Is There a Survival Benefit in Patients With Stage IIIA (N2) Non-small Cell Lung Cancer Receiving Neoadjuvant Chemotherapy and/or Radiotherapy Prior to Surgical Resection

Abstract

Optimal management of clinical stage IIIA (N2) non-small cell lung cancer (NSCLC) is controversial. This study is a systematic review and meta-analysis of published randomized control trials of multimodality management strategies for NSCLC.We conducted a comprehensive literature search of the Pubmed, Embase, Medline, and CENTRAL databases for relevant studies comparing patients with stage IIIA (N2) NSCLC undergoing surgery alone, chemotherapy and/or radiotherapy alone, or surgical resection after neoadjuvant treatment with chemotherapy and/or radiotherapy. We estimated hazard ratios, odds ratios (ORs), and 95% confidence intervals (CIs) for survival data.Seven trials involving 1049 patients were included in this study. There was no significant difference in overall survival (OS) or progression-free survival (PFS) in stage IIIA (N2) NSCLC patients who received neoadjuvant chemotherapy or chemoradiotherapy prior to surgical resection compared to those who received neoadjuvant chemotherapy or chemoradiotherapy prior to radical radiotherapy. There was a significant increase in pathological complete remission in the mediastinal lymph nodes in stage IIIA (N2) NSCLC patients who received neoadjuvant chemoradiotherapy prior to surgical resection compared to those who received neoadjuvant chemotherapy (OR 3.61; 95% CI 1.07–12.15; P = 0.04), but no difference in tumor downstaging, OS, or PFS.Neoadjuvant chemotherapy and/or radiotherapy prior to surgical resection do not appear to be clinically superior to neoadjuvant chemotherapy and/or radiotherapy prior to definitive radiotherapy in IIIA (N2) NSCLC patients. Neoadjuvant chemoradiotherapy does not improve survival compared to neoadjuvant chemotherapy alone.

Variations in positron emission tomography-computed tomography findings for patients receiving neoadjuvant and non-neoadjuvant therapy for non-small cell lung cancer

“…These findings might reflect that NT was in more progressive cancer status. Recent studies reported that survival benefits from initial neoadjuvant therapy followed by surgery over initial surgery result from occult metastases undetectable by PET-CT (1,11,17). We attribute our study findings to survival benefits from neoadjuvant therapy followed by surgery.…”

“…However, after neoadjuvant therapy, invasive mediastinal LN staging might be not needed because of frequent discrepancies between PET-CT and pathological findings, especially with previous mediastinal pathological staging (5,10). In addition, some studies show that DFS and OS are sufficiently high to warrant surgery for persistent N2 disease after neoadjuvant therapy (10,11,(19)(20)(21). We propose with caution that surgery should not be delayed or withheld only based on preoperative PET-CT findings after neoadjuvant therapy, especially after previous LN pathological confirmation.…”

“…Thus preoperative PET-CT findings might provide incorrect information and influence management plan for NSCLC (1,6,14). In addition, whether PET-CT findings differ between patients treated with neoadjuvant therapy (NT) or without neoadjuvant therapy (non-NT) for NSCLC remains unclear (7,11,15). The influences of neoadjuvant therapy on PET-CT findings in NSCLC are unknown (7,9,15).…”

“…Neoadjuvant therapy is usually recommended for NSCLC with N2 disease status by pathological confirmation, if clinically feasible (7,(9)(10)(11). A lesion is usually regarded to be malignant or metastatic when SUVmax is 2.5 or higher and the lesion diameter is larger than 1cm on PET-CT (3,12,13).…”

Physical Therapy in Patients with Cancer

“…Small-cell lung cancer is mostly treated with chemotherapy [67]. Non-small-cell lung cancer can be treated with surgery, chemotherapy, radiotherapy, or a combination of these depending on the stage at which the cancer is diagnosed [68,69].…”