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Joe B Putnam
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ES 05 - Surgical Skills (ID 514)
- Event: WCLC 2017
- Type: Educational Session
- Track: Surgery
- Presentations: 1
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ES 05.01 - Strategy for N2 NSCLC (ID 7599)
15:45 - 16:00 | Presenting Author(s): Joe B Putnam
- Abstract
- Presentation
Abstract:
The clinical stage is the clinician’s best and final estimate of the extent of the disease prior to the initiation of definitive therapy. As such, the clinical stage creates the foundation for all cancer treatment recommendations. Patients with lung cancer and metastasis to the ipsilateral mediastinal and/or subcarinal lymph node(s) (LN) have a nodal descriptor of N2. Such N2 metastasis reflects a biologically advanced disease with spread beyond the primary tumor in the lung itself. In the forthcoming eighth addition of the TNM classification for lung cancer, the current (7th edition) nodal descriptors and location for both clinical and pathological nodal status (N0 to N3) adequately predict prognosis. Although for lung cancer, nodal status is based on the anatomic location of the involved node, and not on the number of metastatic lymph nodes, future staging models could assess the number of involved nodes and location.(1) Determination of metastases to mediastinal lymph nodes constitutes a critical point in staging and treatment recommendations. Computed tomography and FDG-PET + CT scans are helpful to guide treatment decisions; invasive staging is still recommended to confirm mediastinal nodal involvement. (2) (3) (4) Invasive staging for diagnosis of N2 LN includes cervical mediastinoscopy (CME) or mediastinotomy (Chamberlain’s procedure), endoscopic bronchial ultrasound (EBUS), or esophageal ultrasound (EUS). The use of CME regardless of radiographic evidence of nodal involvement (“routine mediastinoscopy”) is not a cost effective approach, and adds little to the accuracy of staging in patients with an adequate noninvasive preoperative evaluation. (5) Endobronchial ultrasound combined with mediastinoscopy (2;4) can be effective. VATS techniques can evaluate enlarged level 5 or 6 lymph nodes, and as well, enlarged level 8 or 9 or low level 7 lymph nodes. Esophageal ultrasound (EUS) guided aspiration can be used for level 7 and AP window LN Patients with clinically early stage NSCLC (cStage I or II), who have complete resection (R0) and subsequently identified microscopic or occult N2 metastases, represent a biologically favorable subset with improved survival following adjuvant therapy. Surgery alone for cStage IIIA (N2) lung cancer is infrequently performed however, selected patients may benefit from a multidisciplinary approach to treatment which include local and systemic components. (6). Definitive concurrent chemoradiotherapy is commonly recommended for N2 disease given the identifiable locally advanced NSCLC and likely occult systemic metastases. . Induction chemoradiotherapy has been evaluated for treatment of clinical stage IIIA (N2) NSCLC. (7;8) In these two phase III trials, surgery did not provide an overall survival benefit; however, in an exploratory analysis, induction therapy followed by lobectomy had improved survival. Multidisciplinary team discussions for individual patients are essential to optimize benefits of treatment. In selected resectable IIIA NSCLC patients, induction chemoradiotherapy followed by resection is an alternative treatment to chemoradiotherapy alone. (6) The Society of Thoracic Surgery National General Thoracic Surgery Database evaluated identified only 3319 patient with cStage IIIA (N2) NSCLC who underwent resection between 2002 and 2012. (9) Patients were >65 years of age and only 46% were treated with induction therapy. 93% had FDG PET scans, and 51% were coded as having undergone invasive mediastinal staging. Nodal over-staging occurred in 43% of patients. Lobectomy was the most common procedure (69%). The unadjusted 5 year survival following induction therapy was 35%. Selection of patients for resection may depend on the number of ipsilateral LN stations involved, and the ability of induction therapy to create a clinical post-induction yN0 nodal status. Endobronchial ultrasound (EBUS) is used initially to diagnosis ipsilateral LN metastasis and exclude contralateral metastasis. Following induction therapy, repeat EBUS may confirm yN0 status of the previously involved LN, and be validated by cervical mediastinoscopy. The surgeon must answer this question for each patient with N2 disease: When does resection following induction therapy consistently provide better survival than definitive C+RT? Large pragmatic clinical trials may facilitate new knowledge in this area. Regardless of approach (open or minimally invasive techniques), a mediastinal lymph node dissection is recommended. A recent study utilizing the National Cancer Database from the American College of Surgeons Commission on Cancer, demonstrated that with Stage I NSCLC better survival was associated with resecting 10 or more lymph nodes to optimally confirm stage I status.(10) Although this is not a therapeutic intervention, it emphasizes the need for mediastinal lymph node dissection to ensure accuracy by decreasing variability in the mediastinal dissection, and optimizing the accuracy of the pathologic staging. Reference List (1) 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 Dec;10(12):1675-84. (2) Silvestri GA, Gonzalez AV, Jantz MA, Margolis ML, Gould MK, Tanoue LT, et al. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013 May;143(5:Suppl):211S-50S. (3) Stamatis G. Staging of lung cancer: the role of noninvasive, minimally invasive and invasive techniques. European Respiratory Journal 2015 Aug;46(2):521-31. (4) Detterbeck FC, Postmus PE, Tanoue LT. The stage classification of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013 May;143(5:Suppl):191S-210S. (5) Fernandez FG, Kozower BD, Crabtree TD, Force SD, Lau C, Pickens A, et al. Utility of mediastinoscopy in clinical stage I lung cancers at risk for occult mediastinal nodal metastases. J Thorac Cardiovasc Surg 2015;149(1):35-41. (6) Ramnath N, Dilling TJ, Harris LJ, Kim AW, Michaud GC, Balekian AA, et al. Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013 May;143(5:Suppl):314S-40S. (7) Albain KS, Swann RS, Rusch VW, Turrisi AT, III, 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 Aug 1;374(9687):379-86. (8) van Meerbeeck JP, Kramer GW, Van Schil PE, Legrand C, Smit EF, Schramel F, et al. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non-small-cell lung cancer. J Natl Cancer Inst 2007 Mar 21;99(6):442-50. (9) Boffa D, Fernandez FG, Kim S, Kosinski A, Onaitis MW, Cowper P, et al. Surgically Managed Clinical Stage IIIA-Clinical N2 Lung Cancer in The Society of Thoracic Surgeons Database. Ann Thorac Surg 2017 Aug;104(2):395-403. (10) Samayoa AX, Pezzi TA, Pezzi CM, Greer GE, Asai M, Kulkarni N, et al. Rationale for a Minimum Number of Lymph Nodes Removed with Non-Small Cell Lung Cancer Resection: Correlating the Number of Nodes Removed with Survival in 98,970 Patients. Annals of Surgical Oncology , 2016 23, Suppl 5:1005-1011.
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