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Ann Thorac Surg 2009;88:2069-2070. doi:10.1016/j.athoracsur.2009.06.104
© 2009 The Society of Thoracic Surgeons
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Correspondence

Single Station N2 NSCLC: A Brief Reflection on Possible Overdoing

Stefano Cafarotti, MDa, Alfredo Cesario, MDa,b, Giacomo Cusumano, MDa, Pierluigi Granone, MDa

a Division of Thoracic Surgery, Catholic University, Policlinico Gemelli Rome, Largo F.Vito 1, Rome, 000168 Italy
b CdC San Raffaele Velletri, IRCCS San Raffaele Pisana, Via della Pisana, 235, Rome, 00163 Italy

(Email: giacomare55{at}hotmail.com).

To the Editor:

We have read with great interest the article by Misthos and colleagues [1] and the attached Invited Commentary by Detterbeck [2], reporting on the peculiar outcome of advanced stage (IIIa) non-small cell lung cancer (NSCLC) cases with the involvement of a single mediastinal (N2) station. This was compared with the outcome of cases of multiple involvement (ie, patients with more than one node) within the same staging class (IIIa) and the same N2 level.

The role of surgery in patients with NSCLC in clinical stage IIIa due to an extension to the homolateral mediastinal nodal stations (N2) is still a forum of open discussion. Some authors have reported clinical series with a mean 5-year survival rate ranging from 5% to 30% [3]. This clearly underlines a substantial heterogeneity of class IIIa patients, which is possibly determined by an intrinsically different (biological) behavior of various tumours, all set in the same stage. The results of two clinical trials, aimed at analyzing the role of surgery in the treatment of clinical N2 diseases [4, 5], show that surgery provides no advantage in comparison with chemotherapy and radiotherapy in terms of overall survival. In detail, these findings outline that satisfactory results, comparable with those generally achievable in cancers at earlier stages, could be obtained for certain types of N2 cancers; this proved to be particularly true for those cases in which the N2 involvement at a single station level is intraoperatively discovered ("incidental") or at final pathology "pathological" [1, 6, 7].

Moving from the findings reported by Misthos and colleagues [1] in the light of the newly proposed context of a general re-definition of the staging criteria, according to the different prognostic classes, we retrospectively analyzed our incidental and pathological N2 cases. Patients' data were matched by survival, stage, T-factor, N-factor, gender, histiotype, type of resection, and grading. An interesting result is the 5-yr survival of patients (22 cases) with unsuspected single-level station 5 or 6 N2 disease (ie, aortopulmonary window and ligament) observed and treated from 2003 to 2007; this, in fact, was 30.9% versus the 45.1% observed for patients with stage IIB T2N1 disease (40 patients; log rank; p = 0.5) (Fig 1).


Figure 1
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  		Fig 1. Kaplan-Meier curves according to the nodal status.

 
Patients with the 5 or 6 N2-single station involvement appeared to have survivals similar to those clinically staged IIb due to the involvement of hylar nodes (N1). Therefore, we support Dr Detterbeck's conclusion emphasizing the need of an accurate review of the landscape encompassing diseases with an N1 and single-station (5 or 6) N2. In fact, the data stemming from the cited and reported experiences (including our own), especially in those settings in which an accurate invasive staging is planned and performed (eg, computed tomography, positron emission tomographic scan for N2-negative cases), prompts the interesting reflection that patients with a limited involvement of a single N2 station (5 or 6), who are nowadays subject to complex and aggressive multidisciplinary treatment strategies, often with an inductive (neoadjuvant) intention and thus including chemoradiation, surgery, and possibly adjuvant chemotherapy, could be over-treated. This induces a possibly unjustifiable high morbidity and mortality risk exposure. A further and carefully planned (randomized) investigation is strongly needed.


   References
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 References
 

  1. Misthos P, Sepsas E, Kokotsakis J, Skottis I, Lioulias A. The significance of one-station N2 disease in the prognosis of patients with non small-cell lung cancer Ann Thorac Surg 2008;86:1626-1631.[Abstract/Free Full Text]
  2. Detterbeck F. Invited commentary Ann Thorac Surg 2008;86:1631.[Free Full Text]
  3. Andrè F, Grunenwald D, Pignon JP, Dujon A, Pujol JL, Brichon PY. Survival of patients with resected N2 non small-cell lung cancer: evidence for a subclassification and implications J Clin Oncol 2000;18:2981-2989.[Abstract/Free Full Text]
  4. Albain KS, Swann RS, Rusch VR, et al. Phase III study of concurrent chemotherapy and radiotherapy (CT/RT) vs CT/RT followed by surgical resection for stage IIIA (pN2) non-small cell lung cancer (NSCLC): outcomes update of North American IntergroupOrlando, FL: ASCO; 2005.
  5. van Meerbeeck JP, Kramer G, van Schil PE, et al. A randomized trial of radical surgery versus thoracic radiotherapy in patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) after response to induction chemotherapyOrlando, FL: ASCO; 2005.
  6. Martini N, Flehinger BJ. The role of surgery I N2 lung cancer Surg Clin North Am 1987;67:1037-1049.[Medline]
  7. Ohta Y, Shimizu Y, Minato H, Matsumoto I, Oda M, Watanabe G. Results of initial operations in non-small cell lung cancer patients with single level n2 disease Ann Thorac Surg 2006;81:427-433.[Abstract/Free Full Text]

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Reply
Frank Detterbeck
Ann. Thorac. Surg. 2009 88: 2070. [Extract] [Full Text] [PDF]



This article has been cited by other articles:


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Surgery for patients with persistent pathological N2 IIIA stage in non-small-cell lung cancer after induction radio-chemotherapy: the microscopic seed of doubt
Eur J Cardiothorac Surg, September 1, 2011; 40(3): 656 - 663.
[Abstract] [Full Text] [PDF]

Home page
 Ann. Thorac. Surg.Home page
F. Detterbeck
Reply.
Ann. Thorac. Surg., December 1, 2009; 88(6): 2070 - 2070.
[Full Text] [PDF]

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