Management of Stage IIIA (N2) Non-Small Cell Lung Cancer: A Transatlantic Perspective

N2-IIIA non-small cell lung cancer: a plea for surgery!

“…A comparative study of the databases of the Society of Thoracic Surgeons and the European Society of Thoracic Surgeons obviates that North American Surgeons favour induction therapy, prefer to limit resection to down-staged patients, and avoid pneumonectomy; European surgeons are eager to perform upfront surgery and are less reluctant to perform pneumonectomy; the proportion of N2 disease was almost twice as high in the European database (6). The editorial on transatlantic perspective by Rocco et al cites several single centre studies anticipating or supporting the results from this database study (5).…”

“…While the disease is the same, it is striking how treatment strategies differ between Europe and North America (5). A comparative study of the databases of the Society of Thoracic Surgeons and the European Society of Thoracic Surgeons obviates that North American Surgeons favour induction therapy, prefer to limit resection to down-staged patients, and avoid pneumonectomy; European surgeons are eager to perform upfront surgery and are less reluctant to perform pneumonectomy; the proportion of N2 disease was almost twice as high in the European database (6).…”

PACIFIC: Time for a surgical IIIA uprising

“…Although more than 90% of queried NCCN surgeons agree with that NCCN recommendation, 47.6% of them would also consider surgery after induction in patients with multi-station N2 disease. Thoracic surgeons decide up front whether a stage IIIA patient will be a candidate for resection after induction 8,9 ; however, posttherapy response assessment is a major consideration for final surgical selection (discussed later), especially since complete mediastinal adenectomy is mandated, if possible, at the time of resection. A more precise quantitative algorithm for choosing patients in the immunotherapy era will be essential before any consideration of abandoning a surgical approach should be considered, hopefully by some imaging or blood-based biomarker modality before therapy is initiated.…”

“…There is no doubt that residual N2 disease after definitive therapy influences survival, and whether restaging should influence subsequent surgical management is not at all standardized, even by leaders in the field. 8,9,18 Some will only restage after therapy ''if there is some concern that the patient may not be a good operative candidate or we think there is persistent multistation, bulky disease that may not be resectable,'' 8 while others who associated improved survival with restaging ''suggest that pathologic restaging allowed for more appropriate selection of patients for surgery.'' 19 Alternatively, why do mediastinal staging at all?…”

Stage III Non-small Cell Lung Cancer

“…The approach to initial staging of resectable NSCLC is covered in more detail in other articles in this issue. Briefly, there are some differences in the methods of staging and treatment selection in North America versus other regions of the world, 6 which are reflected in published guidelines. 7,8 In North America, fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) is routinely added to computed tomography (CT) for the initial staging of NSCLC .…”