Advances in the use of surgery and multimodality treatment for N2 non-small cell lung cancer

Abstract

Stage IIIA-N2 non-small cell lung cancer (NSCLC) represents a heterogeneous group of bronchogenic carcinomas with locoregional involvement. Different categories of N2 disease exist, ranging from unexpectedly encountered N2 involvement after detailed preoperative staging or 'surprise' N2, to potentially resectable disease treated within a combined modality setting, and finally, bulky N2 involvement treated by chemoradiation. Areas covered: Large randomised controlled trials and meta-analyses on stage IIIA-N2 NSCLC have been published but their implications for treatment remain a matter of debate. No definite recommendations can be provided as diagnostic and therapeutic algorithms vary according to local, national or international guidelines. Expert commentary: From the literature, it is clear that patients with stage IIIA-N2 NSCLC should be treated by combined modality therapy including chemotherapy, radiotherapy and surgery. The relative contribution of each modality has not been firmly established. For patients undergoing induction therapy, adequate restaging is important as only down-staged patients will clearly benefit from surgical resection. Each patient should be discussed within a multidisciplinary team to determine the best diagnostic and therapeutic approach according to the specific local expertise. In the near future, it might be expected that targeted therapies and immunotherapy will be incorporated as possible therapeutic options.

Heterogeneity of stage IIIA non-small cell lung cancer—different tumours, different nodal status, different treatment, different prognosis: a narrative review

“…The INT 0139, ESPATUTE, EORTC 08941 trials and Decaluwé et al compared neoadjuvant therapy plus surgery with other bimodality approaches including combinations of chemotherapy and radiotherapy and showed similar 5-year overall survival rates ranging from 14% to 44% (30)(31)(32)(33)(34)(35). Decaluwé et al also showed that there is no significant difference in 5-year survival in ypN1a compared to ypN2a1-2 (40.6% vs. 37%, P=0.89) as well as in ypN0-1a compared to ypN2a1-2 (49.1% vs. 37%, P=0.52).…”

“…Preoperative chemotherapy as well as radiotherapy can induce local tissue inflammation and edema, resulting in tissue adhesions with partially fused interlobar fissure, hilar and mediastinal fibrosis with anthracofibrosis and perivascular/peribronchial lymph node calcification as well as increased tissue and especially vascular fragility. Thus, making surgery in general more difficult and adhesiolysis and anatomic dissection more tedious with potentially higher operation time (35,170,171,253).…”

Distinct efficacy of postoperative radiotherapy in patients with resected pathological Stage IIIA-N2 lung squamous cell carcinoma

“…Surgery remains the most important treatment for stage I/II and IIIA NSCLC. In particular, patients with IIIA-N2 disease require surgery and supplementary treatments to improve the prognosis [2]. However, after adjuvant chemotherapy, this patient population still had a high loco-regional recurrence rate of up to 40% [3,4].…”

Surgical Management of Stage IIIA Non-Small Cell Lung Cancer

“…Combined modality therapy is indicated for most patients with stage III NSCLC who have a good performance status but the precise role of surgery, radiotherapy, and chemotherapy within such combined modalities setting has not been firmly established ( 4 ). Moreover, with the introduction of targeted agents, and more recently, also immunotherapy, the therapeutic options have clearly expanded.…”