The Management of Patients With Stage IIIA Non–Small Cell Lung Cancer With N2 Mediastinal Node Involvement

Abstract

Patients with stage IIIA non-small cell lung cancer, determined based on involvement of ipsilateral mediastinal lymph nodes, represent the most challenging management problem in this disease. Patients with this stage disease may have very different degrees of lymph node involvement. The pathologic confirmation of this involvement is a key step in the therapeutic decision. The difference in the degree of lymph node compromise has prognostic and treatment implications. Based on multiple considerations, patients can be treated with induction chemotherapy, chemoradiotherapy followed by surgery, or definitive chemoradiotherapy without surgery. Data derived from clinical trials have provided incomplete guidance for physicians and their patients. The best therapeutic plan is achieved through the multidisciplinary cooperation of a team specialized in lung cancer.

N2 lung cancer is not all the same: an analysis of different prognostic groups†

“…Multimodality treatment was planned for all patients, and all of them received adjuvant chemotherapy except for 8 patients who did not receive postoperative treatment because they died or showed a poor postoperative performance status. Surprisingly, our median 3-and 5-year survival rates for patients diagnosed as N2a1 were considerably better than those reported for N2 patients treated with neoadjuvant therapy and surgery [14,16]. Similarly, a recent French report [11] on 871 patients advocated for a better stratification of IIIA-N2 NSCLC, because they found a significant difference in OS according to the number and position of the lymph node stations involved.…”

Management of Stage IIIA (N2) Non-Small Cell Lung Cancer: A Transatlantic Perspective

“…In North America, surgical treatment for cN2 disease is generally reserved after induction therapy, given these considerations: (1) patients with N2 disease are more likely to experience systemic failure, (2) patients are more likely to receive full-dose and full-cycle chemotherapy when those are given preoperatively relative to adjuvant delivery, and (3) induction chemotherapy provides an assessment of tumor biology and treatment response. This approach is supported by the National Comprehensive Cancer Center guidelines and by other groups [14][15][16].…”

Is tumor location an independent prognostic factor in locally advanced non-small cell lung cancer treated with trimodality therapy?

“…These findings suggest that the majority of lower lobe tumors with multiple mediastinal station metastases, including superior mediastinal nodes, would not have been candidates for trimodality therapy in the study conducted by Kamel et al Indeed, it has been reported that most institutions (90.5%) that belong to the National Comprehensive Cancer Network in the USA consider surgery in patients with a single lymph node station smaller than 3 cm, while 47.6% of the institutions consider surgery in patients with multiple station involvement (as long as no lymph node is larger than 3 cm), and some institutions (16.7%) consider surgery in patients with multiple stations even if the lymph node is larger than 3 cm (13). The 2013 American College of Chest Physicians (ACCP) guideline categorized the resectability of tumors based on these cN2 statuses, such as infiltrative or discrete nodes type, and recommendations for treatment were made according to the cN2 status (14).…”