HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pierre-Emmanuel Falcoz Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Falcoz, P.-E. Search for Related Content PubMed PubMed Citation Articles by Falcoz, P.-E. Related Collections Lung - cancer Related Article

---

Original Articles: General Thoracic

Invited Commentary

Department of Thoracic and Cardiovascular Surgery, Jean Minjoz Hospital, Blvd Fleming, Besançon 25000, France

(Email: pierre-emmanuel.falcoz{at}wanadoo.fr).

In the present article, Mansour and associates [1] seek to address the very controversial and provocative questions of the optimal management of patients with persistent N2 disease and the impact of pneumonectomy after induction therapy. In a retrospective cohort of 153 patients having undergone pneumonectomy for nonsmall cell lung cancer, three groups were classified according to their pN2 status with respect to induction therapy: (1) persistent N2 after induction therapy, (2) pathologic stage N0 or N1 after induction therapy (downstaged patients), and (3) pathologic N2 disease with immediate surgery. The results showed no statistical difference in operative mortality at 30 days and 90 days, and a similar incidence of major postoperative complications between groups, thus confirming a previous study by the same institution. In addition, the authors found that the prognosis for patients with induction therapy and persistent N2 disease was similar to that of patients with pathologic stage N0 or N1 after induction therapy, but better than that of patients with pN2 disease who underwent immediate surgery. Finally, the authors concluded that pneumonectomy is justified in patients with persistent N2 disease after induction chemotherapy.

This stimulating article helps to clarify some of the controversies regarding surgical management, and moreover it appropriately contradicts some of the dogma in the treatment of stage IIIA–pN2 lung cancer. The results of this well-designed study may well affect the choice of the multimodal approach in the near future. Indeed, this study clearly questions both the accepted theory of better patient selection attributed to downstaging [2] and the results of a recently published meta-analysis, which showed no beneficial effect on survival in stage III patients after induction therapy [3].

Where do we go next in the challenging decision process of stage IIIA–pN2 lung cancer? Three courses deserve mention and may help in decision making. First, the creation of a multicenter, prospective, randomized, controlled trial including histologic-proven N2 patients would better address this issue. Second, the results of the lung adjuvant radiotherapy trial (LungART trial), a multi-institutional European phase III trial comparing conformal post-operative radiotherapy (PORT) to no PORT, along with recent advances in radiation oncology (ie, three-dimensional conformal radiation therapy, image-guided radiotherapy, and stereotactic body radiotherapy, in particular), will certainly show an improvement in the therapeutic ratio of radiotherapy, and may also significantly, and perhaps durably, alter decisions regarding multidisciplinary management in proven N2 disease. Third, molecular biology in the years to come will also play an increasingly important role and its essential contribution may provide the clue. Effectively, analyses performed on surgical macro-biopsies (ie, pre-induction or post-induction therapy, or both, on the remaining tumor) to determine predictive factors of response to chemotherapy give good hope for customizing therapy for each individual patient's molecular profile [4].

For now, Mansour and associates [1] are to be congratulated on their innovative contribution in this area and for having raised questions by highlighting current controversial points that future works may attempt to solve.

	References

Top References

 

1. Mansour Z, Kochetkova EA, Santelmo N, et al. Persistent N2 disease after induction therapy does not jeopardize early and medium term outcomes of pneumonectomy Ann Thorac Surg 2008;86:228-234.[Abstract/Free Full Text]
2. Betticher DC, Hsu Schmitz SF, Tötsch M, et al. Mediastinal lymph node clearance after docetaxel-cisplatin neoadjuvant chemotherapy is prognostic of survival in patients with stage IIIA pN2 non-small-cell lung cancer: a multicenter phase II trial J Clin Oncol 2003;21:1752-1759.[Abstract/Free Full Text]
3. Berghmans T, Paesmans M, Meert AP, et al. Survival improvement in resectable non-small cell lung cancer with (neo)adjuvant chemotherapy: results of a meta-analysis of the literature Lung Cancer 2005;49:13-23.[Medline]
4. Rosell R, Felip E, Taron M, et al. Gene expression as a predictive marker of outcome in stage IIB-IIIA-IIIB nonsmall cell lung cancer after induction gemcitabine-based chemotherapy followed by resectional surgery Clin Cancer Res 2004;10:4215S-4219S.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pierre-Emmanuel Falcoz Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Falcoz, P.-E. Search for Related Content PubMed PubMed Citation Articles by Falcoz, P.-E. Related Collections Lung - cancer Related Article