Aggressive surgical intervention in N2 non-small cell cancer of the lung

Radio-Guided Lung Surgery: A Feasible Approach for a Cancer Precision Medicine

BACKGROUND

Radio-guided surgery is a reliable approach used for localizing ground-glass opacities, lung nodules, and metastatic lymph nodes. Lung nodules, lymph node metastatic involvement, and ground-glass opacities often represent a challenge for surgical management and clinical work-up.

METHODS

PubMed research was conducted from January 1997 to June 2023 using the keywords "radioguided surgery and lung cancer".

RESULTS

Different studies were conducted with different tracers: technetium-99m-albumin macroaggregates, cyanoacrylate combined to technetium-99m-sulfur colloid, indium-111-pentetreotide, and fluorine-18-deoxyglucose. A study proposed naphthalocyanine radio-labeled with copper-64. Radio-guided surgery has been demonstrated to be a reliable approach in localizing a lesion, and has a low radiological burden for personnel exposure and low morbidity. The lack of necessity to conduct radio-guided surgery under fluoroscopy or echography makes this radio-guided surgery an easy way of performing precise surgical procedures.

CONCLUSIONS

Radio-guided surgery is a feasible approach useful for the intraoperative localization of ground-glass opacities, lung nodules, and metastatic lymph nodes. It is a valid alternative to the existing approaches due to its low cost, associated low morbidity, the possibility to perform the procedure after several hours, the low radiation dose applied, and the small amount of time that is required to perform it.

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.

Cisplatin plus vinorelbine as induction treatment in stage IIIA non-small cell lung cancer

Survival rates in patients with stage IIIA non-small cell lung cancer (NSCLC) remain low despite curative treatment. This is due to tumor recurrence at distant sites. The aim of neoadjuvant chemotherapy (NA-CT) is to eradicate occult micrometastatic disease and improve survival in patients that are not candidates for surgery following induction therapy. A total of 21 patients with ipsilateral mediastinal node involvement (N2) with potentially resectable disease, who had been diagnosed with stage IIIA (T1-3 N1-2 and T4N0) NSCLC and who had received cisplatin and vinorelbine as induction treatment were included in this retrospective study. Patients who responded to the treatment underwent surgery, and those who were unresponsive received radical radiotherapy. Follow-up was conducted between March 2008 and April 2014. The median age of patients was 61 years, and all patients exhibited a good Eastern Cooperative Oncology Group performance status. The majority of patients were histologically diagnosed with adenocarcinoma (48%) or squamous cell carcinoma (38%), which was a poor prognostic factor for overall survival (OS). A total of 7 patients underwent surgery (of which 6 were down-staged), with a 3-year survival rate of 42.8%. The most significant factor associated with response to induction treatment was multistation nodal involvement. The complete resection rate for surgical patients was 85.7%. Unresectable patients had a 3-year survival rate of 25.8%. OS time for the whole cohort was 28.5 months, and the 3- and 5-year OS rates were 28.5% and 4.7%, respectively. CT-induced toxicity did not affect any treatment regime or surgical procedures. In conclusion, the use of cisplatin plus vinorelbine is feasible in a neoadjuvant setting, with good response rates and acceptable toxicity. Multistation N2 involvement is the main prognostic factor for a poor response to induction treatment.

Optimum treatment for mediastinal lymph node positive (N2) resectable non-small cell lung cancer: what is the role for surgery?

INTRODUCTION

A third of patients with Non-Small Cell Lung Cancer (NSCLC) present with Stage III disease with mediastinal (N2) nodal involvement representing an extremely heterogeneous population with a generally poor prognosis. Areas covered: This article describes the complexity of Stage III-N2 patients reviewing the outcomes of key clinical trials while highlighting the trial designs and subtleties that have created controversy in management. Both bimodality approaches combining chemotherapy with either surgery or radiation and trimodality approaches combining chemotherapy with both local therapies are reviewed. Finally, prognostic factors and future directions are explored for the management of this population. Expert commentary: Upfront surgery is not recommended for patients with Stage III-N2 NSCLC. Neoadjuvant approaches with both chemotherapy and chemoradiation are acceptable in a multidisciplinary setting if appropriate surgery is performed by a dedicated thoracic surgeon. Non-operative candidates should receive definitive concurrent chemoradiation. Innovative approaches are necessary to improve outcomes in this population.

The ratio of cancer cells to stroma after induction therapy in the treatment of non-small cell lung cancer

PURPOSE

Induction therapy induces degenerative changes of various degrees in both cancerous and non-cancerous cells of non-small cell lung cancer (NSCLC). The effect of induction therapy on histological characteristics, in particular the ratio of residual cancer cells to non-cancerous components, is unknown.

METHODS

Seventy-four NSCLC patients treated with induction therapy followed by surgery were enrolled. Residual cancer cells were identified using anti-pan-cytokeratin antibody (AE1/AE3). We analyzed and quantified the following three factors via digital image analysis; (1) the tumor area containing cancer cells and non-cancerous components (TA), (2) the total area of AE1/AE3 positive cancer cells (TACC), (3) the percentage of TACC to TA (%TACC). These factors were also analyzed in a matched control group (surgery alone, n = 80).

RESULTS

The median TACC of the induction therapy group was significantly lower than that of the control group (p < 0.01). In addition, the median %TACC of the induction therapy group (5.9 %) was significantly lower than that of the control group (58.6 %) (p < 0.01). TACC had a strong positive correlation with TA in the control group (r = 0.93), but not in the induction therapy group. Conversely, TACC had a strong positive correlation with %TACC in the induction therapy group (r = 0.95), but not in the control group.

CONCLUSION

Unlike the control group, the smaller the total area of residual cancer cells, the higher residual tumor contained non-cancerous components in the induction group, which may be the characteristic histological feature of NSCLC after induction therapy.

Survival of Patients after Resection for Lung Cancer

Purpose:

The predictive value of staging of primary lung cancer by CT and thoracotomy with respect to survival was assessed in a series of 151 consecutive patients.

Material and Methods:

The new international staging system for lung cancer was used, with an additional indeterminate stage employed for cases in which a definite classification was impossible by CT.

Results:

The survival rate curves for the stage groups assessed at CT and thoracotomy showed moderate to good parallelism. The patients with tumor stage I at thoracotomy but indeterminate or IIIa at CT had a significantly lower survival rate than those scored stage I at both. It was concluded that a sign of tumor spread obtained at any of the investigations should lead to an active approach, increasing the radicality of surgery or omitting noncurative operations.

Multimodality treatment with surgery for locally advanced non-small-cell lung cancer with n2 disease: a review article

Stage III non-small-cell lung cancer (NSCLC) is composed of a heterogeneous population of lesions (ie, T4N0-3, T3N1-3, and T1a-2aN2-3), which makes it difficult to establish a definitive treatment strategy. Although several retrospective and prospective studies have been conducted to investigate the significance of multimodality treatments with surgery for patients with resectable stage III NSCLC, the role of surgery still remains controversial. In this article, we review the results of retrospective and prospective studies that have investigated the significance of multimodality treatment with surgery for patients with stage III NSCLC, particularly those with mediastinal lymph node metastasis, and the implications for the treatment of this controversial subset of patients.

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.

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.

Nodal involvement pattern in resectable lung cancer according to tumor location

The aim in this study was to define the pattern of lymph node metastasis according to the primary tumor location. In this retrospective cohort study, each of the operable patients diagnosed with lung cancer was grouped by tumor mass location. The International Association for the Study of Lung Cancer nodal chart with stations and zones, established in 2009, was used to define lymph node levels. From 2006 to 2010, 197 patients underwent a lobectomy with systematic nodal resection for primary lung cancer at Chiang Mai University Hospital. There were 123 male and 74 female patients, with ages ranging from 16– 85 years old and an average age of 61.31. Analyses of tumor location, histology type, and nodal metastasis were performed. The locations were the right upper lobe in 63 patients (31.98%), the right middle lobe in 18 patients (9.14%), the right lower lobe in 30 patients (15.23%), the left upper lobe in 55 patients (27.92%), the left lower lobe in 16 patients (8.12%), and mixed lobes (more than one lobe) in 15 patients (7.61%). The mean tumor size was 4.45 cm in diameter (range 1.2–16.5 cm). Adenocarcinoma was the most common histological type, which occurred in 132 cases (67.01%), followed by squamous cell carcinoma in 41 cases (20.81%), bronchiolo alveolar cell carcinoma in nine cases (4.57%), and large cell carcinoma in seven cases (3.55%). Eighteen cases (9.6%) had skip metastasis (mediastinal lymph node metastasis without hilar node metastasis). Adenocarcinoma and intratumoral lymphatic invasion were the predictors of mediastinal lymph node metastases. There were statistically significant differences between a tumor in the right upper lobe and the right lower lobe. However, there were no statistically significant differences between tumors in the other lobes. In conclusion, tumor location is not a precise predictor of the pattern of nodal metastasis. Systematic lymph node dissection is the only way to accurately determine lymph node status. Further studies are required for evaluation and conclusions.

Neo-Adjuvant Chemo/Immunotherapy in the Treatment of Stage III (N2) Non-Small Cell Lung Cancer: A Phase I/II Pilot Study

In a previous randomized study, we showed that adjuvant immunotherapy with tumor-infiltrating lymphocytes and recombinant interleukin-2 (rIL-2) significantly improved survival in resected N2-Non Small Cell Lung Cancer (NSCLC) patients. The present study assesses feasibility, safety and potential efficacy of combined neo-adjuvant chemotherapy and immunotherapy with peripheral blood mononuclear cells (PBMC) and rIL-2 in resectable N2-NSCLC patients. Eighty-two consecutive N2-NSCLC patients underwent neo-adjuvant chemotherapy with cisplatin and gemcitabine. Out of the 82 patients, 23 were also subjected to leukapheresis prior to neo-adjuvant chemotherapy while the remaining 59 did not. Collected PBMC were analyzed for viability and phenotype and then stored frozen in liquid nitrogen. Thawed PBMC were infused intravenously, 5 days before surgery. After the infusion, rIL-2 was administered subcutaneously until surgery. Only patients with a partial or complete response to neoadjuvant chemotherapy underwent surgery: 13 patients in the experimental immunotherapy group (A) and 32 in the reference group (B). The two groups were homogeneous for all major prognostic factors. Median leukapheresis yield was 10 billion PBMC, (range 3–24 billions). Two to six billion PBMC were infused. The phenotypic analysis showed that similar proportions of CD4 and CD8 cells were present in leukapheresis products, and thawed PBMC, as well as in T lymphocytes isolated from the removed tumours. No severe adverse effects were observed following immunotherapy. No significant differences in overall survival (OS) and event-free survival (EFS) were seen between the two groups. However, the 5-year OS in group A was almost twice as much compared to group B (59% vs 32%). After adjustment for major prognostic factors, a statistically significant 66% reduction in the hazard of death was seen in patients receiving immunotherapy. The OS benefit was more evident in patients with adenocarcinoma than in those with squamous cell carcinoma. This study supports the favorable toxicity profile and potential efficacy of combining neo-adjuvant chemotherapy and immunotherapy with PBMC and rIL-2 in the treatment of N2-NSCLC patients.

Significance of smoking history and FDG uptake for pathological N2 staging in clinical N2-negative non-small-cell lung cancer

BACKGROUND

This study was conducted to evaluate whether smoking history and the standardized uptake value (SUV) of 2-[fluorine-18]fluoro-2-deoxy-D-glucose (FDG) uptake are associated with unexpected pathological N2 status (pN2) in non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

We analyzed the data of 220 patients who underwent surgical resection with clinical N2-negative status on computed tomography (CT) and positron emission tomography (PET)-CT. The maximum SUV of primary tumor was chosen for logistic analysis.

RESULTS

Seventy-two patients (33%) had never smoked. The SUV ranged from 1.0 to 29.0 (median 9.1). In univariate analysis, adenocarcinomas (P = 0.019), female gender (P = 0.010), N1 on CT (P = 0.025), and N1 PET-CT (P = 0.001) were associated with a high probability of pN2. The proportion of pN2 in never smokers was higher than in ever smokers (26% versus 10% respectively; P = 0.002). The SUV remained on a multivariate logistic model (odds ratio 1.1; 95% confidence interval 1.0-1.2; P = 0.010) and it had a better predictive value in never smokers than in ever smokers (P = 0.017).

CONCLUSIONS

This study indicates an association between smoking history and pN2 in clinically negative N2 NSCLC. The different roles of FDG uptake were also suggested based on smoking history.

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.

The impact of multiple metastatic nodal stations on survival in patients with resectable N1 and N2 nonsmall-cell lung cancer

BACKGROUND

The aim of the study was to identify common prognostic factors in nonsmall-cell lung cancer (NSCLC) with N1 and N2 nodal involvement.

METHODS

A retrospective review of NSCLC patients who underwent primary surgical resection without neoadjuvant chemotherapy was performed. In all, 280 patients were included in this study, and there were 132 patients with N1 disease (N1 group) and 148 patients with N2 disease (N2 group). The median follow-up period was 26 months, and complete follow-up was possible in 269 patients (96%).

RESULTS

Lobectomy was performed in 194 patients (69%), bilobectomy was performed in 43 (15%), and pneumonectomy was performed in 43 (15%). Complete resection was possible in 273 patients (98%), and operative death occurred in 5 patients (2%). The overall and disease-free 5-year survival rates were 63% and 55%, respectively, in the N1 group, and 44% and 32%, respectively, in the N2 group (p < 0.05). The prognostic factors for overall survival in both the N1 and N2 groups were age and the number of metastatic nodal stations; however, N2 metastasis was not a significant prognostic factor in the multivariate analysis. The poor prognosis of the patients in the N2 group was due to the greater incidence of multiple node involvement in comparison with the N1 group (73% versus 15%; p < 0.05).

CONCLUSIONS

Multiple metastatic nodal stations was the common prognostic factor in resectable NSCLC patients with nodal metastasis, and mediastinal nodal involvement was associated with a higher chance of multiple-station metastasis in this study.

Closed three-port anatomic lobectomy with systematic nodal dissection for lung cancer

Closed three-port anatomic lobectomy of the lung with systematic nodal dissection was performed in 5 patients with clinical stage IA lung cancer. For removal of the resected specimen, a new technique was developed to avoid making an additional skin incision. No complications or deaths occurred after the operation, and all patients were alive longer than 27 months without recurrence, including 5-year survivors.

The evolution of treatment outcomes for resected stage IIIA non–small cell lung cancer over 16 years at a single institution

OBJECTIVES

The effect of multimodality treatment including surgical intervention, chemotherapy, and radiation for potentially resectable stage IIIA non-small cell lung cancer in a practice setting remains to be defined. To determine which treatment factors are associated with improved survival, we evaluated outcomes for these patients at our institution over a 16-year period.

METHODS

We surveyed our institutional pathology database from 1986 through 2001 for patients with resected pathologic stage IIIA (N2) non-small cell lung cancer. Three hundred fifty-three patients were confirmed to have appropriate pathologic staging and attempted complete resection. These patients were assessed by means of univariate and multivariable analysis for factors associated with long-term survival. Stage migration was estimated by using a classification based on nodal station involvement.

RESULTS

Median potential follow-up was 132 months. During the study period, 3- and 5-year survival increased; preoperative staging improved, relatively more lobectomies and fewer pneumonectomies were performed, and multimodality treatment was used more frequently. The number of positive N2 nodal stations did not change over time (P = .14). Surgical intervention alone resulted in 3-year survival of 30%, and perioperative chemotherapy, radiation, or both increased 3-year survival to 38% (P = .004). Multivariable analysis showed that male sex (hazard ratio, 1.44; 95% confidence interval, 1.13-1.84; P = .003), more than 2 positive mediastinal nodal stations (hazard ratio, 1.73; 95% confidence interval, 1.16-2.57; P = .007), R1 or R2 resection (hazard ratio, 1.72; 95% confidence interval, 1.22-2.41; P = .002), lower or middle lobe tumor location (hazard ratio, 1.63; 95% confidence interval, 1.28-2.08; P < .001), and surgical intervention alone (hazard ratio, 1.59; 95% confidence interval, 1.23-2.04; P < .001) were independent predictors of poor survival.

CONCLUSIONS

The use of multimodality therapy appears to contribute to improved outcomes over time in patients with resected stage IIIA (N2) non-small cell lung cancer.

Late Stage (III and IV) Non-small Cell Cancer of the Lung: Results of Surgical Resection at Inova Fairfax Hospital

One hundred forty-two patients underwent surgery and related treatment for advanced stage (III, IV) non-small cell cancer of the lung. One hundred seventeen patients underwent up-front surgery, with a hospital mortality rate of 1.7% (2/117). Kaplan-Meier 5-year survival in this group was 31% (+/- 5). Twenty-five patients underwent neoadjuvant therapy followed by surgical resection, with respective rates of hospital mortality, complete pathologic response, and major pathologic response of 0%, 16%, and 64%. Kaplan-Meier 5-year survival in this latter group was 34% (+/- 11). Of the 16 patients undergoing neoadjuvant therapy who had complete pathologic response or significant downstaging from stage III disease, Kaplan-Meier 5-year survival was 61% (+/- 15). Three clinical observations of interest emerged regarding survival. First, in those patients with postresection FEV1 < 1.0 L, hospital mortality rate was 20%, and there were no 5-year survivors (P < 0.0001). Second, where neoadjuvant therapy was associated with complete pathologic response or significant downstaging of disease, there was a trend for improved survival in the downstaged group, but it did not reach statistical significance (P = 0.14). Third, adjuvant therapy was associated with improved 5-year survival (P = 0.03), particularly for combination chemotherapy and radiotherapy (P = 0.02).

A pragmatic and successful approach to treating nonsmall-cell lung carcinoma

Lung cancer is the single leading cause of cancer deaths for men and women combined. Nonsmall-cell lung carcinoma (NSCLC), which results largely from smoking tobacco, accounts for 87% of all lung cancer cases. Methods of patient selection, preoperative and intraoperative care, and postoperative outcomes for patients with NSCLC who were treated from 1991 through 2003 at Inova Fairfax Hospital are discussed. All patients were treated with surgery, some selectively and progressively with a combination of preoperative neoadjuvant therapy, to try to downstage the disease to make complete resection feasible. Outcomes from this data collection period match or exceed the best results for treatment of late-stage (ie, III and IV) disease reported anywhere to date.

Long-term survival of surgically staged IIIA-N2 non-small-cell lung cancer treated with surgical combined modality approach: analysis of a 7-year prospective experience

BACKGROUND

The aim of this study was to analyse the outcome of surgically staged IIIA-N2 non-small-cell lung cancer (NSCLC) treated with induction chemotherapy followed by surgical exploration.

METHODS

Univariate and multivariate analyses were carried out on a prospective cohort of 131 mediastinoscopy-proven IIIA-N2 NSCLC patients. Three preoperative cycles of vindesine-ifosfamide-cisplatin (VIP) were given. Patients with at least stable disease (SD) were considered for surgery, or radical radiotherapy in selected cases.

RESULTS

The response rate after VIP was 54% (95% confidence interval 45% to 63%) and was important for the final outcome. The median and 5-year survival for the total group were 24 months and 21% (38 months and 30% in responders), respectively. Involvement of subcarinal nodes at diagnosis was the most important prognostic factor (P=0.022). Seventy-five patients were considered for surgery. Downstaging occurred in 34 of 70 resection specimens, with a pathological complete response in six. Median and 5-year survival in the surgical cohort were 45 months and 35%, respectively. Surgery was rewarding both in patients with a response and in those with SD, although the complete resection rate was significantly lower in the latter. On multivariate analysis, favourable prognostic factors were low pathological T-stage (P=0.001) and downstaging of mediastinal nodes in the resection specimen (P=0.008).

CONCLUSIONS

VIP induction chemotherapy followed by surgical exploration was rewarding in mediastinoscopy-proven stage IIIA-N2 NSCLC, both in cases of response and SD, despite a lower complete resection rate in the latter. Patients with subcarinal nodes at diagnosis (5-year survival 8.5%) or without nodal downstaging at post-induction surgery (13.7%) might preferably be treated with a non-surgical approach.

Optimal management when unsuspected N2 nodal disease is identified during thoracotomy for lung cancer: cost-effectiveness analysis

OBJECTIVES

Whether to proceed with lung resection when N2 nodal disease is identified at the time of thoracotomy for lung cancer is controversial. A decision analysis model was developed to address this question.

METHODS

A meta-analysis was performed on data from reports published between 1990 and 2002 evaluating survival for (1) patients who were treated by initial resection for clinically unsuspected N2 nodal disease (initial resection) and (2) survival for patients undergoing resection after neoadjuvant therapy for N2 nodal disease (no initial resection). Hospital cost data for surgery were derived from our institution, and cost data for chemotherapy and radiation therapy were obtained from current literature. A decision model was developed to compare initial resection to no initial resection from the perspective of the medical center using survival, quality-adjusted life years survival, and cost-effectiveness as outcomes.

RESULTS

The no initial resection option provided better median survival (2.1 versus 1.7 years), quality-adjusted life years (1.8 versus 1.3), and cost-effectiveness, with an incremental cost-effectiveness ratio of 17,119 dollars/quality-adjusted life year. Outcomes were influenced by survival estimates for each treatment option.

CONCLUSIONS

When N2 nodal disease is discovered during thoracotomy, the approach of delaying resection until after neoadjuvant therapy provides the best survival and is more cost-effective. This is likely due to the beneficial effects of neoadjuvant therapy and the exclusion of patients with more aggressive disease from the surgical candidate pool.

Operative results of clinical stage I non-small cell lung cancer

BACKGROUND

Clinical stage (c-stage) I non-small cell lung cancer (NSCLC) is generally indicated for surgery, however, surgical exploration sometimes reveals advanced disease, thus resulting in incomplete resection.

PATIENTS AND METHODS

A total of 645 consecutive patients were investigated in which 347 were diagnosed to have c-stage IA in 347 and 298 were diagnosed to have IB disease. All cases underwent operation and were investigated for resectability and the cause of an incomplete resection.

RESULTS

The c-Stage IA patients included 16.6% of T3/4 and 10.4% of N2 whereas clinical stage IB patients included 14.4% of T3/4 and 18.8% of N2/3. A complete resection was performed in 594 patients (91%). In 347 c-stage IA patients, the complete resection rates were 93% in adenocarcinomas (235/252), 100% in squamous cell carcinomas (76/76), and 89% in others (17/19). In 298 c-stage IB patients, the complete resection rates were 86% in adenocarcinomas (141/164), 90% in squamous cell carcinomas (90/100), and 94% in others (31/33). The 5-year survival rates of the c-stage IA and IB patients who underwent a complete resection were 66.4 and 48.3%, respectively. However, the same rates were 18.4 and 14.7% for c-stage IA and IB patients who underwent an incomplete resection. The reasons for an incomplete resection in 54 patients were malignant pleurisy in 38 (70.4%), extranodal invasion of mediastinal nodal metastasis in ten (19%), an incomplete bronchial margin in three (5.6%), and ipsilateral pulmonary metastases in two (3.7%), and ipsilateral adrenal metastasis in one (1.3%). In 13% of the c-stage IB adenocarcinomas, pleural metastasis was discovered during thoracotomy.

CONCLUSIONS

Pleural dissemination was the most frequent cause of an incomplete resection, and its prevalence was high in c-stage IB adenocarcinomas.

Long-term follow-up of patients with unresectable locally advanced non-small cell lung cancer treated with chemoradiotherapy: a retrospective analysis of the data from the Japan Clinical Oncology Group trials (JCOG0003A)

To clarify the long-term survival data and factors that are correlated with survival outcome of unresectable locally advanced non-small cell lung cancer (NSCLC) following chemoradiotherapy, we analyzed patients who entered the Japan Clinical Oncology Group (JCOG) clinical trials for unresectable locally advanced NSCLC. Between October 1989 and August 1997, 240 patients (male 207, female 33; PS (performance status) 0 58, PS 1 172, PS 2 9, unknown 1; stage IIB 2, IIIA 62, IIIB 175, unknown 1) entered the 6 trials. All patients received chemotherapy and radiotherapy. The associations between survival outcome and treatment-related factors were analyzed using Cox regression analysis. Median survival times and 5-year survival rates in the trials were 11.9-19.7 months and 0-17.6%, respectively. Median survival time was 16.1 months and the 5- and 7-year survival rates of all 240 patients were 14.4% and 12.0%, respectively. No deaths were observed 7 years after initiation of the treatment or later. For stage IIIA and IIIB patients, the 5-year survival rates were 16.3% and 13.4%, respectively. Node status and age were significantly associated with survival, but no factors of the treatment were associated with survival of patients with unresectable locally advanced NSCLC. The present retrospective analysis showed that approximately 12% of patients with unresectable locally advanced NSCLC could be cured by various chemoradiotherapy regimens.

The significance of tumour markers as an indication for mediastinoscopy in non-small cell lung cancer

OBJECTIVE

The purpose of this study was to verify the significance of tumour markers as indicators for mediastinoscopy in non-small cell lung cancer.

METHODOLOGY

In the past 4 years, 205 patients with non-small cell lung carcinoma (NSCLC) underwent surgical resection at Chiba Cancer Center, Chiba, Japan. The correlation between the serum levels of eight tumour markers (CEA, AFP, CA19-9, SCC, NSE, CA125, CYFRA, ProGRP) and the presence of N2 disease was analysed. Univariate and multivariate analyses were performed to determine the relationship between both marker levels and clinical findings and N2 disease.

RESULTS

In multivariate analysis, positive CEA was significantly associated with the diagnosis of N2 disease. We also demonstrated that when CA125, CYFRA and ProGRP were positive, they were individually significantly associated with N2 disease. However, CEA was superior to the other markers and equivalent to a combination of various tumour markers.

CONCLUSION

It was concluded that evaluation of CEA in addition to CT is of use in the diagnosis of N2 disease in NSCLC patients and should be used as an indication for mediastinoscopy.

Prognostic significance of persistent mediastinal metastasis following induction therapy in large (> or = 2 cm) N2 or N3 non-small cell lung cancer

OBJECTIVE

It is controversial whether or not surgery is beneficial for patients with non-small cell lung cancer accompanied by persistent lymph node metastasis in the mediastinum following induction therapy. We have therefore conducted a retrospective study to assess this issue.

METHODS

Eligibility criteria were defined as follows: 1) the period of treatment was between January 1991 and April 1998, 2) the clinical stages were IIIA (N2) or IIB (N3) with large lymph nodes (> or = 2 cm), 3) induction therapy had been administered, 4) tumor was resected completely, 5) at least one mediastinal lymph node had necrosis or scar if the pathological N status was p-N0 or p-N1 and 6) the p-stage was not IV. Dichotomous variables included the radiographic response of the tumor, the T status, and the N status.

RESULTS

Thirty-nine patients were eligible. There were 29 males and 10 females aged from 27 to 74 years, and involved 20 cases of adenocarcinoma. The pathological N status was as follows: p-N0 in 18 patients, p-N1 in 3, p-N2 in 16, and p-N3 in the other 2. In overall survival, the median survival time (MST) was 34 months and the actuarial 5-year-survival rate (5-YSR) was 28%. The group of patients with either N0 or N1 (n = 21) had a 71-month MST and a 54% 5-YSR, and the group of patients with either N2 or N3 (n = 18) had a 13-month MST and a 5-YSR of 0% (p < 0.0001). On multivariate analysis, the pathological N factor was confirmed as an independently significant.

CONCLUSIONS

Our retrospective study found that the survival rate of patients with persistent mediastinal nodal metastasis was very poor. A prospective study is needed to investigate whether or not surgery is beneficial for these patients.

Heterogeneity of stage IIIA non-small cell lung cancers (NSCLC) and evaluation of late results of surgical treatment

AIMS

The aim of the study was assessment of the heterogeneity of stage IIIA non-small cell lung cancers (NSCLC) and the late results of surgical treatment.

METHODS

The study group consisted of 83 consecutive patients discharged between 1988 and 1992 undergoing radical operative treatment for stage IIIA NSCLC. Squamous cell carcinoma was diagnosed in 54 (65.1%) patients, adenocarcinoma in 23 (27.7%), large cell carcinoma in 2 (2.4%) and mixed (i.e. adenoid-squamous type) in 4 (4.8%). In respect of pTNM staging, 19 (22.9%) patients had T3N1M0, 35 (42.2%) had T2N2M0 and 29 (34.9%) had T3N2M0.

RESULTS

Overall, 13.3% of patients with stage IIIA NSCLC survived 5 years following the operation and 8.7% survived 10 years. Analysis of follow-up study indicated that this group was heterogenic. In T3N1M0 group 26.3% survived 5 years following the operation, in T2N2M0 group 14.3%, in T3N2M0 group 3.5% (P = 0.015). Of 23 patients with N2 disease and no metastases in hilar lymph nodes ('skip' metastases), 26.1% survived 5 years, whereas none of 41 patients with metastases spreading by continuity survived (P = 0.0015). If mediastinal lymph node metastases were diagnosed in one level, 25% patients survived 5 years, but if two or more levels were affected, 2.3% only (P = 0.0214): 85.7% of patients with well-differentiated (G1) cancer survived 5 years and 62.0% 10 years, whereas among those with moderately differentiated (G2) tumours, 11.8% and 8.8%, respectively. No patient survived 5 years after resection of poorly differentiated (G3) cancer (P < 0.001).

CONCLUSIONS

(1) Patients operated for stage IIIA NSCLC are a heterogeneous group, which makes it difficult to predict late results. (2) Patients operated for stage IIIA NSCLC have a better prognosis if metastases are discovered in level one mediastinal lymph nodes, particularly in the superior part of mediastinum, or if 'skip' metastases (pulmonary hilus unaffected) are discovered, as compared to those with N2 disease. (3) Poor histologic differentiation of the tumour is a bad prognostic factor.

Invasive staging of non-small cell lung cancer: a review of the current evidence

STUDY OBJECTIVES

To determine the test performance characteristics of transbronchial needle aspiration (TBNA), transthoracic needle aspiration (TTNA), endoscopic ultrasound-guided needle aspiration (EUS-NA), and mediastinoscopy in staging non-small cell lung cancer (NSCLC).

DESIGN, SETTING, AND PARTICIPANTS

Systematic search of MEDLINE, HealthStar, and Cochrane Library databases to July 2001 and print bibliographies. Included were studies comparing staging results of TBNA, TTNA, EUS-NA, or mediastinoscopy against either tissue histologic confirmation or long-term clinical follow-up (> or = 1 year). Patients included were those with NSCLC or small cell lung cancer.

MEASUREMENT AND RESULTS

For patients with lung cancer, the pooled sensitivity for TBNA was 0.76, the pooled specificity was 0.96, and the negative predictive value (NPV) was 0.71. For TTNA, the pooled sensitivity was 0.91, with an NPV of 0.78. EUS-NA had a pooled sensitivity of 0.88, a pooled specificity of 0.91, and an NPV of 0.77. For standard cervical mediastinoscopy, the pooled sensitivity was 0.81, with an NPV of 0.91. The addition of either extended cervical mediastinoscopy or anterior mediastinotomy to standard cervical mediastinoscopy appeared to improve the sensitivity of any of the procedures alone.

CONCLUSIONS

Invasive clinical staging of NSCLC can be performed effectively by TBNA, TTNA, EUS-NA, or mediastinoscopy. Selection of the appropriate study is dependent on the degree of suspicion for metastatic disease, the patient's comorbid illnesses, and the availability and performance characteristics of procedural options.

Building a better therapy for stage IIIA non-small cell lung cancer

What do clinicians know about stage IIIA lung cancer? They know accurate staging is critical and requires wide application of mediastinoscopy. They know that surgery and radiation alone each can cure a small subset of patients, and complete resection is of the utmost importance in surgically treated patients. They know that chemotherapy can increase the number of patients cured when combined with definitive radiation, and concurrent chemoradiotherapy seems superior to sequential. Neoadjuvant chemotherapy also seems to cure more patients than surgery alone, but more data are necessary. Trimodality therapy remains a promising but unproved approach in patients with stage IIIA disease. With the exciting new molecularly targeted agents, trials examining quad-modality therapy are just around the corner.

Outcomes and cost-effectiveness of alternative staging strategies for non-small-cell lung cancer

PURPOSE

To identify the optimal strategy for staging the mediastinum of patients with known non-small-cell lung cancer (NSCLC), stratified by tumor (T) classification.

METHODS

We used a decision-analytic model to compare the health outcomes and cost-effectiveness of three staging strategies: (1) chest computed tomography alone, (2) selective mediastinoscopy, and (3) routine mediastinoscopy. The overall effectiveness and cost of each strategy was a function of the proportion of patients accurately staged and the risks, benefits, and costs of the diagnostic tests and treatments used. Probability estimates and costs were derived from primary data and the literature. We adopted a societal perspective and calculated incremental cost-effectiveness ratios (ICERs) as cost per quality-adjusted life year (QALY) gained.

RESULTS

Both mediastinoscopy strategies correctly identified more patients with mediastinal involvement (N2/N3 disease) and assigned them to multimodal regimens. Routine mediastinoscopy maximized quality-adjusted life expectancy in all patients, irrespective of T classification, and this result was robust to varying the model estimates over their reported ranges. In T1 patients, selective mediastinoscopy cost $24,500 per QALY gained, compared with $78,800 per QALY gained for routine mediastinoscopy. In T2 and T3 patients, the ICER of routine mediastinoscopy was more favorable ($42,800 and $53,400 per QALY gained, respectively).

CONCLUSION

Routine mediastinoscopy maximizes quality-adjusted life expectancy in patients with known NSCLC, and its ICER compares favorably with other currently accepted medical technologies. The survival benefit and cost-effectiveness of this strategy are greater in patients with T2 and T3 tumors and are likely to improve with advances in multimodal therapy.

Overall survival and local recurrence of 406 completely resected stage IIIa-N2 non-small cell lung cancer patients: questionnaire survey of the Japan Clinical Oncology Group to plan for clinical trials

BACKGROUND

the group of completely resected stage IIIA-N2 non-small cell lung cancer patients (NSCLC) is considered to be heterogeneous in various aspects including survival and the recurrent pattern. In the present study, we attempted to clarify the factors which separate these patients into high and low risk groups based on the survival and local recurrence.

METHODS

a questionnaire survey on the survival and local recurrence of non-small cell lung cancer patients with pathological stage IIIA-N2 disease who underwent a complete resection from January 1992 to December 1993 was performed by the Japan Clinical Oncology Group as of July 1999. The information on the survival of 406 patients and that of local recurrence in 332 of them was available.

RESULTS

the 5-year survival of the 406 patients was 31.0%. In a univariate analysis, the age, clinical and pathological T status, number of N2 stations, pathological N1 disease, operative modality and postoperative radiotherapy were all found to be important prognostic factors. Clinical N2 disease marginally influenced the survival (P=0.07). In a multivariate analysis of these variables including clinical N2 disease, the survival was significantly worse in the case of multiple N2 stations (hazard ratio=1.741), the presence of pathological N1 disease (1.403), pathological T2 or 3 disease (1.399) and an age older than 65 (1.327). The rate of freedom from any local recurrence at the bronchial stump, or in the hilar, mediastinal or supraclavicular lymph nodes at 5 years was 64%. In a univariate analysis of the freedom from local recurrence, the clinical N status, pathological T status, pathological N1 disease and number of N2 stations were all found to be important prognostic factors. A multivariate analysis revealed the freedom from local recurrence to be adversely influenced by multiple N2 stations (hazard ratio=2.05), and the presence of either clinical N1 or 2 (1.733) disease. The 5-year survival and the rate of freedom from local recurrence at 5 years were 43 and 75% in patients with a single N2 station and 17 and 48% in those with multiple N2 stations, respectively.

CONCLUSIONS

the number of N2 stations (single vs. multiple N2 stations) was found to be a useful prognostic factor, which can separate completely resected stage IIIA-N2 patients into high and low risk groups regarding both the overall survival and local recurrence.

Completely resected stage IIIA non-small cell lung cancer: the significance of primary tumor location and N2 station

BACKGROUND

The number of N2 stations (single vs multiple N2 stations) is an important prognostic factor in patients with completely resected stage IIIA-N2 non-small cell lung cancer. However, the significance of both the N2 station(s) actually involved and the primary tumor location remains unclear.

METHODS

The database was built with the use of a questionnaire survey on the survival of patients with pathologic stage IIIA-N2 non-small cell lung cancer completely resected between January 1992 and December 1993. The survey was performed by the Japan Clinical Oncology Group as of July 1999. The data include information on the survival and N2 stations of 402 patients.

RESULTS

A frequently metastasized single N2 station was the lower pretracheal station in primary tumors in the right upper lobe, the subaortic station in the left upper lobe, and the subcarinal station in the right middle or lower lobe and the left lower lobe. In multiple N2 stations, the frequency of metastasis of the N2 station observed in a single N2 station was as high as 72% to 89%, and one or two other frequently metastasized stations were added to each group. Regarding the survival of patients with a primary tumor in each lobe except for the left lower lobe, a single N2 station resulted in a significantly better survival than did multiple N2 stations. Furthermore, the overall survivals classified according to each primary site showed a significant difference among the four primary sites (P =.04).

CONCLUSIONS

The primary tumors in each lobe showed a prevalence of N2 station(s). The number of N2 stations is a good prognosticator except in patients with a primary tumor in the left lower lobe. In addition, the site of a primary tumor itself is also considered to influence the survival of the patients.

Nodal occult metastasis in patients with peripheral lung adenocarcinoma of 2.0 cm or less in diameter

BACKGROUND

Detection of occult micrometastasis in regional lymph nodes is crucial for diagnosis and selection of appropriate therapy for patients with pN0 non-small-cell lung carcinoma. Using immunohistochemical staining, we evaluated the impact of detection of occult micrometastasis on the prevalence and prognosis of patients with lung adenocarcinoma of 2.0 cm or less in diameter.

METHODS

A total of 103 pN0 disease patients with peripheral lung adenocarcinomas of 2.0 cm or less in diameter were enrolled in this study. We studied 1,438 regional lymph nodes for occult micrometastasis by immunohistochemical staining for cytokeratins.

RESULTS

Micrometastasis was detected in 49 lymph nodes (3.4%) of 21 patients (20.4%) but not in patients with localized bronchioloalveolar carcinoma or localized bronchioloalveolar carcinoma with foci of collapse of alveolar structure. The 5-year survival rate (61.9%) of patients with micrometastasis was significantly (p = 0.0041) lower than that of patients without micrometastasis (86.3%).

CONCLUSIONS

There still remains a risk of nodal micrometastasis in patients with primary peripheral lung adenocarcinoma, even if the diameter of the tumor is smaller than 2.0 cm. Selection of patients for limited surgery should be done prudently, taking into consideration the risk of nodal micrometastasis.

[Surgery and combined therapy for non-small cell lung cancer with invasion of the mediastinal nodes. A retrospective study]

OBJECTIVE

To analyze the survival of patients classified N2M0 (N2 cytology/histology)with non-small cell lung cancer treated by surgical resection of the primary tumor, lymphadenectomy and neo-adjuvant therapy.

PATIENTS AND METHODS

Among 1,043 consecutive patients with lung cancer treated between 1990 and 2000, 155 were classified N2M0 by histology. Of 130 patients undergoing thoracotomy, excision of the primary pulmonary tumor and lymphadenectomy were performed in 116. Among the 116 N2M0patients undergoing surgical resection, 23 were diagnosed N2c(c3)by mediastinoscopy and/or mediastinotomy and received induction chemotherapy (CT) with mitomycin/ifosfamide/cisplatin (3 cycles)and 93 were diagnosed N2pM0 after examination of samples of mediastinal lymph tissue taken during thoracotomy; for 19 of these patients,earlier surgical exploration of the mediastinum had been negative. The patient diagnosed N2p after thoracotomy also received CT and/or radiotherapy (RT). N2p patients who received induction CT also received RT. Those who were negative after lymphadenectomy and severely ill patients received no adjuvant therapy of any type.

RESULTS

Mean survival of resected patients (23/49) diagnosed N2(C3) by mediastinoscopy/mediastinotomy and who received induction CT was 18 months. Survival at 1, 2 and 5 years was 80%, 45% and 30%, respectively. No postoperative deaths occurred in this group. One patient developed a bronchopleural fistula. Nine patients showed no signs of residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients (93/106) diagnosed N2p after thoracotomy was 13 months and survival rates at 1, 2 and 5 years were 56%, 31% and 19%,respectively. Fourteen patients in this group died within 30 days of surgery. Nine patient developed bronchopleural fistulas. The difference in survival between the two groups was not significant.

CONCLUSIONS

Histologic or cytologic confirmation of N2 disease can be considered to indicate poor prognosis. Standard, complete surgery with induction CT in selected patients improves survival for those diagnosed N2 upon thoracotomy, with no statistically significant differences.

[Surgical treatment of non-small cell lung cancer with mediastinal node invasion. A retrospective study]

OBJECTIVE

To analyze the survival of patients classified as N2M0 (N2 by cytohistology) with non-small cell lung cancer treated by surgical resection of the primary tumor and lymphadenectomy.

PATIENTS AND METHODS

Among 1043 consecutive patients with lung cancer who were considered for surgery between 1990 and 2000, 155 were classified N2M0 by histology. Surgical exeresis of the primarily pulmonary tumor and lymphadenectomy were performed in 116 patients of the 130 patients who underwent thoracotomy. Among the 116 N2M0 patients undergoing surgical resection, 23 were diagnosed N2c(C3) by mediastinoscopy and/or mediastinotomy and were given induction chemotherapy (ChT) (mitomycin/ifosfami-de/cisplatin, 3 cycles) and 93 were diagnosed N2pM0 based on samples obtained from mediastinal lymph tissue during thoracotomy. Nineteen of the latter had previously been classified negative during surgical exploration. The patients diagnosed N2p after thoracotomy were given adjuvant ChT, radiotherapy or both. N2p patients who received induction therapy were given radiotherapy. Those found negative after lymphadenectomy and patients with severe disease were given no adjuvant treatment.

RESULTS

Mean survival was 18 months for resected patients diagnosed N2 by mediastinoscopy/mediastinotomy and with induction ChT and survival at one, two and five years was 80%, 45% and 30%, respectively. No postoperative mortality was recorded in this group. One patient suffered bronchopleural fistula. Nine patients showed no residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients diagnosed N2p by thoracotomy was 13 months, and one, two and five year survival rates were 56%, 31% and 19%, respectively. Fourteen patients died within 30 days of surgery. Nine patients developed a bronchopleural fistula. The difference in survival of the two groups was not significant.

CONCLUSIONS

The prognosis after cytohistologic confirmation of N2 disease can be considered poor. Standard, complete surgery plus induction therapy in screened patients improved survival for those diagnosed N2 by thoracotomy, with no statistically significant differences.

Neoadjuvant chemoradiotherapy of stage III non-small-cell lung cancer

Twenty to 30% of patients with non-small-cell lung cancer (NSCLC) in stage III are not resectable primarily with 5-year survival less than 10%. Since the majority of patients die from metastases, efforts have been made in the past to improve prognosis by application of neoadjuvant chemoradiotherapy regimens followed by subsequent resection. In a phase II study performed between 1993 and 1998, 93 patients in stage III (IIIA, 16%; IIIB, 84%) received an induction chemotherapy consisting of two cycles cisplatin (100 mg/m2) and vindesine (3 mg/m2) with subsequent sequential radiotherapy of 36 Gy. Sixty-five patients demonstrated partial or complete remission. Sixty underwent surgery; in 49 of them complete resection was possible. Five-year survival in the whole group was 24%, and that in the surgical cohort 39%. Six patients had no residual tumor. Postoperative N0 status was associated with a 5-year survival of 75%, and stage N1-3 with 13%. Thirty-day mortality was 7% postoperatively. Neoadjuvant chemoradiotherapy can significantly improve long-term survival in stage III NSCLC with an acceptable therapy-induced mortality.

Assessing the prognostic value of the extent of mediastinal lymph node infiltration in surgically-treated non-small cell lung cancer (NSCLC)

Although there have been several attempts in dividing N2 patients into several subgroups on the basis of different prognoses, the correct treatment for these patients is still a moot point. Even multimodal treatment, which is the most common therapy used, does not result in a consistent outcome. The aim of our study is to assess the prognostic value of the extent of mediastinal lymph node infiltration in surgically treated non-small cell lung cancer (NSCLC). From January 1990 to December 1997, 682 patients underwent surgery for NSCLC at the Thoracic Surgery Unit, University Hospital of Siena, 87 of which (12%) had mediastinal involvement. Studies on the number of lymph node stations show that those with one station involved tend to have a better 5-year survival rate with respect to the others. We studied the number of lymph node stations by using a new critique based on the percentage of lymph node infiltration. The percentage is obtained from a ratio of the number of involved nodes to the total number of nodes removed. The result was an improved 5-year survival ratio in patients with lymph node infiltration, lower than 50% with respect to the others, and the difference was significant (P=0.0001). It appears that surgery may be the most suitable option for treating those N2 patients that we consider to be in 'early N2 phase', in view of long term survival. Although an invasive technique like mediastinoscopy seems to be the appropriate indicator in selecting N2 patients, it does not allow the calculation of the ratio a priori.

Neoadjuvant therapy and surgical resection for locally advanced non-small cell lung cancer

During the past 15 years, treatment of stage IIIA (N2) non-small cell lung cancer has evolved considerably because of improvements in patients selection, staging, and combined modality therapy. Results of several clinical trials suggest that induction chemotherapy or chemoradiation and surgical resection is superior to surgery alone. However, the optimal induction regimen has not been defined. An intergroup trial is also underway to determine whether chemoradiation and surgical resection leads to better survival than chemotherapy and radiation alone. Future studies will assess ways to combine radiation and novel chemotherapeutic agents, and will identify molecular abnormalities that predict response to induction therapy.

Anastomotic complications after bronchoplastic procedures for nonsmall cell lung cancer

BACKGROUND

Anastomotic complications associated with bronchoplastic procedures cannot be completely avoided despite the improvements made in surgical techniques and suture materials. Thus, the present study attempted to clearly define the significant factors influencing anastomotic complications.

METHODS

Between 1978 and 1998, 47 patients with primary nonsmall cell lung cancer underwent bronchoplastic procedures. The incidences of anastomotic complications were calculated according to each of the following clinical factors: primary site, age, pathologic type, pT factor, pN factor, pulmonary arterioplasty, surgical procedure, suture material, coverage of the anastomotic line, positive resection margin, and preoperative chemotherapy. The results were analyzed using univariate and multiple logistic regression analysis.

RESULTS

Anastomotic complications occurred in 8 patients. Four had anastomotic dehiscence and 4 had stenosis. Of these 8 patients, the resection margin was diagnosed as being positive in 6 patients. Three showed metastasis of the most distal mediastinal lymph node whereas the others had a residual tumor at the bronchial resection margin. According to multiple logistic regression analysis, only pN factor (p = 0.04) and positive resection margin (p = 0.02) had a significant influence on the complications.

CONCLUSIONS

Thus, pN2 patients, especially those with metastasis of the most distal mediastinal lymph node and patients with a residual tumor at the bronchial resection margin, have a significantly higher risk of anastomotic complications.

Survival of patients with resected N2 non-small-cell lung cancer: evidence for a subclassification and implications

PURPOSE

Patients who suffer from non-small-cell lung cancer (NSCLC) with ipsilateral mediastinal lymph node involvement (N2) belong to a heterogeneous subgroup of patients. We analyzed the prognosis of patients with resected N2 NSCLC to propose homogeneous patient subgroups.

PATIENTS AND METHODS

The present study comprised 702 consecutive patients from six French centers who underwent surgical resection of N2 NSCLC. Initially, two groups of patients were defined: patients with clinical N2 (cN2) and those with minimal N2 (mN2) disease were patients in whom N2 disease was and was not detected preoperatively at computed tomographic scan, respectively.

RESULTS

The median duration of follow-up was 52 months (range, 18 to 120 months). A multivariate analysis using Cox regression identified four negative prognostic factors, namely, cN2 status (P <. 0001), involvement of multiple lymph node levels (L2+; P <.0001), pT3 to T4 stage (P <.0001), and no preoperative chemotherapy (P <. 01). For patients treated with primary surgery, 5-year survival rates were as follows: mN2, one level involved (mN2L1, n = 244): 34%; mN2, multiple level involvement (mN2L2+, n = 78): 11%; cN2L1 (n = 118): 8%; and cN2L2+ (n = 122): 3%. When only patients with mN2L1 disease were considered, the site of lymph node involvement according to the American Thoracic Society numbering system had no prognostic significance (P =.14). Preoperative chemotherapy was associated with a better prognosis for those with cN2 (P <.0001). Five-year survival rates were 18% and 5% for cN2 patients treated with and without preoperative chemotherapy, respectively.

CONCLUSION

This study has identified homogeneous N2 NSCLC prognostic subgroups and suggests different therapeutic approaches according to the subgroup profile.