Nodal stage after induction therapy for stage IIIA lung cancer determines patient survival

Primary endpoints to assess the efficacy of novel therapeutic approaches in epidermal growth factor receptor-mutated, surgically resectable non-small cell lung cancer: A review

While the discovery of oncogenic driver mutations has personalized the metastatic non-small cell lung cancer (NSCLC) treatment landscape with effective targeted therapies, implementation of new treatments in resectable NSCLC has been limited due to the long follow-up needed for overall survival (OS). Until recently, treatment for patients with early-stage resectable NSCLC has been limited to perioperative chemotherapy, which provides modest benefits. However, the regulatory acceptance of two surrogate endpoints for OS has allowed recent approval of both adjuvant osimertinib and atezolizumab, providing patients with new treatment options to improve outcomes. In phase 3 oncology trials, OS has historically been viewed as the gold-standard efficacy measure, but disease-free survival and event-free survival (EFS) are now validated surrogate endpoints for OS in clinical trials and should be considered when mature OS data is unavailable. Another potential surrogate endpoint in the adjuvant NSCLC setting is circulating tumor DNA (ctDNA)-based minimal residual disease (MRD), although prospective validation is needed. For neoadjuvant targeted therapies, EFS, major pathologic response and ctDNA-based MRD are potential surrogate endpoints. To fully translate the success of the personalized treatment advances in the metastatic setting to earlier-stage disease, prospective validation studies of these potential surrogate endpoints that can accelerate the evaluation of drug efficacy are needed. A collaborative effort is also needed from all clinical and regulatory parties to collate surrogate endpoint data for large-scale validation. In this review we discuss the trends in surrogate endpoints used in oncology trials, with a focus on considerations for selecting appropriate primary endpoints in early-stage resectable EGFR-mutant NSCLC, an area of unmet need for novel treatment options.

Completion Pneumonectomy for Non-Small-Cell Lung Cancer: Does Induction Treatment Influence Postoperative Outcomes?

Simple Summary

In recent years there have been important improvements in surgical and adjuvant therapy for lung cancer which have led to an increasing number of patients with non-small-cell lung cancer (NSCLC) which had been previously cured by surgery being identified as having a second primary NSCLC or a recurrence of the previous tumor. In these cases, a completion pneumonectomy (CP), defined as the complete removal of the remaining lung after an ipsilateral pulmonary resection, may be performed. Although this procedure has a higher morbidity and mortality than standard pneumonectomy due to the high degree of surgical difficulty strongly associated with the previous surgery, the number of patients undergoing CP is increasing with improvement in morbidity and mortality. To the best of our knowledge, there is no study evaluating the role of induction therapy (IT) on the outcomes of patients who have undergone CP. We reviewed our single-center experience in patients receiving CP for recurrent/second NSCLC after IT and analyzed perioperative results and long-term outcomes. Our results revealed that postoperative complications were not influenced by IT, and long-term survival was adversely influenced by the absence of IT, the presence of squamous cell carcinoma, and cancers at advanced stages. Correct patient selection is crucial to evaluating possible contraindications and adopting technical details to reduce the complication rate.

Abstract

Background: Completion pneumonectomy (CP) is associated with high morbidity and mortality. We reviewed our experience to evaluate whether induction treatment (IT) may affect postoperative outcomes and analyzed factors influencing long-term results. Methods: Between 1998 and 2020, 69 patients with lung cancer underwent CP (50 males, median age 63 years, right CP in 47 patients). A total of 23 patients (33.3%) received IT (chemotherapy in 15, chemoradiotherapy in 7, and radiation in 1). Surgery included 25 (36.2%) extended resections and five (7.2%) tracheal sleeve CP. Results: The 30-day mortality rate was 7.2% (5/69), and overall morbidity was 37.6%. Major complications occurred in five patients (7.2%): one cardiac dislocation, one diaphragmatic hernia, one transient ischemic attack (TIA), and two bronchopleural fistulas. Minor complications occurred in 21 cases (30.4%): pulmonary in 12, cardiac in 7, and neurological in 2. The median hospital stay was 8 days (range, 5–56 days). IT did not influence postoperative morbidity and mortality. Pathological staging included 19 (27.5%) stage I, 36 (52.2%) stage II, and 14 (20.3%) stage III. Overall 5-year survival was 51.7%. Factors influencing survival were IT (p = 0.01), extension of resection (p = 0.04), histology (p = 0.01), pathological stage (p = 0.03), and T and N factors (p = 0.2, respectively). Factors affecting survival in multivariate analysis included IT (p = 0.02) and histology (p = 0.03). Conclusions: In our experience, CP had a low mortality, acceptable morbidity, and good long-term survival, which justifies this surgical procedure. Postoperative complications were not influenced by IT. Long-term survival was adversely influenced by the absence of IT, the presence of extended resection, the presence of squamous cell carcinoma, and cancers at advanced stages.

Survival Analysis of Surgically Resected ypN2 Lung Cancer after Neoadjuvant Therapy

INTRODUCTION

 Surgery is widely accepted today when downstaging of mediastinal lymph nodes after neoadjuvant therapy is achieved. However, the role of surgery in patients with persistent N2 disease is still controversial. This study aims to detail the diagnostic problems, prognostic features, and long-term survival of the persistent N2 non-small cell lung cancer patient group.

PATIENTS AND METHODS

 One-hundred fifty patients who received neoadjuvant therapy and subsequently underwent resection, in-between 2003 and 2015, were retrospectively analyzed. In this study, "persistent N2" group refers to patients who received neoadjuvant therapy for clinically or histologically proven N2, who underwent a surgery after having been classified as "downstaged" at restaging, but in whom ypN2 lesions were subsequently confirmed on the operative specimens. Patients with multistation N2 were included in the study. There were 119 patients who met the criteria, whereas persistent ypN2 was detected in 28.5% (n = 34) of all patients.

RESULTS

 Overall 5-year survival rate was 47.2%, while it was 23.4% for patients with persistent N2. Factors that adversely affected survival were to have nonsquamous cell histological type (p = 0.006), high ypT stage (p = 0.001), persistent N2 (p = 0.02), and recurrence during follow-up (p < 0.001). A trend toward a shorter survival was observed when the ypN2 zone was subcarinal versus other zones, but did not reach statistical significance (p = 0.08). In addition, a trend toward a shorter survival of patients with multiple N2 involvement (p = 0.412) was observed.

CONCLUSION

 In the persistent N2 group, when multiple involvement or subcarinal involvement was excluded, relatively good survival was detected.

Surgical complications and clinical outcomes after dose-escalated trimodality therapy for non-small cell lung cancer in the era of intensity-modulated radiotherapy

BACKGROUND

Trimodality therapy (TMT) with preoperative chemoradiation followed by surgical resection is used for locally-advanced non-small-cell lung cancer (LA-NSCLC). Traditionally, preoperative radiation doses ≤54 Gy are used due to concerns regarding excess morbidity, but little is known about outcomes and toxicities after TMT with intensity-modulated radiotherapy (IMRT) to higher doses.

METHODS

A retrospective analysis of patients who received planned TMT with IMRT for LA-NSCLC at Brigham and Women's Hospital/Dana-Farber Cancer Institute between 2008 and 2017 was performed. Clinical and treatment characteristics, pathologic response, and surgical toxicity were assessed. Kaplan-Meier method and log-rank test was used for survival outcomes. Cox proportional-hazards regression was used for multivariable analysis.

RESULTS

Forty-six patients received less than definitive doses of <60 Gy and 30 patients received definitive doses ≥60 Gy. Surgical outcomes, pathologic complete response, and postoperative toxicity did not differ significantly between the groups. With median follow-up of 3.6 years (range: 0.4-11.4), three-year locoregional recurrence-free survival (78.0% vs. 68.3%, p = 0.51) and overall survival (OS) (61.0% vs. 69.4%, p = 0.32) was not significantly different between patients receiving <60 Gy and ≥60 Gy, respectively. On multivariable analysis, older age, clinical stage, and length of hospital stay (LOS) >7 days were associated with OS.

CONCLUSIONS

With IMRT, there was no increased rate of surgical complications in patients receiving higher doses of radiation. Survival outcomes or LOS did not differ based on radiation dose, but increased LOS was associated with worse OS. Larger prospective studies are needed to further examine outcomes after IMRT in patients with LA-NSCLC receiving TMT.

Surgery for Locally Advanced and Oligometastatic Non-Small Cell Lung Cancer

Locally advanced non-small cell lung cancer is a heterogeneous group of tumors that require multidisciplinary treatment. Although there is much debate with regard to their management, a multimodal treatment strategy for carefully selected patients that includes surgery can extend survival compared with nonoperative definitive therapy. As the role of targeted therapies and immune checkpoint inhibitors for these tumors becomes better defined, practices will continue to evolve.

A PET/CT nomogram incorporating SUVmax and CT radiomics for preoperative nodal staging in non-small cell lung cancer

Objectives

To develop and validate a PET/CT nomogram for preoperative estimation of lymph node (LN) staging in patients with non-small cell lung cancer (NSCLC).

Methods

A total of 263 pathologically confirmed LNs from 124 patients with NCSLC were retrospectively analyzed. Positron-emission tomography/computed tomography (PET/CT) examination was performed before treatment according to the clinical schedule. In the training cohort (N = 185), malignancy-related features, such as SUVmax, short-axis diameter (SAD), and CT radiomics features, were extracted from the regions of LN based on the PET/CT scan. The Minimum-Redundancy Maximum-Relevance (mRMR) algorithm and the Least Absolute Shrinkage and Selection Operator (LASSO) regression model were used for feature selection and radiomics score building. The radiomics score (Rad-Score) and SUVmax were incorporated in a PET/CT nomogram using the multivariable logistic regression analysis. The performance of the proposed model was evaluated with discrimination, calibration, and clinical application in an independent testing cohort (N = 78).

Results

The radiomics scores consisting of 14 selected features were significantly associated with LN status for both training cohort with AUC of 0.849 (95% confidence interval (CI), 0.796–0.903) and testing cohort with AUC of 0.828 (95% CI, 0.782–0.919). The PET/CT nomogram incorporating radiomics score and SUVmax showed moderate improvement of the efficiency with AUC of 0.881 (95% CI, 0.834–0.928) in the training cohort and AUC of 0.872 (95% CI, 0.797–0.946) in the testing cohort. The decision curve analysis indicated that the PET/CT nomogram was clinically useful.

Conclusion

The PET/CT nomogram, which incorporates Rad-Score and SUVmax, can improve the diagnostic performance of LN metastasis.

Key Points

• The PET/CT nomogram (Int-Score) based on lymph node (LN) PET/CT images can reliably predict LN status in NSCLC.

• Int-Score is a relatively objective diagnostic method, which can play an auxiliary role in the process of clinicians making treatment decisions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-020-07624-9.

Adjuvant therapy following induction therapy and surgery improves survival in N2-positive non-small cell lung cancer

BACKGROUND

The purpose of this study was to evaluate treatment strategies and factors influencing overall survival (OS) and disease-free survival (DFS) in resectable, non-small cell lung cancer (NSCLC) with mediastinal (N2) lymph node metastasis.

METHODS

All patients undergoing surgery for NSCLC with N2 disease between 2006 and 2016 were included. Treatment approaches included surgery only, neoadjuvant therapy followed by surgery, surgery followed by adjuvant therapy, and neoadjuvant therapy followed by surgery and adjuvant therapy (triple therapy). Patient clinical and pathologic data were retrospectively collected.

RESULTS

A total of 281 patients were included in the study. In total, 209 patients had neoadjuvant therapy, 47.4% of which went on to received additional adjuvant therapy. The pathologic complete response rate was 12.9%. The treatment strategy which included triple therapy was isolated as a significant contributor to improved OS and DFS. Nodal downstaging (N0) after induction therapy conferred an OS benefit (38.3% vs. 15.6%, p = .03). Patients with single-station N2 disease experienced higher DFS. Video-assisted thoracic surgery (VATS) lobectomy completion rates were higher at the end of the study period compared to the beginning (p < .001).

CONCLUSIONS

Patients who undergo neoadjuvant therapy for N2-positive NSCLC may benefit from additional adjuvant therapy. Single-station N2 disease confers higher DFS. VATS completion rates for lobectomy increase as experience increases.

Adjuvant Chemotherapy Improves Survival in pN-positive Clinical Stage IIIA Non-Small Cell Lung Cancer After Neoadjuvant Therapy and Resection

BACKGROUND

The utility of adjuvant chemotherapy (AC) after neoadjuvant therapy and curative intent surgery for clinical stage IIIA (cIIIA) non-small cell lung cancer (NSCLC) is not defined. We sought to evaluate the contribution of AC to overall survival (OS) in patients with cIIIA NSCLC who underwent neoadjuvant therapy followed by curative intent surgical resection.

METHODS

The National Cancer Database was queried from 2010 to 2016 for patients with cIIIA NSCLC who underwent curative intent surgical resection after neoadjuvant therapy. Patients were grouped by receipt of AC, and OS was calculated using the Kaplan-Meier method. The association between mortality and AC was evaluated using Cox regression. Ninety-day landmark and propensity score-matched analyses were performed to address bias associated with early postoperative morbidity and mortality.

RESULTS

Of 3847 patients who met the inclusion criteria, 780 received AC (20.2%). In the unadjusted cohort there was no difference in 5-year OS between the AC and no AC groups (42.8% vs 43.9%, P = .105). Cox regression demonstrated a decreased risk of mortality in pN > 0 patients receiving AC (hazard ratio, 0.79; 95% confidence interval, 0.68-0.92; P < .003), whereas no difference was seen in node-negative patients (hazard ratio, 0.95; 95% confidence interval, 0.78-1.17; P = .64). In the propensity score-matched groups OS was significantly increased in pN > 0 patients who received AC (5-year OS: 42.4% vs 37%, P < .01), whereas no survival benefit was seen in those who were pN0.

CONCLUSIONS

For patients with completely resected cIIIA NSCLC after neoadjuvant therapy, AC is associated with an increase in OS for patients with residual pathologic lymph node involvement.

Resectable IIIA-N2 Non-Small-Cell Lung Cancer (NSCLC): In Search for the Proper Treatment

Locally advanced non-small cell lung cancer accounts for one third of non-small cell lung cancer (NSCLC) at the time of initial diagnosis and presents with a wide range of clinical and pathological heterogeneity. To date, the combined multimodality approach involving both local and systemic control is the gold standard for these patients, since occult distant micrometastatic disease should always be suspected. With the rapid increase in treatment options, the need for an interdisciplinary discussion involving oncologists, surgeons, radiation oncologists and radiologists has become essential. Surgery should be recommended to patients with non-bulky, discrete, or single-level N2 involvement and be included in the multimodality treatment. Resectable stage IIIA patients have been the subject of a number of clinical trials and retrospective analysis, discussing the efficiency and survival benefits on patients treated with the available therapeutic approaches. However, most of them have some limitations due to their retrospective nature, lack of exact pretreatment staging, and the involvement of heterogeneous populations leading to the awareness that each patient should undergo a tailored therapy in light of the nature of his tumor, its extension and his performance status.

Preoperative Staging by EBUS in cN0/N1 Lung Cancer: Systematic Review and Meta-Analysis

BACKGROUND

Performance of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) for staging the radiologically normal mediastinum has been reported with inconsistent findings. We assessed the sensitivity of systematic staging using EBUS-TBNA for detection of radiologically occult mediastinal metastases in cN0/N1 lung cancer.

METHODS

Studies evaluating EBUS-TBNA for systematic mediastinal staging in cN0/N1 lung cancer were identified by systematic review. Data extracted included: participant age and sex; EBUS-TBNA protocol; stage determined by radiology, EBUS-TBNA and surgery; 2×2 tables. Primary outcome was diagnostic accuracy of EBUS-TBNA for detection of unsuspected N2/N3 disease.

RESULTS

We identified 1173 articles. In total, 13 were included in a qualitative review and 9 (1146 patients) in a quantitative meta-analysis. Mean prevalence of N2/N3 disease was 15% (6% to 24%). EBUS-TBNA had pooled sensitivity of 49% [95% confidence interval (CI), 41%-57%], pooled specificity of 100% (95% CI, 99%-100%), mean negative predictive value 91% (82% to 100%) for detection of unsuspected N2/N3 metastases. Number needed to test to detect occult N2/N3 disease was 14 (95% CI, 10.8-16.3), which halved with addition of per-esophageal endoscopic ultrasound.

CONCLUSION

Preoperative systematic staging by EBUS-TBNA of early lung cancer can reduce postoperative upstaging. Sensitivity for detection of radiologically occult mediastinal metastases seems lower than selective sampling of pathologic lymph nodes. Verification of negative results by mediastinoscopy in selected cases remains of value.

Preoperative Risk Assessment of Lymph Node Metastasis in cT1 Lung Cancer: A Retrospective Study from Eastern China

Background

Lymph node status of clinical T1 (diameter ≤ 3 cm) lung cancer largely affects the treatment strategies in the clinic. In order to assess lymph node status before operation, we aim to develop a noninvasive predictive model using preoperative clinical information.

Methods

We retrospectively reviewed 924 patients (development group) and 380 patients (validation group) of clinical T1 lung cancer. Univariate analysis followed by polytomous logistic regression was performed to estimate different risk factors of lymph node metastasis between N1 and N2 diseases. A predictive model of N2 metastasis was established with dichotomous logistic regression, externally validated and compared with previous models.

Results

Consolidation size and clinical N stage based on CT were two common independent risk factors for both N1 and N2 metastases, with different odds ratios. For N2 metastasis, we identified five independent predictors by dichotomous logistic regression: peripheral location, larger consolidation size, lymph node enlargement on CT, no smoking history, and higher levels of serum CEA. The model showed good calibration and discrimination ability in the development data, with the reasonable Hosmer-Lemeshow test (p = 0.839) and the area under the ROC being 0.931 (95% CI: 0.906-0.955). When externally validated, the model showed a great negative predictive value of 97.6% and the AUC of our model was better than other models.

Conclusion

In this study, we analyzed risk factors for both N1 and N2 metastases and built a predictive model to evaluate possibilities of N2 metastasis of clinical T1 lung cancers before the surgery. Our model will help to select patients with low probability of N2 metastasis and assist in clinical decision to further management.

Is multidisciplinary management possible in the treatment of lung cancer? A report from three Italian meetings

PURPOSE

To report criticisms and barriers to the "real-life" application of international guidelines and recent developments in the management of locally advanced non-small cell lung cancer (NSCLC) in Italy.

METHODS

Three 2-day courses were organized. During the first day, experts in different fields of thoracic oncology gave their lecture on diagnosis and therapy for locally advanced NSCLC. During the second day, all participants were divided into four groups to discuss on a clinical case as a multidisciplinary team (MDT). The aim was to stimulate the discussion on practical issues in the management of NSCLC patients in the real-life practice.

RESULTS

A total of 196 physicians were involved in the courses as learners. Invasive diagnosis of nodal disease for staging purposes, a priori definition of "surgical resectability" and a regular MDT with all crucial participants available were the three main key points identified for a good management of these patients. The main barriers to the clinical application of a good diagnostic and therapeutic approach to the patient were the absence of a regular and complete MDT in the South and Centre of Italy, while in the North of Italy, time for discussion of clinical cases in the MDT and waiting lists for staging and therapeutic interventions were deemed as the major concerns.

CONCLUSION

The meetings showed that diagnosis and treatment of locally advanced NSCLC are still extremely variable between different Italian regions. Logistic issues, waiting lists, paucity of well-trained staff and expertise seem to be the main barriers to international guidelines application.

Evaluation of adherence to the Commission on Cancer lung cancer quality measures

OBJECTIVE

In this study we present historic data on adherence to and survival outcomes associated with recently introduced quality measures for the management of non-small-cell lung cancer.

METHODS

The National Cancer Data Base was queried to identify all patients with non-small-cell lung cancer from 1998 to 2011. Adherence to guidelines was assessed for each of 3 Commission on Cancer-defined quality measures: (1) sampling 10 regional lymph nodes at surgery; (2a) surgery within 120 days of neoadjuvant chemotherapy or, (2b) 180 days of adjuvant chemotherapy; and (3) nonsurgical primary therapy in cN2 disease. The likelihood of measure adherence and the association of measure adherence with all-cause mortality were analyzed controlling for patient, hospital, and time period characteristics.

RESULTS

Regional lymph node sampling was inadequate in 72.7% of cases. Only 28.7% began adjuvant chemotherapy within 180 days of surgery. However, 96.5% of patients who received neoadjuvant chemotherapy proceeded to surgery within 120 days and surgery was first-line treatment for cN2 disease in only 3.7% of patients. Uninsured or Medicaid status was an independent risk factor for a prolonged delay between neoadjuvant chemotherapy and surgery (odds ratio, 1.36; 95% confidence interval, 1.08-1.72) and surgery and adjuvant treatment (odds ratio, 1.92; 95% confidence interval, 1.69-2.19). Overall survival was significantly better in patients whose care conformed to quality standards for nodal sampling (measure 1), and timing of chemotherapy.

CONCLUSIONS

Adherence rates for nodal sampling at the time of surgery and receipt of adjuvant chemotherapy were low. These findings highlight opportunities for improvement efforts, but more measures are needed to more broadly assess the quality of lung cancer care.

Role of pneumonectomy for lung cancer in current scenario: An Indian perspective

BACKGROUND

Surgical treatment for lung cancer has evolved from pneumonectomy to lobectomy/sleeve resection around the world. Although condemned for poor outcomes, pneumonectomy may still be required in a select group of patients in developing countries. With the better patient selection, optimization of medical comorbidities, better perioperative care; pneumonectomy may show better results. Thus, there is a need to reconsider the role of pneumonectomy in patients with locally advanced lung cancer in the current scenario.

PATIENTS AND METHODS

The aim of this study was to analyze the demographic and clinicopathologic profile of lung cancer patients and the role of pneumonectomy at a tertiary cancer center in India. The records of patients, who underwent surgery for lung cancer at our institute from January 2011 to April 2014, were analyzed retrospectively, and various parameters in pneumonectomy were compared to lobectomy patients.

RESULTS

Out of 48 patients undergoing major lung resections, nearly 80% patients were symptomatic at presentation and were mostly in advanced stages, thus requiring neoadjuvant chemotherapy in 45.8% cases and pneumonectomy in 41.6% patients. There was no difference in morbidity and mortality in pneumonectomy (25%, 5%) versus lobectomy (21.2%, 3.5%). Disease-free survival at 1, 2, and 3 years after pneumonectomy (71.8%, 51.4%, and 42.8%) was comparable to lobectomy (73.3%, 66.1%, and 55.6%). After neoadjuvant therapy, survival was not affected by the type of surgery.

CONCLUSIONS

In the Indian scenario, as the majority of lung cancer patients present at an advanced stage, pneumonectomy still plays a major role, and the acceptable postoperative outcome can be achieved with aggressive perioperative management.

High-Dose Radiotherapy as Neoadjuvant Treatment in Non-Small-Cell Lung Cancer

BACKGROUND

Trimodality therapy (chemoradiation followed by surgery) provides a benefit in progression-free survival but not overall survival. We sought to determine if a high dose of radiation could be delivered safely and provide a clinical benefit.

METHODS

Consecutive patients with stage IIIA or IIIB non-small-cell lung cancer (NSCLC) treated with concurrent chemoradiotherapy followed by surgery were reviewed with IRB approval.

RESULTS

A total of 48 patients were treated from November 2007 to May 2014. Of these, 64% had stage IIIA disease while 36% had stage IIIB; 46% had adenocarcinoma, 34% squamous, and 23% NSCLC not otherwise specified. The median dose of chemoradiotherapy was 72 Gy (60-72). Overall, 86% of patients received cisplatin (50 mg/m2) and etoposide (50 mg/m2) concurrently with radiotherapy; 72% of patients underwent lobectomy following chemoradiotherapy and 28% underwent pneumonectomy. The 30- and 90-day mortality rates were 0%. The nodal downstaging rate was 82% and there was a 64% rate of pathologic complete response. The overall survival was 29.9 months (95% CI, 19-86 months). The median time to locoregional progression was 35.1 months and the median time to distant progression was 39.3 months. Locoregional failure was 8% and distant failure was 44%.

CONCLUSION

High-dose preoperative chemoradiotherapy was safe and effective. This combination should be further considered.

Neoadjuvant Therapy in Non-Small Cell Lung Cancer

Locally advanced (stage IIIA) non-small cell lung cancer (NSCLC) is confined to the chest, but requires more than surgery to maximize cure. Therapy given preoperatively is termed neoadjuvant, whereas postoperative therapy is termed adjuvant. Trimodality therapy (chemotherapy, radiation, and surgery) has become the standard treatment regimen for resectable, locally advanced NSCLC. During the past 2 decades, several prospective, randomized, and nonrandomized studies have explored various regimens for preoperative treatment of NSCLC. The evaluation of potential candidates with NSCLC for neoadjuvant therapy as well as the currently available therapeutic regimens are reviewed.

Prognosis of multi-level N2-positive non-small cell lung cancer according to lymph node staging using endobronchial ultrasound-transbronchial biopsy

Background

The optimal treatment for stage IIIA‐N2 non‐small cell lung cancer (NSCLC) remains controversial, and multidisciplinary team approaches are needed. Downstaging after induction therapy is a good prognostic factor in surgical patients; however, re‐evaluation of nodal status before surgery is challenging. The aim of this study was to evaluate the prognosis of patients with multi‐level N2 NSCLC who received surgery or chemoradiation therapy (CRT) according to restaging using endobronchial ultrasound‐transbronchial aspiration (EBUS‐TBNA).

Methods

This was a single center, prospective study that included 16 patients with biopsy‐proven multi‐level N2 disease on initial EBUS‐TBNA that was restaged using EBUS‐TBNA after induction therapy. Cases downstaged after rebiopsy were treated surgically. Three‐year progression‐free survival (PFS) and locoregional PFS were determined using Kaplan–Meier analysis.

Results

Of the 16 patients (median age 58 years, male 63%), eight had persistent N2 disease and eight showed N2 clearance on restaging using EBUS‐TBNA. Ten patients underwent surgery, including two patients without N2 clearance. Recurrence and locoregional recurrence occurred in eight and five patients, respectively. The three‐year PFS was longer in patients with N2 clearance than in those with N2 persistent disease (57.1% vs. 37.5%). Patients with N2 clearance also had longer three‐year locoregional PFS than those with N2 persistent disease (71.4% vs. 62.5%).

Conclusions

EBUS‐TBNA could be an effective diagnostic method for restaging in multi‐level N2 NSCLC patients after induction CRT. As this was a pilot study, further large‐scale randomized studies are needed.

Comparing the benefits of chemoradiotherapy and chemotherapy for resectable stage III A/N2 non-small cell lung cancer: a meta-analysis

Background

Induction chemotherapy has been shown to improve survival of patients with stage III A/N2 (T1–3, N2, M0) non-small cell lung cancer (NSCLC), followed by resection, but the benefits of neoadjuvant radiotherapy still remain controversial.

Methods

PubMed, Embase, and Cochrane library databases were searched for relevant randomized controlled trials (RCTs) comparing the outcomes of induction chemoradiotherapy over induction chemotherapy, in patients with resectable stage IIIA/N2 NSCLC. Odds ratios (ORs) with corresponding 95% confidence intervals (95% CIs) were calculated using random- or fixed-effects model, and heterogeneity was assessed using I² test. Publication bias was examined by funnel plots analysis.

Results

A total of three RCTs met the inclusion criteria of our meta-analysis. The pooled results demonstrated that, in comparison to induction chemotherapy, induction chemoradiotherapy has a significant benefit in tumor response, mediastinal downstaging, and pathological complete response of mediastinal lymph nodes. In addition, no more peri-intervention mortality was detected in patients from chemoradiotherapy group, and a higher number of patients from this group had R0 resection. However, our results did not show any difference between overall survival and progression-free survival after 2, 4, and 6 years of follow-ups, in patients undergoing radiation therapy vs. induction chemotherapy.

Conclusion

Preoperative chemoradiotherapy, as compared to induction chemotherapy alone, is associated with similar peri-intervention mortality, a greater tumor response, mediastinal nodule downstaging, and rate of R0 resection, but does not improve survival of resectable stage IIIA/N2 NSCLC patients.

Pneumonectomy is safe and effective for non-small cell lung cancer following induction therapy

BACKGROUND

Uncertainty surrounds the safety and efficacy of pneumonectomy in the setting of induction chemoradiation for non-small cell lung cancer (NSCLC). We sought to evaluate fifteen years of experience with pneumonectomy with and without induction therapy.

METHODS

Over a 15-year period [1999-2014], data were extracted from medical records of patients undergoing pneumonectomy for NSCLC. Primary outcomes were 5-year overall survival and mortality at 30, 60 and 90 days following operation. Morbidity data was also reviewed. Statistical comparisons were performed using the Chi-Square test. Kaplan-Meier curves were compared using the log rank test. Significance was defined as a P value less than 0.05. Patients with a prior cancer history, bilateral lung nodules and oligometastatic disease at presentation were excluded.

RESULTS

After exclusion criteria were applied, 240 patients were analyzed and 137 (57%) underwent induction therapy prior to pneumonectomy. Five-year overall survival was 38.5%. Mortality at 90 days was 7.94%. There was no statistically significant difference in perioperative mortality with the addition of induction therapy. In fact, in the subset of patients with N2 disease (n=65), induction therapy was associated with improved 5-year overall survival (10.7% vs. 32.7%, P=0.014). Thirty-five percent of patients with N2 disease exhibited a complete response in the nodal basin following induction therapy; however, this did not confer a statistically significant overall or disease-free survival benefit.

CONCLUSIONS

Pneumonectomy can safely be performed in the setting of induction chemoradiation. In patients with N2 disease, induction therapy may confer a survival benefit when the surgery can be done with limited morbidity and mortality.

Transcervical Extended Mediastinal Lymphadenectomy: Experience From a North American Cancer Center

BACKGROUND

Accurate staging of the mediastinum is a critical element of therapeutic decision making in non-small cell lung cancer. We sought to determine the utility of transcervical extended mediastinal lymphadenectomy (TEMLA) in staging non-small cell lung cancer for large central tumors and after induction therapy.

METHODS

A retrospective record review was performed of all patients who underwent TEMLA at our institution from 2010 to 2015. Clinical stage as assessed by positron emission tomography integrated with computed tomography (PET-CT), stage as assessed by TEMLA, final pathologic stage, lymph node yield, and clinical characteristics of tumors were assessed along with TEMLA-related perioperative morbidity. Accuracy of staging by TEMLA for restaging the mediastinum after neoadjuvant therapy was compared with that of PET-CT.

RESULTS

Of 164 patients who underwent TEMLA, 157 (95.7%) were completed successfully. Combined surgical resection along with TEMLA was performed in 138 of these patients, with 131 (94.2%) undergoing a video-assisted thoracoscopic resection. The recurrent laryngeal nerve injury rate was 6.7%. TEMLA was performed in 118 of 164 patients for restaging after neoadjuvant therapy, and 101 of these patients were also restaged by PET-CT. Based on TEMLA, 7 patients did not go on to have resection. Of the 101 patients who did have a resection, TEMLA was more accurate than PET-CT in staging the mediastinum (95% vs 73%, p < 0.0001). However, the pneumonia rate in this subgroup of patients was 13%.

CONCLUSIONS

TEMLA is a safe procedure and superior to PET-CT for restaging of the mediastinum after neoadjuvant therapy for non-small cell lung cancer. However, this increased accuracy comes with a high postoperative pneumonia rate.

Lymph node volume predicts survival but not nodal clearance in Stage IIIA-IIIB NSCLC

BACKGROUND

Locally advanced non-small cell lung cancer (LA-NSCLC) patients have poorer survival and local control with mediastinal node (N2) tumor involvement at resection. Earlier assessment of nodal burden could inform clinical decision-making prior to surgery. This study evaluated the association between clinical outcomes and lymph node volume before and after neoadjuvant therapy.

MATERIALS AND METHODS

CT imaging of patients with operable LA-NSCLC treated with chemoradiation and surgical resection was assessed. Clinically involved lymph node stations were identified by FDG-PET or mediastinoscopy. Locoregional recurrence (LRR), distant metastasis (DM), progression free survival (PFS) and overall survival (OS) were analyzed by the Kaplan Meier method, concordance index and Cox regression.

RESULTS

73 patients with Stage IIIA-IIIB NSCLC treated with neoadjuvant chemoradiation and surgical resection were identified. The median RT dose was 54 Gy and all patients received concurrent chemotherapy. Involved lymph node volume was significantly associated with LRR and OS but not DM on univariate analysis. Additionally, lymph node volume greater than 10.6 cm3 after the completion of preoperative chemoradiation was associated with increased LRR (p<0.001) and decreased OS (p = 0.04). There was no association between nodal volumes and nodal clearance.

CONCLUSION

For patients with LA-NSCLC, large volume nodal disease post-chemoradiation is associated with increased risk of locoregional recurrence and decreased survival. Nodal volume can thus be used to further stratify patients within the heterogeneous Stage IIIA-IIIB population and potentially guide clinical decision-making.

Feasibility and efficacy of salvage lung resection after definitive chemoradiation therapy for Stage III non-small-cell lung cancer

OBJECTIVES

For highly selected patients with Stage III non-small-cell lung cancer (NSCLC) who relapse or have residual disease after definitive chemoradiotherapy, salvage lung resection is likely to be one of the options for local control and possible better prognosis. However, the long-term benefit has not been verified.

METHODS

We conducted a retrospective study on salvage surgery on a multicentre basis. Patients included in this study met the following criteria: (i) prior treatment of lung cancer with curative-intent radiotherapy (≥60 Gy); (ii) no a priori plans for induction multimodality therapy; (iii) confirmation of loco-regional recurrence or persistent tumour in the irradiated area; (iv) pretherapeutic pathological results of NSCLC and (v) Stage III disease prior to chemoradiotherapy.

RESULTS

A total of 18 patients were eligible for evaluation (Stage IIIA/IIIB, 14/4). The prior median radiation therapy dose was 60 Gy (60-74 Gy), and the median time between the last day of radiotherapy and resection was 38 weeks. The indications for surgery were primary tumour regrowth (10 patients) or tumour persistence (8 patients). Surgical procedures included lobectomy in 13 patients and pneumonectomy in 5 patients. Postoperative complications occurred in 5 patients (28%) without perioperative death. Complete resection was shown in 16 patients (89%) and a complete pathological response in 5 patients (28%). The median follow-up time was 1405 days, and the 3-year overall survival and recurrence-free survival rates were 78 and 72%, respectively.

CONCLUSIONS

In the highly selected Stage III NSCLC after curative-intent chemoradiation therapy, salvage surgery was safely performed and contributed to satisfactory long-term survival.

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis

BACKGROUND

Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients.

METHODS

Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses.

RESULTS

The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95] (first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second meta-analysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled three- and five- year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability.

CONCLUSIONS

Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.

Microscopic N2 disease exhibits a better prognosis in resected non-small-cell lung cancer

OBJECTIVES

The management of pIIIA-N2 non-small-cell lung cancer (NSCLC) is still controversial. In particular, there are wide variations in overall survival (OS), suggesting the existence of subgroups among N2 patients. We aimed to evaluate the prognostic value of microscopic pN2 in NSCLC.

METHODS

Between 1996 and 2015, the data from all 982 pathologically stage IIIA-N2 patients who underwent surgery with curative intent for NSCLC were retrospectively reviewed. Microscopic pN2 disease was defined as a nodal metastasis ranging from 0.2 to 2 mm in size.

RESULTS

With a median follow-up of 17 months (2-101), the 5-year OS for the whole cohort was 31%. Microscopic N2 was observed in 309 (31.5%) patients. Microscopic N2 was associated with better median OS compared with macroscopic N2 [42 months (95% CI 36.85-47.15) vs 23 months (95% CI 19.7-26.29), P < 0.0001, with a corresponding 5-year OS rate of 39 and 21%, respectively]. In multivariate analysis, microscopic N2 remained a favourable independent prognostic factor [HR 0.681 (95% CI 0.481-0.967), P = 0.03]. The median OS of microscopic N2 patients who benefitted from simple follow-up was significantly better than those who underwent chemotherapy, radiation therapy or both [43 months (95% CI 24.22-61.78) vs 22 months (95% CI 17.43-26.47) vs 31 months (95% CI 27.66-34.34) vs 16 months (95% CI 14.6-17.4), P = 0.008].

CONCLUSION

Microscopic N2 seems to be associated with better prognosis in patients with pIIIA-N2 NSCLC and these could benefit from a simple follow-up. Prospective cohort studies are necessary to confirm these preliminary results.

Current methods of staging and restaging of the mediastinal nodes in non-small-cell lung cancer

To analyze the current methods of primary staging and repeated staging (restaging) of the mediastinal nodes in non-small-cell lung cancer (NSCLC), all methods currently used for staging of NSCLC are analyzed. These methods include imaging techniques [computer tomography (CT), positron emission tomography (PET) combined with CT (PET/CT)], endoscopic/ultrasound techniques (endobronchial ultrasound/transbronchial needle aspiration) and endoscopic ultrasound/fine needle aspiration and surgical techniques [standard cervical mediastinoscopy, video-assisted mediastinoscopy, extended mediastinoscopy, video-assisted mediastinoscopic lymphadenectomy, transcervical extended mediastinal lymphadenectomy, anterior mediastinotomy (Chamberlain procedure) and video-assisted thoracic surgery]. The diagnostic yield of Chest CT is regarded insufficient for both, primary staging and restaging. The PET/CT became a standard imaging technique preceding curative surgery of radical chemo-radiotherapy. The issue of intraoperative staging is also described. Finally, the author’s proposed algorithm of staging, both for primary staging and restaging after neoadjuvant therapy is presented. Detailed staging of NSCLC enables selection of patients with early stage disease for curative surgical/multimodality treatment and helps to avoid unnecessary surgery in advanced disease.

Staging of lung cancer: the role of noninvasive, minimally invasive and invasive techniques

Accurate staging and restaging of primary tumour and mediastinal nodes in patients with lung cancer is of significant importance. For primary tumours, computed tomography (CT) scans of the chest are recommended. Positron emission tomography (PET) imaging should be used in patients with curative intent treatment to evaluate metastatic disease. Diagnosis of the primary tumour should be performed using bronchoscopy or CT-guided transthoracic needle aspiration. In patients with enlarged mediastinal nodes and no distant metastasis, invasive staging of the mediastinum is required. For suspicious N2 or N3 disease, endoscopic needle techniques, such as endobronchial ultrasound and transbronchial needle aspiration, oesophageal ultrasound and fine needle aspiration, or a combination of both, are preferred to any surgical staging technique. In cases of suspicious nodes and negative results using needle aspiration techniques, invasive surgical staging using mediastinoscopy or video-assisted thoracic surgery should be performed. In central tumours or N1 nodes, preoperative invasive staging is indicated.Restaging after induction therapy remains a controversial topic. Today, neither CT, PET nor PET/CT scans are accurate enough to make final further therapeutic decisions for mediastinal nodal involvement. An invasive technique providing cytohistological information is still recommended.

Standard treatment option in stage III non-small-cell lung cancer: case against trimodal therapy and consolidation drug therapy

Prospective randomized trials and meta-analyses established concurrent radiochemotherapy (RT-CHT) as standard treatment approach in patients with inoperable, locally advanced (stage IIIA and B) non-small-cell lung cancer (NSCLC). In patients with either clinically (c) or pathologically (p) staged disease (stage IIIA), including those with pN2 disease, trimodal therapy was also frequently practiced in the past and is currently still advocated by large cooperative groups and organizations. Similarly, consolidation CHT provided after concurrent RT-CHT was suggested to be feasible and effective in inoperable stage III NSCLC. Contrasting these practices and suggestions, there is no evidence that trimodal therapy in stage IIIA (clinically or pathologically staged) or consolidation CHT in inoperable stage III NSCLC plays any role in its treatment. In both cases, evidence clearly demonstrates that concurrent RT-CHT is of similar efficacy and less toxic, and it should be considered a standard treatment option for all patients with stage III NSCLC.

Phase II study of perioperative chemotherapy with cisplatin and pemetrexed in non-small-cell lung cancer

INTRODUCTION

Pathologic complete response (pCR) with neoadjuvant chemotherapy is associated with improved survival in many solid tumors. We evaluated pCR rate of cisplatin with pemetrexed in non-small-cell lung cancer.

METHODS

Patients with stages IB to IIIA non-small-cell lung cancer, Eastern Cooperative Oncology Group performance status 0 to 1 were enrolled in this single-arm phase II trial using two-stage design with 90% power to detect pCR rate of more than or equal to 10%. Pretreatment mediastinal lymph node biopsy was required. Patients received three cycles of cisplatin 75 mg/m with pemetrexed 500 mg/m (day 1 every 21 days) preoperatively and additional two cycles within 60 to 80 days after surgery. The primary end point was pCR. Polymorphisms in FPGS, GGH, SLC19A1, and TYMS genes were correlated with treatment outcomes.

RESULTS

Thirty-eight patients were enrolled, with median age of 62.5 years. Preoperatively, 26% had squamous histology, and 34% had biopsy-proven N2 involvement. R0 resection was achieved in 94% of the 34 patients who underwent surgery, and 54% had documented N2 clearance. There was no pCR seen. Median disease-free survival (DFS) and overall survival of these patients have not yet been reached in contrast to median of 13.8 and 24.2 months, respectively, in patients with persistent N2 disease (p = 0.3241 and p = 0.1022, respectively). There was a statistically significant association between DFS and postoperative tumor, node, metastasis stage (p = 0.0429), SLC19A1 rs3788189 TT genotype (p = 0.0821), and viable tumor defined as less than or equal to 10% of resected specimen (p = 0.026).

CONCLUSION

The primary end point was not met. Patients with N2 clearance, less than or equal to 10% viable tumor in the resected specimen, and SLC19A1 rs3788189 TT genotype have favorable DFS outcomes.

The efficacy of restaging endobronchial ultrasound in patients with non-small cell lung cancer after preoperative therapy

BACKGROUND

Patient selection for surgery after neoadjuvant therapy for locally advanced non-small cell lung cancer depends on accurate restaging of mediastinal (N2) lymph nodes. Our objective is to assess the accuracy of endobronchial ultrasound (EBUS) for restaging N2 lymph nodes after neoadjuvant therapy.

METHODS

This is a retrospective review of patients with non-small cell lung cancer who underwent staging with repeat computed tomography and positron emission tomography and had restaging EBUS for sampling of N2 lymph nodes. Endobronchial ultrasound was performed for suspicious nodes in stations 2R, 2L, 4R, 4L, and 7. Selected patients who were N2-negative underwent thoracotomy with complete thoracic lymphadenectomy.

RESULTS

There were 32 patients with N2 disease who underwent preoperative chemotherapy or radiotherapy, or both, and subsequently had restaging EBUS. There were 3 patients who had recalcitrant N2 nodal disease detected by EBUS. There were 5 patients with pulmonary function or comorbidities that were prohibitive for surgery. Of the remaining 24 patients with negative EBUS, 3 underwent mediastinoscopy and 2 had recalcitrant N2 disease. The remaining 22 patients underwent thoracotomy. Recalcitrant N2 disease was noted in 1 patient at thoracotomy in the EBUS-assessable nodal stations. Thus EBUS was falsely negative in 3 patients. The sensitivity and negative predictive value of restaging EBUS were 50% and 88%, respectively.

CONCLUSIONS

Restaging EBUS is relatively accurate at predicting the absence of metastatic disease in N2 mediastinal lymph node in patients who underwent neoadjuvant therapy for non-small cell lung cancer.

Survivin mRNA Level in Blood Predict the Efficacy of Neoadjuvant Chemotherapy in Patients with Stage IIIA-N2 Non-Small Cell Lung Cancer

In a previous study, survivin mRNA expression in non-small cell lung cancer (NSCLC) tissue had been demonstrated to be associated with unfavorable prognosis of patients treated with chemotherapy. In this study, we investigated the survivin mRNA levels in blood of patients with stage IIIA-N2 NSCLC and their association with the efficacy of neoadjuvant chemotherapy (NCT) and disease-free survival (DFS) and overall survival (OS). Blood specimens were collected from 56 patients with stage IIIA-N2 NSCLC before (N0) and after the complete of NCT (N1). Survivin mRNA was measured by real-time quantitative-PCR assay. Receiver operating characteristics curve analysis was undertaken to determine the best cutoff value for survivin mRNA. Results showed that high blood survivin mRNA levels at N0 and N1 were significantly associated with clinical (P = 0.01 and P = 0.008, respectively) and pathologic response (both P = 0.004, respectively). Moreover, the change of blood survivin mRNA levels in these NSCLC patients is associated with the clinical and pathologic response to NCT. Patients with high survivin mRNA levels at N0 and N1 had significantly shorter DFS and OS than those with low survivin mRNA levels (P = 0.021 and P = 0.014, respectively for DFS; P = 0.009 and P = 0.005, respectively for OS). Multivariate analysis demonstrated that high blood survivin mRNA level was an independent predictor for worse DFS and OS in the NSCLC patients receiving NCT. In conclusion, survivin mRNA level in blood from stage IIIA-N2 NSCLC patients receiving NCT is predictive of cancer outcome.

Pathological response after neoadjuvant chemotherapy in resectable non-small-cell lung cancers: proposal for the use of major pathological response as a surrogate endpoint

Improvements in outcomes for patients with resectable lung cancers have plateaued. Clinical trials of resectable non-small-cell lung cancers with overall survival as the primary endpoint require a decade or longer to complete, are expensive, and limit innovation. A surrogate for survival, such as pathological response to neoadjuvant chemotherapy, has the potential to improve the efficiency of trials and expedite advances. 10% or less residual viable tumour after neoadjuvant chemotherapy, termed here major pathological response, meets criteria for a surrogate; major pathological response strongly associates with improved survival, is reflective of treatment effect, and captures the magnitude of the treatment benefit on survival. We support the incorporation of major pathological response as a surrogate endpoint for survival in future neoadjuvant trials of resectable lung cancers. Additional prospective studies are needed to confirm the validity and reproducibility of major pathological response within individual histological and molecular subgroups and with new drugs.

Treating locally advanced disease: an analysis of very large, hilar lymph node positive non-small cell lung cancer using the National Cancer Data Base

BACKGROUND

Very large, locally advanced non-small cell lung cancers (NSCLC) remain a therapeutic challenge. This retrospective study compares the effect of treatment modalities on survival of patients with large NSCLC with hilar lymph node involvement (T3>7 cmN1).

METHODS

The National Cancer Data Base was used to identify adult patients who were diagnosed with T3>7 cmN1 NSCLC from 1999 to 2005 (n=642). Nonsurgical treatments included chemoradiation, chemotherapy, radiation therapy, or no treatment, whereas primary surgical treatments included surgery, chemoradiation or chemotherapy prior to surgery, chemoradiation or chemotherapy after surgery, or postoperative radiotherapy. Five-year overall survival (OS) was estimated by the Kaplan-Meier method and comparisons made using log-rank tests and Cox regression models.

RESULTS

A total of 642 patients were evaluated; 425 nonsurgical (66%) and 217 surgical (34%). Primary surgical therapy was associated with improved 5-year OS; 28% versus 8% and 4% for nonsurgical and no treatment, respectively (p<0.001). The 5-year OS were 11%, 5%, 2%, and 4% for chemoradiation, chemotherapy, radiation therapy, and no treatment, respectively (p<0.001). The 5-year OS were 16% for surgery only, 40% and 44% for neoadjuvant chemoradiation or chemotherapy with surgery, respectively, 40% and 38% for adjuvant chemoradiation or chemotherapy with surgery, respectively, and 18% for postoperative radiotherapy (p<0.001). On multivariate analysis, surgery and chemotherapy in most combinations were associated with significantly improved OS compared with chemoradiation only.

CONCLUSIONS

Surgery with systemic therapy delivered in a neoadjuvant or adjuvant fashion for patients with T3>7 cmN1 NSCLCs is associated with improvements in OS.

Prospective phase II trial of preresection thoracoscopic mediastinal restaging after neoadjuvant therapy for IIIA (N2) non-small cell lung cancer: results of CALGB Protocol 39803

OBJECTIVE

Accurate pathologic restaging of N2 stations after neoadjuvant therapy in stage IIIA (N2) non-small cell lung cancer is needed.

METHODS

A prospective multi-institutional trial was designed to judge the feasibility of videothoracoscopy to restage the ipsilateral nodes in mediastinoscopy-proven stage IIIA (N2) non-small cell lung cancer after 2 cycles of platinum-based chemotherapy and/or 40 Gy or more of radiotherapy. The goals included biopsy of 3 negative N2 node stations or to identify 1 positive N2 node or pleural carcinomatosis.

RESULTS

Ten institutions accrued 68 subjects. Of the 68 subjects, 46 (68%) underwent radiotherapy and 66 (97%) underwent chemotherapy. Videothoracoscopy successfully met the prestudy feasibility in 27 patients (40%): 3 negative stations confirmed at thoracotomy in 7, persistent stage N2 disease in 16, and pleural carcinomatosis in 4. In 20 procedures (29%), no N2 disease was found, 3 stations were not biopsied because of unanticipated nodal obliteration. Thus, 47 videothoracoscopy procedures (69%, 95% confidence interval, 57%-80%) restaged the mediastinum. Videothoracoscopy was unsuccessful in 21 patients (31%) because the procedure had to be aborted (n = 11) or because of false-negative stations (n = 10). Of the 21 failures, 15 were right-sided, and 10 had a positive 4R node. The sensitivity of videothoracoscopy was 67% (95% confidence interval, 47%-83%), and the negative predictive value was 73% (95% confidence interval, 56%-86%) if patients with obliterated nodal tissue were included. The sensitivity was 83% (95% confidence interval, 63%-95%) and the negative predictive value was 64% (95% confidence interval, 31%-89%) if those patients were excluded. The specificity was 100%. One death occurred after thoracotomy.

CONCLUSIONS

Videothoracoscopy restaging was "feasible" in this prospective multi-institutional trial and provided pathologic specimens of the ipsilateral nodes. Videothoracoscopy restaging was limited by radiation and the 4R nodal station.