Survival Benefit of Surgery after Chemoradiotherapy for Stage III (N0–2) Non-Small-Cell Lung Cancer Is Dependent on Pathologic Nodal Response

Abstract

Surgical patients with complete nodal clearance experienced superior survival, but those with RND fared no better than CRT alone. Mediastinal response may play an important role in the decision to proceed with surgical resection after CRT for stage III NSCLC.

A Model to Predict the Use of Surgical Resection for Advanced-Stage Non-Small Cell Lung Cancer Patients

“…Survival for advanced-stage NSCLC is only 4%, and outcomes are generally governed by response to systemic therapy [1]. Yet, the inclusion of surgical therapy into multimodality treatment regimens has been reproducibly associated with improved outcomes [3][4][5][6][7][8]15]. A recurrent criticism of these studies is that the observation of improved survival with surgical intervention is attributable to selection bias for patients with favorable characteristics (fewer comorbidities, lower-volume disease) rather the surgical treatment.…”

“…Our findings are not surprising, because these factors are known to favorably influence prognosis, reinforcing the concept that patients with an expectation of greater survival are offered higher-risk treatments. In fact, the independent relationship between lower metastatic status, nodal status, and younger age with longer survival is well established in clinical trials and also in previously created prediction models [7,[15][16][17].…”

Multidisciplinary team approach for the management of patients with locally advanced non-small cell lung cancer: searching the evidence to guide the decision

“…In a retrospective study of preoperative CCRT (44–45 Gy) with etoposide/cisplatin (EP) or docetaxel/cisplatin in patients with N2-positive stage IIIA NSCLC (n = 355), ypN stage was the most important prognostic factor for survival; neither initial bulk nor the extent of cN2 disease influenced the prognosis [31]. Patients with stage III NSCLC treated with surgery after induction CCRT and with pathologically complete lymph node response showed significantly higher survival compared to that of patients with CCRT only (81 vs. 31.8 months; p = 0.0004) and patients with residual nodal disease after surgery experienced poor OS (median, 16.1 months) [32]. Although the preoperative radiation dose has traditionally been limited to 45 Gy, primarily owing to concerns of excess postoperative morbidity and mortality, the hypothesis that full-dose of CRT would result in higher pathologic complete response and excellent long-term survival requires testing.…”

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

“…Although multi‐level mediastinal lymph node involvement is an adverse prognostic factor for survival in NSCLC patients with clinical N2 disease, several studies have shown that downstaging after induction therapy is associated with a better prognosis . Buenro et al .…”

“…Although multi-level mediastinal lymph node involvement is an adverse prognostic factor for survival in NSCLC patients with clinical N2 disease, 17,18 several studies have shown that downstaging after induction therapy is associated with a better prognosis. 9,17,19,20 Buenro et al reported that the median cancer-free survival was significantly better in patients with N2 NSCLC who achieved complete remission after neoadjuvant therapy and surgery than in those whose disease was not downstaged (21.3 vs. 15.9 months; P = 0.023). 9 Katakami et al also concluded that N2 NSCLC patients with downstaged cancer who underwent surgery after induction chemotherapy or CRT had significantly longer PFS than patients whose cancer was not downstaged after induction chemotherapy or CRT.…”