Surgery in NSCLC: Carving Out a Role

Lung cancer is often diagnosed late in its course.

Most patients with locally advanced non-small cell lung cancer (NSCLC) with mediastinal lymph node (N2) involvement were generally not considered good candidates for surgery, with this current standard of care, 5-year survival rates were roughly 15-20%.

But, when surgery is used, the preferred approach is induction chemotherapy or chemoradiotherapy followed by surgery.

However, surgery's role remains controversial.

In a study published ahead-of-print in Surgery Today, investigators looked at four criteria that might suggest initial surgery in NSCLC patients was prudent and examined the outcomes.

The investigators evaluated 1,290 patients who underwent complete resection for NSCLC during an 8-year period. They examined 4 criteria:

· Single-station N2, which has been associated with better prognosis

· Non-bulky N2, which unlike bulky disease, may have a better chance of resection

· N2 with regional mode of spread, which may indicate the cancer is not yet systemic

· N2 without N1, also called "skip N2" disease and also associated with better prognosis

The team found that clinical N2 disease cases that fulfilled these specific criteria were distinct and different from other presentations. Among study participants, 808 patients underwent initial standard resection, including 779 patients with cN0—1 and 29 with cN2.

According to the study, the median follow-up among study participants was 45.5 months, with a range of 3 to 119 months. Also, 70 (9%) had p-N2 in the cN0—1 and 24 (82.8 %) patients had p-N2 in cN2 groups, respectively.

Patients in the cN0-1 and cN2 groups had remarkably robust 5-year disease-free survival (DFS) rates of 73.3% and 50.6 %, respectively. Their 5-year overall survival (OS) rates were 81.3 and 71.1%, respectively.

Patients with cN2—pN2 also had better than expected 5-year DFS and OS rates of 52.5% and 72.6 %, respectively.

The researchers proposed their criteria as a means to select patients who may be candidates for initial surgical resection followed by chemotherapy or chemoradiation.