The Survival Efficiency of Initial Surgical Treatment in Stage IIIa-N2 Positive Non-Small Cell Lung Cancer

Year 2021, Volume: 7 Issue: 3, 416 - 422, 31.12.2021

Muhammet Ali Beyoglu , Selim Şakir Erkmen Gulhan , Ayperi Öztürk , Leyla Nesrin Acar , Mehmet Şahin , Gokturk Findik

https://doi.org/10.19127/mbsjohs.981036

Abstract

​ Objective: The role of surgical treatment in the multimodal treatment of stage IIIA-N2 positive non-small cell lung cancer (NSCLC) patients is a matter of debate. We aim to investigate initial surgical treatment's survival efficiency in patients with IIIA N2 positive NSCLC.
Methods: The patients treated for stage IIIA N2 positive NSCLC in a single center between January 2009 and December 2014 were retrospectively analyzed. A total of 134 patients with 5 cm tumors in diameter or less and without involvements of the chest wall, mediastinal pleura, phrenic nerve, recurrent laryngeal nerve, pericardium, heart, diaphragm, vertebra, esophagus, large vessel invasion, and satellite nodule were detected. Of these patients, initial surgical treatment before chemoradiotherapy was performed in 72 (Group 1), while definitive concurrent chemoradiotherapy was performed in 62 patients (Group 2). Each patient's gender, age, physical performance status, tumors size, pathological diagnosis, lung resection types, and long-term survival data were evaluated.
Results: No statistically significant difference was found in patients' gender, physical performance, tumor size, and tumor histology. Survival rates were higher among patients aged ≤65 years and higher in Group 1 than Group 2. While one-, three, five-, and seven-year survival rates were detected as 86.1%, 62.5%, 41.6%, and 31% in Group 1, respectively, the rates were observed to be as 77.4%, 30.6%, 10.8%, and 6.7% in Group 2, respectively. However, no difference was seen between patients' survival rates with single and multiple ipsilateral mediastinal lymph node metastases.
Conclusion: Despite those advocating surgical treatment after neoadjuvant chemotherapy in treating stage IIIA N2 positive patients, others supporting surgical treatment should initially be performed. When conducted as the first step, surgical treatment achieves significant increases in survival.

Keywords

Non-small cell lung cancer, stage IIIA, N2 positive, survival.

References

• 1. Nicholson AG, Chansky K, Crowley J, Beyruti R, Kubota K, Turrisi A, et al. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the Clinical and Pathologic Staging of Small Cell Lung Cancer in the Forthcoming Eighth Edition of the TNM Classification for Lung Cancer. J Thorac Oncol. 2016;11(3):300-311. doi:10.1016/j.jtho.2015.10.008
• 2. Asamura H, Chansky K, Crowley J, Goldstraw P, Rusch VW, Vansteenkiste JF, et al. The International Association for the Study of Lung Cancer Lung Cancer Staging Project: Proposals for the Revision of the N Descriptors in the Forthcoming 8th Edition of the TNM Classification for Lung Cancer. J Thorac Oncol. 2015;10(12):1675-1684. doi:10.1097/JTO.0000000000000678
• 3. DeSantis CE, Lin CC, Mariotto AB, Siegel RL, Stein KD, Kramer JL, et al. Cancer treatment and survivorship statistics, 2014. CA Cancer J Clin. 2014;64(4):252-271. doi:10.3322/caac.21235 .
• 4. Yoon SM, Shaikh T, Hallman M. Therapeutic management options for stage III non-small cell lung cancer. World J Clin Oncol. 2017;8(1):1-20. doi:10.5306/wjco.v8.i1.1
• 5. Ettinger DS, Wood DE, Akerley W, Bazhenova LA, Borghaei H, Camidge DR, et al. NCCN Guidelines Insights: Non-Small Cell Lung Cancer, Version 4.2016. J Natl Compr Canc Netw. 2016;14(3):255-264. doi:10.6004/jnccn.2016.0031
• 6. Hekimoglu B, Gulhan SSE, Akkas Y, Acar LN, Kaya S. Survival Analysis in N2 (+) Patients for Whom Surgical Resection Was Performed. Akd Med J. 2019; 5: 104-11. doi: 10.17954/amj.2018.1131
• 7. Hess LM, Smith D, Cui ZL, Montejano L, Liepa AM, Schelman W, et al. The relationship between Eastern Cooperative Oncology Group performance status and healthcare resource utilization among patients with advanced or metastatic colorectal, lung or gastric cancer. J Drug Assess. 2020;10(1):10-17. Published 2020 Dec 16. doi:10.1080/21556660.2020.1851504
• 8. Lee JG, Lee CY, Kim DJ, Chung KY, Park IK. Non-small cell lung cancer with ipsilateral pulmonary metastases: prognosis analysis and staging assessment. Eur J Cardiothorac Surg. 2008;33(3):480-484. doi:10.1016/j.ejcts.2007.12.005
• 9. Pless M, Stupp R, Ris HB, Stahel RA, Weder W, Thierstein S, et al. Induction chemoradiation in stage IIIA/N2 non-small-cell lung cancer: a phase 3 randomised trial [published correction appears in Lancet. 2015 Sep 12;386(9998):1040]. Lancet. 2015;386(9998):1049-1056. doi:10.1016/S0140-6736(15)60294-X
• 10. Shah AA, Berry MF, Tzao C, Gandhi M, Worni M, Pietrobon R, et al. Induction chemoradiation is not superior to induction chemotherapy alone in stage IIIA lung cancer. Ann Thorac Surg. 2012;93(6):1807-1812. doi:10.1016/j.athoracsur.2012.03.018
• 11. Gurses A, Turna A, Bedirhan MA, Ozalp T, Kocaturk C, Demir A, et al. The value of mediastinoscopy in preoperative evaluation of mediastinal involvement in non-small-cell lung cancer patients with clinical NO disease. Thorac Cardiovasc Surg. 2002 Jun;50(3):174-7. doi: 10.1055/s-2002-32416. PMID: 12077692.
• 12. Youlden DR, Cramb SM, Baade PD. The International Epidemiology of Lung Cancer: geographical distribution and secular trends. J Thorac Oncol. 2008;3(8):819-831. doi:10.1097/JTO.0b013e31818020eb
• 13. Novaes FT, Cataneo DC, Ruiz Junior RL, Defaveri J, Michelin OC, Cataneo AJ. Lung cancer: histology, staging, treatment and survival. J Bras Pneumol. 2008;34(8):595-600. doi:10.1590/s1806-37132008000800009
• 14. Fernandes AT, Mitra N, Xanthopoulos E, Evans T, Stevenson J, Langer C. et al. The impact of extent and location of mediastinal lymph node involvement on survival in Stage III non-small cell lung cancer patients treated with definitive radiotherapy. Int J Radiat Oncol Biol Phys. 2012;83(1):340-347. doi:10.1016/j.ijrobp.2011.05.070
• 15. Le Pechoux C, Arriagada R, Pignon JP. Need for new powered trials to assess the role of post-operative radiotherapy for stage III non-small cell lung cancer. Radiother Oncol. 2014;112(2):314-315. doi:10.1016/j.radonc.2014.05.015
• 16. Ma Q, Liu D, Guo Y, Shi B, Song Z, Tian Y. Surgical therapeutic strategy for non-small cell lung cancer with mediastinal lymph node metastasis (N2). Zhongguo Fei Ai Za Zhi. 2010;13(4):342-348. doi:10.3779/j.issn.1009-3419.2010.04.14 17. Katagiri Y, Jingu K, Yamamoto T, Matsushita H, Umezawa R, Ishikawa Y, et al. Differences in patterns of recurrence of squamous cell carcinoma and adenocarcinoma after radiotherapy for stage III non-small cell lung cancer. Jpn J Radiol. 2021;39(6):611-617. doi:10.1007/s11604-021-01091-y 18. Albain KS, Swann RS, Rusch VW, Turrisi AT 3rd, Shepherd FA, Smith C. et al. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial. Lancet. 2009;374(9687):379-386. doi:10.1016/S0140-6736(09)60737-6
• 19. Shi W, Zhang W, Sun H, Shao Y. Sleeve lobectomy versus pneumonectomy for non-small cell lung cancer: a meta-analysis. World J Surg Oncol. 2012;10:265. Published 2012 Dec 11. doi:10.1186/1477-7819-10-265
• 20. Tsiambas E, Ragos V, Lefas AY, Georgiannos SN, Grapsa D, Grapsa D. et al. Chromosome 7 deregulation in non-small cell lung carcinoma molecular landscape. J BUON. 2015;20(6):1635-1639.
• 21. Asamura H, Goya T, Koshiishi Y, Sohara Y, Eguchi K, Mori M, et al. A Japanese Lung Cancer Registry study: prognosis of 13,010 resected lung cancers. J Thorac Oncol. 2008;3(1):46-52. doi:10.1097/JTO.0b013e31815e8577
• 22. Cerfolio RJ, Maniscalco L, Bryant AS. The treatment of patients with stage IIIA non-small cell lung cancer from N2 disease: who returns to the surgical arena and who survives. Ann Thorac Surg. 2008;86(3):912-920. doi:10.1016/j.athoracsur.2008.04.073
• 23. Misthos P, Sepsas E, Kokotsakis J, Skottis I, Lioulias A. The significance of one-station N2 disease in the prognosis of patients with nonsmall-cell lung cancer. Ann Thorac Surg. 2008;86(5):1626-1630. doi:10.1016/j.athoracsur.2008.07.076