Division of Thoracic Surgery, Swedish Cancer Institute, Seattle, Washington.
Division of Thoracic Surgery, Swedish Cancer Institute, Seattle, Washington.
Ann Thorac Surg. 2022 Aug;114(2):394-400. doi: 10.1016/j.athoracsur.2021.11.010. Epub 2021 Dec 8.
Surgical management for potentially resectable stage IIIA-N2 non-small cell lung cancer (NSCLC) is controversial. For some, persistent N2 disease after induction therapy is a contraindication to resection. We examined outcomes of a well-selected surgical cohort of postinduction IIIA-N2 NSCLC patients with persistent N2 disease.
We retrospectively reviewed all resected clinical IIIA-N2 NSCLC patients from 2001 to 2018. Thorough preoperative staging, including invasive mediastinal staging, was performed. Those with nonbulky N2 disease, appropriate restaging, and potential for a margin-negative resection were included. After resection, patients were classified as having persistent N2 disease or mediastinal downstaging (N2 to >N0/N1). Persistent N2 patients were further classified as uncertain resection (R[un]) or complete resection (R0) according to the International Association for the Study of Lung Cancer definition. Kaplan-Meier survival analysis was used.
Fifty-four patients met inclusion criteria. After induction, 31 patients (57%) demonstrated persistent N2 disease, and 23 patients (43%) had mediastinal downstaging. Preinduction invasive mediastinal staging was performed in 98.1%. Most had clinical single-station N2 disease (75.9%). Margin-negative resections were performed in 100%. Eight patients were reclassified as R(un) due to positive highest sampled mediastinal station. The median overall survival for persistent N2 was 26 months for R(un) and 69 months for R0. Overall survival for the downstaged group was 67 months (P = .31).
Overall survival for patients with non-R(un) or persistent N2 (true R0) was similar to those with mediastinal downstaging. Well-selected patients with persistent N2 disease experience reasonable survival after resection and should have surgery considered as part of their multimodality treatment. This study underscores the importance of classifying the extent of mediastinal involvement for persistent N2 patients, supporting the proposed International Association for the Study of Lung Cancer R(un) classification.
对于潜在可切除 IIIA-N2 期非小细胞肺癌（NSCLC），手术治疗存在争议。对于某些人来说，诱导治疗后持续存在 N2 疾病是手术切除的禁忌症。我们检查了一组经过精心选择的接受诱导治疗后 IIIA-N2 NSCLC 患者中持续存在 N2 疾病的患者的手术结果。
我们回顾性分析了 2001 年至 2018 年所有接受手术治疗的临床 IIIA-N2 NSCLC 患者。进行了彻底的术前分期，包括有创性纵隔分期。纳入了非肿块性 N2 疾病、适当的重新分期和有边缘阴性切除可能的患者。切除后，根据国际肺癌研究协会的定义，患者被分类为持续存在 N2 疾病或纵隔降期（N2 至 >N0/N1）。根据国际肺癌研究协会的定义，持续存在 N2 疾病的患者进一步分为不确定切除（R[un]）或完全切除（R0）。使用 Kaplan-Meier 生存分析。
54 例患者符合纳入标准。诱导后，31 例（57%）患者持续存在 N2 疾病，23 例（43%）患者纵隔降期。98.1%的患者进行了诱导前有创性纵隔分期。大多数患者为临床单站 N2 疾病（75.9%）。所有患者均进行了边缘阴性切除术。由于最高采样纵隔站阳性，有 8 例患者被重新分类为 R(un)。R(un)的持续 N2 患者的中位总生存期为 26 个月，R0 的中位总生存期为 69 个月。降期组的总生存期为 67 个月（P=0.31）。
非 R(un)或持续 N2（真正的 R0）患者的总生存期与纵隔降期患者相似。经过精心选择的持续存在 N2 疾病患者在接受手术后可获得合理的生存，应将手术视为其多模式治疗的一部分。本研究强调了对持续存在 N2 患者的纵隔受累程度进行分类的重要性，支持了国际肺癌研究协会提出的 R(un)分类。
