Which patients should be operated on after induction chemotherapy for N2 non–small cell lung cancer? Analysis of a 7-year experience in 175 patients

Objective

The role of surgery in patients with N2 non–small cell lung cancer is debated. The aim of this study was to evaluate the results of surgical resection after induction chemotherapy.

Methods

We retrospectively reviewed the cases of patients with N2 non–small cell lung cancer who underwent neoadjuvant chemotherapy followed by resection between 2001 and 2007. They all had tumors deemed resectable.

Results

One hundred seventy-five patients entered the study. Most of them received 2 or 3 cycles of chemotherapy (81%), in all cases platinum-based regimens. Chemotherapy response rate was 62%. Operations included 96 lobectomies/bilobectomies and 79 pneumonectomies. Complete resection rate was 94%, and perioperative mortality was 4.5%. A pathologic mediastinal downstaging was found in 39% of patients. Overall median survival time and 5-year survival were 34.7 months and 30%, respectively. Survival was affected by clinical response (median survival time 51 months and 5-year survival 42% for responders versus 19 months and 10% for nonresponders) and by nodal downstaging (51 months and 45% versus 25% and 22%). In the group of responders, nondownstaged patients showed satisfying survival (median survival time 30 months, 5-year survival 30%). In the group of nonresponders, survival was unsatisfactory when a lobectomy was performed (median survival time 20 months, 5-year survival 13%) and poor in case of pneumonectomy (15 months and 6%). Multivariate analysis found 4 factors significantly affecting survival: clinical response, nodal downstaging, number of chemotherapy cycles, and histopathologic response.

Conclusions

Surgery after chemotherapy could be effective for selected patients with N2 non–small cell lung cancer. Survival for responders is satisfactory, even in case of persistent N2 disease. Prognosis for nonresponders is disappointing.

CTSNet classification: 10

Abbreviations and Acronyms: CT, computed tomography, EORTC, European Organisation for Research and Treatment of Cancer, MST, median survival time, NSCLC, non–small cell lung cancer, PET, positron emission tomography, PFS, progression-free survival