Is Pneumonectomy Justified in Patients With Locally Advanced NSCLC and Persistent N2 Disease After Induction Chemotherapy?

Abstract

With some concern we read the article by Mansour and colleagues [1Mansour Z. Kochetkova E.A. Santelmo N. et al.Persistent N2 disease after induction therapy does not jeopardize early and medium term outcomes of pneumonectomy.Ann Thorac Surg. 2008; 86: 228-233Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar] in the July 2008 issue of The Annals of Thoracic Surgery on the outcome in patients with nonsmall cell lung cancer (NSCLC) and N2 disease after pneumonectomy. They discuss the question of whether it is reasonable to subject a patient to this high-risk procedure with postoperative (< 90 day) mortality of 10% after induction therapy.Their conclusion is in favor of aggressive surgical management (ie, perform pneumonectomy in patients with or without downstaging after induction therapy), as long-term survival in their series was satisfactory.Unfortunately, there seems to be something wrong with the presented survival analysis. The study included patients between January 1999 and July 2005. The last date of follow-up was January 1, 2007. From 36 months to 84 months of follow-up, the presented numbers of patients at risk are the same, although the censoring marks of the survival curves suggest otherwise. Also, it seems unlikely that the majority of patients were treated before the year 2000, as only these patients could be followed for 84 months. A 5-year disease-free survival rate of 43.3% was reported for the group of patients who underwent pneumonectomy after induction chemotherapy, and had persistent N2 disease, whereas the 5-year overall survival rate was reported to be 32.2%. This is impossible, as the proportion of disease-free patients can not be higher than the proportion of patients alive.We tend to disagree with the conclusion of the authors that pneumonectomy is justified in patients with persistent N2 disease after induction chemotherapy. In the light of this discussion, the recently reported data by the German Lung Cancer Cooperative Group are interesting, as they reported a 5-year disease-free survival of 12% in patients with complete resection (ie, lobectomy or pneumonectomy) and persistent N2 disease [2Thomas M. Rube C. Hoffknecht P. et al.Effect of preoperative chemoradiation in addition to preoperative chemotherapy: a randomised trial in stage III non-small-cell lung cancer.Lancet Oncol. 2008; 9: 636-648Abstract Full Text Full Text PDF PubMed Scopus (268) Google Scholar]. With some concern we read the article by Mansour and colleagues [1Mansour Z. Kochetkova E.A. Santelmo N. et al.Persistent N2 disease after induction therapy does not jeopardize early and medium term outcomes of pneumonectomy.Ann Thorac Surg. 2008; 86: 228-233Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar] in the July 2008 issue of The Annals of Thoracic Surgery on the outcome in patients with nonsmall cell lung cancer (NSCLC) and N2 disease after pneumonectomy. They discuss the question of whether it is reasonable to subject a patient to this high-risk procedure with postoperative (< 90 day) mortality of 10% after induction therapy. Their conclusion is in favor of aggressive surgical management (ie, perform pneumonectomy in patients with or without downstaging after induction therapy), as long-term survival in their series was satisfactory. Unfortunately, there seems to be something wrong with the presented survival analysis. The study included patients between January 1999 and July 2005. The last date of follow-up was January 1, 2007. From 36 months to 84 months of follow-up, the presented numbers of patients at risk are the same, although the censoring marks of the survival curves suggest otherwise. Also, it seems unlikely that the majority of patients were treated before the year 2000, as only these patients could be followed for 84 months. A 5-year disease-free survival rate of 43.3% was reported for the group of patients who underwent pneumonectomy after induction chemotherapy, and had persistent N2 disease, whereas the 5-year overall survival rate was reported to be 32.2%. This is impossible, as the proportion of disease-free patients can not be higher than the proportion of patients alive. We tend to disagree with the conclusion of the authors that pneumonectomy is justified in patients with persistent N2 disease after induction chemotherapy. In the light of this discussion, the recently reported data by the German Lung Cancer Cooperative Group are interesting, as they reported a 5-year disease-free survival of 12% in patients with complete resection (ie, lobectomy or pneumonectomy) and persistent N2 disease [2Thomas M. Rube C. Hoffknecht P. et al.Effect of preoperative chemoradiation in addition to preoperative chemotherapy: a randomised trial in stage III non-small-cell lung cancer.Lancet Oncol. 2008; 9: 636-648Abstract Full Text Full Text PDF PubMed Scopus (268) Google Scholar].