primary tumor to the right paratracheal or aortic window lymph nodes is often noted in pN2 disease. This multi-institutional retrospective study investigated the outcomes of upfront surgery in patients with clinical skip N2 disease (N2 disease without N1 disease) and a tumor in the right upper lobe or left upper segment based on results of modern radiological examinations, including positron emission tomography (PET).

Methods

We identified 143 patients with cN2 disease who underwent upfront surgery in 12 institutions under the Thoracic Surgery Study Group of Osaka University between January 2006 and December 2013. Among 143 patients, 94 who underwent PET were analyzed. We classified these patients into Group A (n=39; clinical skip N2 disease and a tumor in the right upper lobe or left upper segment) and Group B (n=55; other).

Results

The median follow-up was 56.5 months. Among the 94 patients, 50 (53.2%) had skip N2 disease and 65 (69.1%) had a tumor in the right upper lobe or left upper segment. The 5-year overall survival (OS) rates of the 94 patients with cN2 disease was 47.9%. The 5-year OS rates for the cN2pN0/1 (n=22) and cN2pN2 (n=70) groups were 74.9% and 41.2%, respectively (P=0.034). The univariate analysis of OS revealed no significant differences in age, sex, histology, carcinoembryonic antigen (CEA) level, tumor size, PET findings, and number of metastatic lymph nodes when these parameters were dichotomized. A significantly better 5-year OS rate was observed in Group A than in Group B (64.0% vs. 37.0%; P=0.039). The multivariate analysis of OS revealed that Group A was a significantly prognostic factor (P=0.030).

Conclusions

Patients with cN2 disease in Group A had a more favorable prognosis. Upfront surgery may be a treatment option for such selected patients with non-small lung cancer in the specific group.

Outcomes of initial surgery in patients with clinical N2 non-small cell lung cancer who met 4 specific criteria

PURPOSE

The role of surgery for patients with non-small cell lung cancer (NSCLC) with clinical mediastinal lymph node metastasis (N2) remains controversial. We specified 4 criteria for performing initial surgery in these patients (single-station N2, non-bulky N2, N2 with regional mode of spread, and N2 without N1) and examined the outcomes to validate the treatment options.

METHODS

Between September 2002 and December 2010, of 1290 patients who underwent complete resection for NSCLC, 808 patients underwent initial standard resection, including 779 patients with cN0-1 and 29 with cN2. We compared the outcomes, and evaluated patients with cN2-pN2.

RESULTS

The median follow-up was 45.5 months (3-119 months). Seventy (9.0 %) and 24 (82.8 %) patients had p-N2 in the cN0-1 and cN2 groups, respectively (p < 0.0001). The 5-year disease-free survival (DFS) rates in the cN0-1 and cN2 groups were 73.3 and 50.6 %, respectively (p = 0.0053), and the 5-year overall survival (OS) rates were 81.3 and 71.1 %, respectively (p = 0.051). The 5-year DFS and OS of patients with cN2-pN2 were 52.5 and 72.6 %, respectively.

CONCLUSIONS

Patients with clinical N2 disease based on our criteria represent a highly specific group with a favorable prognosis. Resection should therefore be the initial treatment for these patients.

Role of particle beam therapy in a trimodality approach to locally advanced non-small cell lung cancer

Lung cancer accounts for nearly one-fifth of all cancer deaths worldwide and is the most common cause of cancer-related death in the United States. Outcomes for locally advanced non-small cell lung cancer remain extremely poor with regards to both local control and overall survival. Modest gains in local control were obtained with the incorporation of multimodality treatment, including preoperative chemotherapy followed by surgical resection; combination chemoradiotherapy also improved survival, secondary to improved local control. While the natural progression to trimodality therapy resulted in superior local control, it did not translate to improved overall survival, secondary to increased toxicity. The additional morbidity is likely from radiation toxicity, the minimization of which will be crucial to the future success of trimodality therapy. One strategy to decrease toxicity is to utilize charged particles, such as protons, which deposit a high dose at the Bragg peak with a minimal dose beyond the peak, thereby reducing the dose to distal normal tissues. Trimodality therapy incorporating preoperative proton radiation therapy and chemotherapy, followed by surgery, is currently being evaluated as a potential strategy to achieve improved local control and overall survival in locally advanced non-small cell lung cancer.

Hope for progress after 40 years of futility? Novel approaches in the treatment of advanced stage III and IV non-small-cell-lung cancer: Stereotactic body radiation therapy, mediastinal lymphadenectomy, and novel systemic therapy

Non-small-cell lung cancer (NSCLC) remains a leading cause of cancer mortality. The majority of patients present with advanced (stage III-IV) disease. Such patients are treated with a variety of therapies including surgery, radiation, and chemotherapy. Despite decades of work, however, overall survival in this group has been resistant to any substantial improvement. This review briefly details the evolution to the current standard of care for advanced NSCLC, advances in systemic therapy, and novel techniques (stereotactic body radiation therapy [SBRT], and transcervical extended mediastinal lymphadenectomy [TEMLA] or video-assisted mediastinal lymphadenectomy [VAMLA]) that have been used in localized NSCLC. The utility of these techniques in advanced stage therapy and potential methods of combining these novel techniques with systemic therapy to improve survival are discussed.

Complete resection in lung cancer surgery: proposed definition

OBJECTIVE

To propose an internationally accepted definition of complete resection in lung cancer surgery.

MATERIAL AND METHODS

The International Association for the Study of Lung Cancer (IASLC) Staging Committee created the Complete Resection Subcommittee in 2001 to work on an international definition of complete resection in lung cancer surgery. The previous definitions of complete resection and the rules of the International Union Against Cancer regarding the TNM residual tumor classification, together with a thorough review of the pertinent literature, and the input of the members of the IASLC Staging Committee were considered in order to get an international consensus on the definition of complete resection in lung cancer surgery.

RESULTS

Complete resection requires all of the following: free resection margins proved microscopically; systematic nodal dissection or lobe-specific systematic nodal dissection; no extracapsular nodal extension of the tumor; and the highest mediastinal node removed must be negative. Whenever there is involvement of resection margins, extracapsular nodal extension, unremoved positive lymph nodes or positive pleural or pericardial effusions, the resection is defined as incomplete. When the resection margins are free and no residual tumor is left, but the resection does not fulfill the criteria for complete resection, there is carcinoma in situ at the bronchial margin or positive pleural lavage cytology, the term uncertain resection is proposed.

CONCLUSION

The proposed definitions of complete, incomplete and uncertain resections are clear and reproducible in an international setting to study their prognostic impact prospectively.

Prognostic significance of micrometastasis in non-small-cell lung cancer

Accurate staging of non-small-cell lung cancer (NSCLC) determines prognosis and facilitates decisions regarding treatment options. Unfortunately, even after an apparently complete resection in patients with stage I disease, the recurrence rates range from 25% to 50%, and overall survival is not encouraging. One possible reason for this may be that those patients with a poor outcome actually have more extensive disease, with occult locoregional and/or distant metastasis than originally identified by routine pathologic staging techniques. There is now a sizable body of literature on the detection and possible prognostic role of occult disease in lung cancer. The majority of these studies are based on immunohistochemical analysis of lymph nodes and/or bone marrow, but a handful of studies use molecular approaches. The purpose of this review is to summarize and critique the current literature on occult tumor cell spread to lymph nodes and bone marrow in patients with NSCLC. Based on this literature, we believe that the prognostic significance of bone marrow micrometastasis remains unclear. However, the majority of studies indicate that occult lymph node disease is associated with a poor outcome. Thus, our ability to detect individual tumor cells could result in more accurate staging of NSCLC in patients and would potentially lead to the development of novel therapies, as well as influence decisions regarding the use of appropriate multimodality treatment strategies, the choice of surgical technique, and extent of dissection. As data accumulate, the presence or absence of occult nodal involvement should probably be considered at the next revision of the staging system for NSCLC.

Lobe-specific extent of systematic lymph node dissection for non-small cell lung carcinomas according to a retrospective study of metastasis and prognosis

BACKGROUND

Complete lymphadenectomy of the mediastinum is advised for patients with lung cancer to provide prognostic information and possible survival benefit. The proper extent of dissection should be further defined.

METHOD

The lymphatic metastatic patterns according to the primary site and prognoses were retrospectively analyzed in 166 patients with non-small cell carcinoma who underwent at least lobectomy with hilar and mediastinal lymphadenectomy. All patients had histologically proven mediastinal metastasis (pN2).

RESULTS

Among 54 right upper lobe tumors the most common site of metastasis was the lower pretracheal station (74%), whereas metastases to the subcarinal station were seen only in 13%. Among 8 patients with right middle lobe tumors and 41 patients with right lower lobe tumors, both superior mediastinal and subcarinal stations were involved. The 34 left upper segment tumors metastasized to the aorticopulmonary window most commonly (71%) and to the subcarina only in 12% of cases. Inversely, the 10 left lingular tumors metastasized to the subcarina most commonly (50%) and to the aorticopulmonary window only in 20% of cases. Among 44 left lower lobe tumors the subcarinal station was most common for metastasis (58%), with infrequent metastases to the aorticopulmonary window. The 5-year survival for all 166 patients was 35%. Patients with single-station and single-node metastases had a significantly better prognosis than those with more extensive metastases. Right lower lobe tumors with superior mediastinal metastasis carried a particularly poor 5-year survival of only 4.1%.

COMMENT

Subcarinal lymphadenectomy is not always necessary for tumors of the right upper lobe and left upper segment. For tumors of other lobes both superior mediastinal dissection and subcarinal dissection are advised. However, superior mediastinal metastasis should be recognized as an indicator of poor prognosis in tumors of both lower lobes.

Effectiveness of radical systematic mediastinal lymphadenectomy in patients with resectable non-small cell lung cancer: results of a prospective randomized trial

OBJECTIVE

To evaluate the effectiveness of lymphadenectomy in the treatment of non-small cell lung cancer (NSCLC).

SUMMARY BACKGROUND DATA

The extent of lymphadenectomy in the treatment of NSCLC is still a matter of controversy. Although some centers perform mediastinal lymph node sampling (LS) with resection of only suspicious lymph nodes, others recommend a radical, systematic mediastinal lymphadenectomy (LA) to improve survival and to achieve a better staging.

METHODS

In a controlled, prospective, randomized clinical trial, the effects of LA on recurrence rates and survival were analyzed, comparing LS and LA in 169 patients with operable NSCLC.

RESULTS

After a median follow-up of 47 months, LA did not improve survival in the overall group of patients (hazard ratio: 0.78; 95% confidence interval: 0.47-1.24). Although recurrences rates tended to be reduced among patients who underwent LA, these decreases were not statistically significant (hazard ratio: 0.82; 95% confidence interval: 0.54-1.27). However, analysis of subgroups of patients according to histopathologic lymph node staging revealed that LA appears to prolong relapse-free survival (p = 0.037) with a borderline effect on overall survival (p = 0.058) in patients with limited lymph node involvement (pN1 disease or pN2 disease with involvement of only one lymph node level); in patients with pN0 disease, no survival benefit was observed.

CONCLUSIONS

Radical systematic mediastinal lymphadenectomy does not influence disease-free or overall survival in patients with NSCLC and without overt lymph node involvement. However, a small subgroup of patients with limited mediastinal lymph node metastases might benefit from a systematic lymphadenectomy.

Impact of radical systematic mediastinal lymphadenectomy on tumor staging in lung cancer

The extent of lymphadenectomy in the treatment of non-small cell lung cancer is still a matter of controversy. While some centers perform mediastinal lymph node sampling with resection of only suspicious lymph nodes, others recommend a radical, systematic mediastinal lymphadenectomy (LA) to improve survival and achieve a better staging. Herein we report on the impact of LA on tumor staging in a controlled, prospective, randomized clinical trial comparing lymph node sampling and LA in a total of 182 patients with operable non-small cell lung cancer. Regardless of the type of lymphadenectomy performed, the percentage of patients with pathologic N1 or N2 (sampling: n = 23, 23.0%; LA: n = 22, 26.8%) disease was very similar in both groups, indicating that systematic radical lymphadenectomy is not an essential prerequisite to determine the N stage of a patient. In contrast, the number of patients detected to have lymph node involvement at multiple levels was significantly increased by LA. In the lymph node sampling group only 4 of 23 patients (17.4%) with N2 disease were found to have more than one lymph node level involved, whereas LA results in the detection of excessive N2 disease in 12 of 21 patients (57.2%; p = 0.007), which was associated with a shorter distant metastases-free (p = 0.021) and overall survival. In conclusion, LA is not essential to determine the N stage of a patient, but results in a more detailed staging of the N2 region, which is of prognostic significance. Therefore, it might be useful to identify patients with a higher risk for tumor relapse.

Radical systematic mediastinal lymphadenectomy in non-small cell lung cancer: a randomized controlled trial

The value of radical systematic lymphadenectomy in the treatment of bronchial carcinoma is controversial. In a randomized controlled clinical trial, radical lymphadenectomy was compared with conventional node dissection in 182 patients with non-small cell lung cancer. Comparison of short-term results revealed a significantly longer operating time in those undergoing systematic lymphadenectomy, but overall morbidity and mortality rates were comparable between groups. However, there were complications associated with radical lymphadenectomy such as prolonged air leakage and haemorrhage. Interim analysis of results at a median follow-up of 26.8 months showed no significant influence of radical lymphadenectomy on local recurrence-free interval, metastasis-free interval or cancer-related survival. In conclusion, radical systematic lymphadenectomy is a safe operation that leads to a better staging of non-small cell lung cancer, but its prognostic benefit is questionable.

Lung cancer in Australia

Lung cancer is the leading cause of death of cancer in Australian men and the third leading cause in Australian women. Efforts are being made to reduce the incidence of this disease by smoking-cessation programmes and improved industrial hygiene, and these measures need to be encouraged strongly by all sectors of the community. On a population basis, insufficient evidence is available to justify screening procedures for the early detection of lung cancer in "at-risk" groups. Cure is possible by surgical resection in early cases. Improvements in therapeutic results with traditional cancer treatments largely have reached a plateau, but a number of newer therapies, and combinations of standard therapies, currently are being evaluated. Of particular interest is concurrent radiotherapy and chemotherapy in localized non-small-cell lung cancer; laser "debulking" in conjunction with radiotherapy in non-small-cell lung cancer, and biological response-modifying agents in non-small-cell and small-cell lung cancer. It is important that data be collected adequately to define epidemiological changes and to evaluate treatment results (including repeat bronchoscopy, to assess local control of tumour), and that the quality of life is recorded and reported in the evaluation process. Finally, phase-III studies in lung-cancer treatments require adequate numbers of subjects to enable meaningful conclusions to be achieve objectives within a reasonable study period.

The role of surgery in N2 lung cancer

Whereas most physicians believe that long-term survival is unlikely when mediastinal lymph node metastases are present, a significant number of these patients do have resectable tumors with encouraging long-term survival results. Data are presented to support this view, and steps identified to guide the physicians in selecting the patients who can benefit from this surgical approach.

New frontiers in the treatment of lung cancer

Surgical resection still is the only significant curative approach in nonsmall cell lung cancer. Recent surgical experience indicates that a modest decrease in the death rate from bronchogenic carcinoma may occur in three general areas: (1) the detection and treatment of radiographically occult squamous cell carcinoma; (2) the combination of adjuvant chemotherapy and surgical excision in selected patients with small cell carcinoma; and (3) surgical resection and postop irradiation of patients with hilar and mediastinal lymph node metastases. At the time of diagnosis, 80 to 85% of the patients present with unresectable lung cancer. These patients may benefit from other modalities of therapy, i.e., radiotherapy, chemotherapy, or immunotherapy. Failures following radiotherapy in unresectable nonsmall cell lung cancer are due to (1) distant metastasis, (2) local region failure, and (3) local and distant failure. To increase the local control, new methods of treatment have been tried, such as hyperfractionation of radiotherapy and the use of 131I antiferritin immunoglobulin. The development of effective systemic chemotherapy is necessary to treat metastatic bronchogenic carcinoma. The response rate to chemotherapeutic agents is substantially lower in nonsmall cell carcinoma than in small cell carcinoma. Investigation is ongoing to assess the effectiveness of new antitumor drugs used alone, in combination with other drugs, or combined with other modalities for the treatment of bronchogenic carcinoma.

Fifteen years surgical experience with carcinoma of the lung

This review has emphasized the need to manage carcinoma of the lung with a systematic approach. Diagnostic and staging procedures should be performed to prevent unnecessary thoracotomy. In patients with limited pulmonary reserve, segmentectomy or wedge resection is an acceptable procedure. A staging mediastinal node dissection should be included in every resection for lung cancer. Those patients with positive mediastinal nodes found in this manner should receive postoperative mediastinal irradiation.

Value of perioperative brachytherapy in the management of non-oat cell carcinoma of the lung

Nearly one-half of all patients with non-oat cell carcinoma of the lung are found to have mediastinal lymph node metastases at the time of initial presentation. There is no consensus today on what constitutes best treatment in patients whose disease is confined to the chest and in whom mediastinal lymph node metastases are the only evident site of tumor spread. The overall survival of these patients is so low that the majority have been either excluded from therapy or have been treated palliatively by external radiation therapy. In an attempt to improve the control of mediastinal lymph node metastases in the operable patients, we began a pilot study in 1977 at Memorial Hospital to determine the value of perioperative brachytherapy (permanent Iodine-125 implantation of primary lung and a temporary Iridium-192 implantation of the mediastinum) with or without resection followed by a moderate dose of postoperative external beam irradiation. Eighty-eight patients with disease limited to one hemithorax (N2 MO) were treated with this combined method during the period 1977 through 1980. Locoregional control was observed in 76% of the 88 patients. The median survival is 26 months and the 2 year actuarial survival is 51%. There was no post-operative mortality. This pilot study has demonstrated that the combination of surgery, perioperative brachytherapy and external beam irradiation in non-oat cell carcinoma of the lung, metastatic to mediastinal lymph nodes, can improve the locoregional control and prolong survival with minimal early or late morbidity.