How Effective Is Neoadjuvant Therapy Followed by Surgery for Pathologic Single-Station N2 Non–Small Cell Lung Cancer?

Abstract

The optimal treatment strategy for pathologic single-station N2 (pN2a1) non-Àsmall cell lung cancer (NSCLC)-surgery first followed by adjuvant treatment (SF) or neoadjuvant therapy followed by surgery (NS)-remains unclear. We compared disease-free survival (DFS) and overall survival (OS) after NS versus SF for pN2a1 NSCLC. We retrospectively identified patients with pN2a1 NSCLC resected between 2000 and 2018. Patients in the SF group had cN0 disease and were treated with surgery before adjuvant chemotherapy; patients in the NS group had known preoperative nodal disease, cN2 disease, and were treated with neoadjuvant therapy before surgery. The matching-weights procedure was applied to generate a cohort with similar characteristics between groups. DFS and OS were calculated using the Kaplan-Meier approach and compared between groups using weighted logrank test and Cox proportional hazards models. We identified 227 patients with pN2a1 disease: 121 treated with SF and 106 with NS. After the matching-weights procedure, 5-and 10-year DFS were 45% and 27% for SF versus 26% and 21% for NS (log-rank P = 0.056; hazard ratio [HR], 1.61; 95% confidence interval [CI], 0.98À2.65); 5-and 10-year OS were 49% and 30% for SF versus 43% and 20% for NS (log-rank P = 0.428; HR, 1.24; 95% CI, 0.67À2.28). SF and NS for pN2a1 NSCLC resulted in similar survival. A study comparing SF for known preresectional pN2a1 with occult pN2a1 disease could be a next step. Further investigation of SF for known N2a1 versus occult pN2a1 disease could power a clinical trial focused on N2a NSCLC.

Endosonography With or Without Confirmatory Mediastinoscopy for Resectable Lung Cancer: A Randomized Clinical Trial

“…28,29 Moreover, lacking randomized data on this topic, retrospective studies found no survival benefit of neoadjuvant treatment compared with upfront surgery in patients with minimal N2. 30,31 We observed that most uN2 cases in our study were single-level intranodal metastases, also after immediate resection. One of the strengths of the MEDIASTrial was the employment of independent data and monitoring specialists as well as upfront publication of protocol and statistical analysis plan.…”

“…The higher rate of mediastinal nodal spread among patients receiving more diagnostic tests was also demonstrated by Sanz-Santos, demonstrating a 19.5% higher N2-3 prevalence in studies performing confirmatory mediastinoscopy. 24 Although this meta-analysis showed large heterogeneity, the randomized ASTER trial found a 32) 48 (31) .7900…”

Survival Analysis of Surgically Resected ypN2 Lung Cancer after Neoadjuvant Therapy

“…5YS in published series of patients with persistent N2 disease after neoadjuvant therapy is poor compared with patients with pN0 disease (5YS <20 vs. 30-40%, respectively). 3,15,[22][23][24][25] In our study, the risk factors affecting recurrence were to have a nonsquamous cell histological tumor (p ¼ 0.006) and to receive chemotherapy only (p ¼ 0.04). Similarly, in the study of Montemuiño et al, locoregional recurrence was significantly lower in the CRT group (8.5 vs. 13.5%; p ¼ 0.047), but distant recurrence rates were similar in the two groups.…”

“…5YS in published series of patients with persistent N2 disease after neoadjuvant therapy is poor compared with patients with pN0 disease (5YS <20 vs. 30–40%, respectively). 3 15 22 23 24 25…”

Survival impact of unexpected N2 in stage IIIB/N2 non-small cell lung cancer patients

“…In some studies, comparing survival in cN2 and pN2 cases, no difference in survival was observed between the two groups. 15,16 However, the point to be noted here is that most of the cases here are T1-T2 cases. Regardless of the T factor, OS is reported to be between 25% and 27% in patients who were operated on as cN0 but were found to have pN2 in different series, and this rate rises to 35-50% with the addition of adjuvant therapy.…”