Multimodality Therapy for N2 Non-Small Cell Lung Cancer: An Evolving Paradigm.

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The Annals of thoracic surgery


BACKGROUND: Induction chemoradiation for resectable N2 non-small cell lung cancer (NSCLC) is used with the intent to optimize locoregional control, whereas induction chemotherapy given in systemic doses is meant to optimally target potential distant disease. However, the optimal preoperative treatment regimen is still unknown and practice patterns continue to vary widely. We compared multi-institutional oncologic outcomes for N2 NSCLC from four experienced lung cancer treatment centers.

METHODS: This collaborative retrospective study unites four major thoracic oncology centers. Patients with N2 NSCLC undergoing surgical resection after induction chemotherapy (CxT) or concurrent chemoradiation (CxRT) were included. Primary outcomes were overall and disease-free survival (OS and DFS).

RESULTS: 822 patients were identified (CxT = 662 and CxRT = 160). There were no differences in 5-year OS (CxT 39.9% vs CxRT 42.9%, p=0.250) nor in DFS (CxT 28.7% vs 29.8%, p=0.207). Recurrence rates (CxT 46.8% vs CxRT 51.6%, p=0.282) and recurrence patterns were not significantly different (Local: CxT 9.8% vs CxRT 9.7%; and Distant: CxT 30.4% vs CxRT 33.1%, p=0.764). There was no difference in perioperative mortality. In the analyses of patients who underwent pretreatment invasive mediastinal staging (N=555), there were still no significant differences in OS (p=0.341) and DFS (p=0.455) between the two treatment strategies.

CONCLUSIONS: Both treatment strategies produce equivalent and better than expected outcomes compared to historical controls for N2 NSCLC, with no differences in recurrence patterns. How these conventional therapeutic strategies will compare to those involving immunotherapy combined with surgical loco-regional disease control for N2 disease remains to be determined.

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