Long Term Survival of Patients with Unsuspected N2 Disease in Non-Small Cell Lung Cancer

Abstract

BackgroundThe aim of this study was to determine the survival rate of patients with non-small cell lung cancer (NSCLC) who were preoperatively diagnosed with a negative N2 lymph node, but postoperatively confirmed as a positive N2 node based on a pathological evaluation.Materials and MethodsThe hospital records of 248 patients from 1994 to 2009 with resected primary NSCLC who were preoperatively diagnosed with negative N2 lymph node, were retrospectively reviewed. Of these, after surgery, there were 148 (59.7%) patients with pathological N0, 54 (21.8%) with pathological N1 and 46 (18.5%) with pathological N2.ResultsThe median follow-up period was 24 months (range, 1 to 132 months). The 5-year disease free survival rates were 60% in pN0, 44% in pN1, and 29% in pN2. The 5-year overall survival rates were 63.1% in pN0, 51.9% in pN1, and 33.5% in pN2. There were no statistically significant differences between pN1 and pN2 (p=0.326 and p=0.106, respectively). Thirty-three (71.7%) of the 46 pN2 patients had single-zone metastasis, and 13 patients (28.3%) had multiple-zone metastases over the two nodal zone metastasis. There were no statistical differences in the 5-year disease free survival rate and the 5-year overall survival rates between the two groups.ConclusionThe 5-year disease free survival and the overall survival rate of the patients with unsuspected N2 disease were statistically similar with that of the patients with pathological N1 disease. There was no statistically significant difference between the patients with a single-zone metastasis and a multiple zone metastasis.

Long-term outcomes after lobectomy for non–small cell lung cancer when unsuspected pN2 disease is found: A National Cancer Data Base analysis

“…2,4-6,9 The incidence of unsuspected pN2 disease of 4.4% in our cohort is within but on the low side of the range previously reported by other single institution studies (2.0% to 18.5%). 2-8 The NCDB does not have information on how patients were clinically staged, but presumably, given the dates of the study from 1998-2006, a significant percentage of patients were staged with positron emission tomography (PET)/computed tomography (CT) which may have contributed to the low incidence of unsuspected N2 disease.…”

“…2-8 The NCDB does not have information on how patients were clinically staged, but presumably, given the dates of the study from 1998-2006, a significant percentage of patients were staged with positron emission tomography (PET)/computed tomography (CT) which may have contributed to the low incidence of unsuspected N2 disease. Studies that have reported higher incidences of unsuspected pN2 disease were often older 9,11 and may have relied more on computed tomography (CT) or X-ray 2,4,5 alone than on PET/CT. Studies reporting lower incidences of unsuspected N2 disease (2.9-7.3%) often were from centers that used a combination of CT and PET/CT imaging.…”

“…This clinical scenario has been reported to occur in 2.0% to 18.5% of patients, 2-8 and is associated with a 5-year overall survival ranging from 10% to 40%. 2,4,6,9-12 Some reports, 2,6,9-11,13 including those by the National Comprehensive Cancer Network and the American College of Chest Physicians (ACCP), 14,15 have suggested that the proper course of action for patients with unsuspected N2 disease diagnosed at the time of surgery is to continue with resection, although this guideline is based on very limited data and noted to be a Grade 2C recommendation. 15 Other authors have suggested a preference towards aborting resection in order to administer induction therapy.…”

Preoperative Risk Factors for Pathologic N2 Metastasis in Positron Emission Tomography-Computed Tomography–Diagnosed N0–1 Non-Small Cell Lung Cancer

“…In our study, patients underwent surgery only when preoperative PET-CT showed no mediastinal LN metastasis. However, we identified pN2 metastasis in 22 of the 166 patients (13.3%), consistent with previous studies [10,11]. In a univariate analysis, we identified central tumor location, larger tumor size, and high SUVmax uptake as statistically significant risk factors for pN2 status.…”

MEDIASTinal staging of non-small cell lung cancer by endobronchial and endoscopic ultrasonography with or without additional surgical mediastinoscopy (MEDIASTrial): study protocol of a multicenter randomised controlled trial

“…Cerfolio et al demonstrated good 5-yr survival by surgical resection and adjuvant therapy in single nodal station unforeseen N2 disease (40%) and hereby reached comparable survival as in patients with N1 disease [ 12 ]. Several others also showed favourable 5-yr survival rates in these patients [ 13 , 14 ]. To strengthen these figures, recent survival data from the ASTER trial demonstrated equal 5-yr survival rates of 35% in both randomization groups, despite significantly different detection rates of upfront N2 disease [ 15 ].…”