Stage IIIA-N2 Non-small Cell Lung Research Articles

Risk Factor Analysis of Morbidity and 90-Day Mortality of Curative Resection in Patients with Stage IIIA-N2 Non-Small Cell Lung Cancer after Induction Concurrent Chemoradiation Therapy.

Major pulmonary resection after neoadjuvant concurrent chemoradiation therapy (nCCRT) is associated with a substantial risk of postoperative complications. This study investigated postoperative complications and associated risk factors to facilitate the selection of suitable surgical candidates following nCCRT in stage IIIA-N2 non-small cell lung cancer (NSCLC). We conducted a retrospective analysis of patients diagnosed with clinical stage IIIA-N2 NSCLC who underwent surgical resection following nCCRT between 1997 and 2013. Perioperative characteristics and clinical factors associated with morbidity and mortality were analyzed using univariable and multivariable logistic regression. A total of 574 patients underwent major lung resection after induction CCRT. Thirty-day and 90-day postoperative mortality occurred in 8 patients (1.4%) and 41 patients (7.1%), respectively. Acute respiratory distress syndrome (n=6, 4.5%) was the primary cause of in-hospital mortality. Morbidity occurred in 199 patients (34.7%). Multivariable analysis identified significant predictors of morbidity, including patient age exceeding 70 years (odds ratio [OR], 1.8; p=0.04), low body mass index (OR, 2.6; p=0.02), and pneumonectomy (OR, 1.8; p=0.03). Patient age over 70 years (OR, 1.8; p=0.02) and pneumonectomy (OR, 3.26; p<0.01) were independent predictors of mortality in the multivariable analysis. In conclusion, the surgical outcomes following nCCRT are less favorable for individuals aged over 70 years or those undergoing pneumonectomy. Special attention is warranted for these patients due to their heightened risks of respiratory complications. In high-risk patients, such as elderly patients with decreased lung function, alternative treatment options like definitive CCRT should be considered instead of surgical resection.

A review of perioperative treatment strategies with immunotherapy and tyrosine kinase inhibitors in resectable and stage IIIA-N2 non-small cell lung cancer.

Stage IIIA-N2 non-small cell lung cancer (NSCLC) is a heterogeneous group with different potential therapeutic approaches. Treatment is typically multimodal with either surgical resection after neoadjuvant chemotherapy and/or radiation or concurrent chemotherapy and radiation if unresectable. Despite the multimodal treatment and early stage, cure rates have traditionally been low. The introduction of immunotherapy changed the treatment landscape for NSCLC in all stages, and the introduction of immunotherapy in early-stage lung cancer has improved event free survival and overall survival. Tyrosine Kinase inhibitors (TKIs) have also improved outcomes in early-stage mutation-driven NSCLC. Optimal treatment choice and sequence is increasingly becoming based upon personalized factors including clinical characteristics, comorbidities, programmed death-ligand 1 (PD-L1) score, and the presence of targetable mutations. Despite encouraging data from multiple trials, the optimal multimodal sequence of stage IIIA-N2 NSCLC treatment remains unresolved and warrants further investigation. This review article summarizes recent major clinical trials of neoadjuvant and adjuvant treatment including stage IIIA-N2 NSCLC with a focus on immunotherapy and TKIs.

Is there role of adjuvant radiotherapy after complete resection of locally advanced nonsmall cell lung cancer?

This review aims to provide a timely and relevant overview of the role of postoperative radiotherapy (PORT) in completely resected stage IIIA-N2 nonsmall cell lung cancer (NSCLC). Given the controversy surrounding the use of PORT and the emergence of advanced radiation techniques and therapies, this review provides valuable insight into current and potential treatment strategies. The Lung ART and PORT-C trials have provided valuable insights into the efficacy of PORT in stage IIIA-N2 NSCLC. While the results have been mixed, studies have shown that advanced radiation techniques, such as intensity-modulated radiotherapy (IMRT) and proton therapy, can reduce cardiopulmonary toxicities associated with PORT. Molecular targeted therapies and immunotherapies have also shown potential in improving NSCLC treatment outcomes. The role of radiotherapy becomes smaller and smaller in new era. However, it is too early to abolish radiotherapy for all the patients after complete resection of locally advanced NSCLC. Nowadays, it is recommended to adopt individualized treatment approaches guided by multidisciplinary team consultations. The integration of IMRT, proton therapy, and emerging therapies offers the potential to enhance treatment efficacy while minimizing toxicity. Further research is needed to optimize the use of PORT and explore the method to identify the patients who can really benefit from PORT.

The high-risk features and effect of postoperative radiotherapy on survival for patients with surgically treated stage IIIA-N2 non-small cell lung cancer

ObjectivesAlthough postoperative radiotherapy (PORT) could reduce the incidence of local recurrence in patients with IIIA-N2 non-small cell lung cancer (NSCLC), the role of PORT on survival in patients with surgically treated stage IIIA-N2 NSCLC remains controversial. Therefore, this study was designed to evaluate the effect of PORT on survival for patients with surgically treated stage IIIA-N2 NSCLC.Materials and methodsThis study population was chosen from the Surveillance, Epidemiology, and End Results database. The Cox proportional hazards regression analysis was used to determine significant contributors to overall survival (OS) and cancer special survival (CSS) outcomes. To balance baseline characteristics between the non-PORT group and PORT group, propensity score matching (PSM) with 1:1 propensity nearest-neighbor match by 0.001 matching tolerance was conducted by R software. Furthermore, a Kaplan–Meier curve was used to visualize the OS and CSS between the PORT group and non-PORT group survival probability.ResultsOf all evaluated cases, 4511 with IIIA-N2 NSCLC were eligible for inclusion, of which 1920 were enrolled into the PORT group. On univariate analysis and multivariate analysis, sex, age, year of diagnosis, race, histologic type, T stage, PORT, use of chemotherapy, and positive regional nodes were significantly associated with OS and CSS in IIIA-N2 NSCLC (P < 0.05). However, PORT was not significantly associated with OS (univariate HR = 0.92, 95%CI 0.85–0.99, P = 0.02; multivariate HR = 1.01, 95%CI 0.93–1.08, P = 0.91) and CSS (univariate HR = 0.92, 95%CI 0.85–1.01, P = 0.06; multivariate HR = 1.103 95%CI 0.94–1.12, P = 0.56) in IIIA-N2 NSCLC. Meanwhile, after PSM, neither OS nor CSS did differ significantly between the non-PORT group and PORT group (OS HR = 1.08, 95%CI 0.98–1.19, P = 0.12; CSS HR = 1.10, 95%CI 0.99–1.23, P = 0.07).ConclusionPORT did not contribute to a survival benefit in patients with surgically treated stage IIIA-N2 NSCLC.

Erlotinib versus gemcitabine plus cisplatin as neoadjuvant treatment of stage IIIA-N2 EGFR-mutant non-small-cell lung cancer: final overall survival analysis of the EMERGING-CTONG 1103 randomised phase II trial

EMERGING-CTONG 1103 showed improved progression-free survival (PFS) with neoadjuvant erlotinib vs. chemotherapy for patients harbouring EGFR sensibility mutations and R0 resected stage IIIA-N2 non-small cell lung cancer (NSCLC) (NCT01407822). Herein, we report the final results. Recruited patients were randomly allocated 1:1 to the erlotinib group (150 mg/day orally; neoadjuvant phase for 42 days and adjuvant phase to 12 months) or to the GC group (gemcitabine 1250 mg/m2 plus cisplatin 75 mg/m2 intravenously; 2 cycles in neoadjuvant phase and 2 cycles in adjuvant phase). Objective response rate (ORR), complete pathologic response (pCR), PFS, and overall survival (OS) were assessed along with safety. Post hoc analysis was performed for subsequent treatments after disease recurrence. Among investigated 72 patients (erlotinib, n = 37; GC, n = 35), the median follow-up was 62.5 months. The median OS was 42.2 months (erlotinib) and 36.9 months (GC) (hazard ratio [HR], 0.83; 95% confidence interval [CI], 0.47–1.47; p = 0.513). The 3- and 5-year OS rates were 58.6% and 40.8% with erlotinib and 55.9% and 27.6% with GC (p3-y = 0.819, p5-y = 0.252). Subsequent treatment was administered in 71.9% and 81.8% of patients receiving erlotinib and GC, respectively; targeted therapy contributed mostly to OS (HR, 0.35; 95% CI, 0.18–0.70). After disease progression, the ORR was 53.3%, and the median PFS was 10.9 months during the EGFR-TKI rechallenge. During postoperative therapy, grade 3 or 4 adverse events (AEs) were 13.5% in the erlotinib group and 29.4% in the GC group. No serious adverse events were observed. Erlotinib exhibited clinical feasibility for resectable IIIA-N2 NSCLC over chemotherapy in the neoadjuvant setting.

Improved survival in N2 non-small cell lung cancer: better staging or better treatment; a SEER database retrospective cohort analysis

Background: Over the past several decades, there has been an apparent improvement in survival of patients with stage IIIA-N2 non-small cell lung cancer (NSCLC). Positron emission tomography (PET)-scanning for NSCLC staging/restaging was approved by the Centers of Medicare and Medicaid Services (CMS) in 2001. We sought to determine whether this survival improvement was due to more sensitive staging-modalities and/or an evolution in surgical practice.

Value of postoperative radiotherapy for stage IIIa-N2 non-small cell lung cancer: an analysis based on SEER database.

BackgroundThe role of postoperative radiotherapy (PORT) in resected stage IIIa-N2 non-small cell lung cancer (NSCLC) patients who have received adjuvant chemotherapy remains controversial. This study aimed to explore the value of PORT and determine which patients could benefit from PORT.MethodsStage IIIa-N2 NSCLC patients treated with surgery and adjuvant chemotherapy were identified from the Surveillance, Epidemiology and End Results (SEER) databases from 2004 to 2015. Eligible patients were divided into the following two groups: PORT group and non-PORT group. Overall survival (OS) was estimated by the Kaplan-Meier (KM) method, and differences in survival were evaluated with log-rank test. Long-term cause-specific mortality consisted of lung cancer-related mortality and non-lung cancer-related mortality was investigated through competing risk analysis. Cox regression analysis was performed to identify variables that significantly affected OS.ResultsWe identified 2,347 eligible patients, after propensity score matching (PSM), 877 pairs were selected. Overall, there was no significant difference in OS between two groups, but the patients who received PORT had a lower lung cancer-related mortality rate. Subgroup analysis showed that PORT was associated with a significantly better OS and lower lung cancer-related mortality rate in patients with T2, grade I–II and positive/resected lymph node ratio (LNR) ≥0.31. The non-lung cancer-related mortality of PORT group was higher in the patients with squamous cell carcinoma, although the difference was not significant. The independent prognostic factors for OS were age, sex, grade, histology, the American Joint Committee on Cancer (AJCC) T stage and LNR.ConclusionsOur results revealed that PORT appears to be the optimal treatment strategy in patients with AJCC T2, grade I–II and LNR ≥0.31. PORT may not be recommended for patients with squamous cell carcinoma.

120P Efficacy of postoperative radiotherapy (PORT) in stage IIIA-N2 non-small cell lung cancer: Meta-analysis of randomized controlled studies

Although adjuvant systemic therapy is the standard in patients with stage 3A-N2 non-small cell lung cancer (NSCLC) who underwent curative surgical resection, discussions about radiotherapy (RT) continue. This meta-analysis evaluated the efficacy of randomized controlled trials (RCTs) investigating the addition of RT (PORT) (sequential or concurrent) to adjuvant ChT in patients with operated stage 3A-N2 NSCLC. Pubmed, Embase, Cochrane Library, and Clinical Trials databases were scanned, and original research articles published until December 01, 2021, were included. Data on overall survival (OS), disease-free survival (DFS), local-regional recurrence-free survival (LRFS), and distant metastasis-free survival (DMSF) were extracted from the included studies and jointly analyzed. As a result of the database search, 5 RCTs involving a total of 1138 patients were included in the analysis (three phase 3, two phase 2). In the joint analysis of these 5 studies, it was seen that PORT did not contribute to OS (HR: 0.99, CI 95% 0.82-1.18, p = 0.87). In the analysis for DFS, it was observed that PORT provided a survival advantage (HR:0.84, CI 95% 0.72-0.97, p= 0.02). In the joint analysis of 4 RCTs (n:637) reporting LRFS and DMFS results, it was observed that PORT provided a significant survival advantage in terms of RLFS (HR:0.66, CI 95% 0.51-0.84, p= 0.001), but it did not contribute significantly to DMSF ( HR:0.84, CI 95% 0.70-1.02, p= 0.06). In this meta-analysis; In stage 3A-N2 NSCLC, it was observed that PORT prolonged DFS and LRFS, but did not contribute to OS and DMSF. Considering the possible cardiopulmonary toxicities of RT in this patient group, it would be more appropriate to make a patient-based decision.

Postoperative radiotherapy for patients with completely resected stage IIIA-N2 non-small cell lung cancer: opt-in or opt-out.

The role of adjuvant radiotherapy in completely resected pIIIA‐N2 non‐small cell lung cancer (NSCLC) has long been debated. Evidence from previous retrospective and prospective studies showed that postoperative radiotherapy could reduce the incidence of local recurrence and prolong disease‐free survival, while two recently reported randomized controlled trials (lung ART and PORT‐C) both demonstrated no survival benefit of postoperative radiotherapy. The great gap between our knowledge and reality has made us rethink the value of postoperative radiotherapy. In this mini review, we elaborate on the role of postoperative radiotherapy in completely resected pIIIA‐N2 NSCLC.

A non-parametric approach for jointly combining evidence on progression free and overall survival time in network meta-analysis.

Randomised controlled trials of cancer treatments typically report progression free survival (PFS) and overall survival (OS) outcomes. Existing methods to synthesise evidence on PFS and OS either rely on the proportional hazards assumption or make parametric assumptions which may not capture the diverse survival curve shapes across studies and treatments. Furthermore, PFS and OS are not independent; OS is the sum of PFS and post-progression survival (PPS). Our aim was to develop a non-parametric approach for jointly synthesising evidence from published Kaplan-Meier survival curves of PFS and OS without assuming proportional hazards. Restricted mean survival times (RMST) are estimated by the area under the survival curves (AUCs) up to a restricted follow-up time. The correlation between AUCs due to the constraint that OS > PFS is estimated using bootstrap re-sampling. Network meta-analysis models are given for RMST for PFS and PPS and ensure that OS=PFS + PPS. Both additive and multiplicative network meta-analysis models are presented to obtain relative treatment effects as either differences or ratios of RMST. The methods are illustrated with a network meta-analysis of treatments for stage IIIA-N2 non-small cell lung cancer. The approach has implications for health economic models of cancer treatments, which require estimates of the mean time spent in the PFS and PPS health-states. The methods can be applied to a single time-to-event outcome, and so have wide applicability in any field where time-to-event outcomes are reported, the proportional hazards assumption is in doubt, and survival curve shapes differ across studies and interventions.

Persistent N2 After Induction Is Not a Contraindication to Surgery for Lung Cancer

BackgroundSurgical management for potentially resectable stage IIIA-N2 non-small cell lung cancer (NSCLC) is controversial. For some, persistent N2 disease after induction therapy is a contraindication to resection. We examined outcomes of a well-selected surgical cohort of postinduction IIIA-N2 NSCLC patients with persistent N2 disease. MethodsWe retrospectively reviewed all resected clinical IIIA-N2 NSCLC patients from 2001 to 2018. Thorough preoperative staging, including invasive mediastinal staging, was performed. Those with nonbulky N2 disease, appropriate restaging, and potential for a margin-negative resection were included. After resection, patients were classified as having persistent N2 disease or mediastinal downstaging (N2 to >N0/N1). Persistent N2 patients were further classified as uncertain resection (R[un]) or complete resection (R0) according to the International Association for the Study of Lung Cancer definition. Kaplan-Meier survival analysis was used. ResultsFifty-four patients met inclusion criteria. After induction, 31 patients (57%) demonstrated persistent N2 disease, and 23 patients (43%) had mediastinal downstaging. Preinduction invasive mediastinal staging was performed in 98.1%. Most had clinical single-station N2 disease (75.9%). Margin-negative resections were performed in 100%. Eight patients were reclassified as R(un) due to positive highest sampled mediastinal station. The median overall survival for persistent N2 was 26 months for R(un) and 69 months for R0. Overall survival for the downstaged group was 67 months (P = .31). ConclusionsOverall survival for patients with non-R(un) or persistent N2 (true R0) was similar to those with mediastinal downstaging. Well-selected patients with persistent N2 disease experience reasonable survival after resection and should have surgery considered as part of their multimodality treatment. This study underscores the importance of classifying the extent of mediastinal involvement for persistent N2 patients, supporting the proposed International Association for the Study of Lung Cancer R(un) classification.

Recurrence Dynamics After Complete Resection and Adjuvant Chemotherapy in Patients With Stage IIIA-N2 Non-Small Cell Lung Cancer

To investigate the timing and pattern of recurrence in stage IIIA-N2 non-small cell lung cancer (NSCLC) patients after complete resection and adjuvant chemotherapy.The study cohort included pathologically confirmed stage IIIA-N2 NSCLC patients treated with complete resection and adjuvant chemotherapy from 2003 to 2015 in our single institution. Recurrence was categorized as local-regional recurrence (LRR), distant metastasis (DM) and both LRR and DM. The risk distribution was assessed by using clinical and pathological factors. The hazard rate function and competing risk analysis were used to evaluate the recurrence dynamics. The Gray's test was employed to estimate the cumulative recurrence rates and compare the differences between groups.Among 854 patients, 61.9% had multiple station N2 involvement. The 1, 3 and 5-year cumulative incidence rates of recurrence was 16.85%, 50.74% and 67.37%, respectively. Of the 510 patients who experienced recurrence, 95 (18.6%) experienced LRR, 285 (55.9%) experienced DM, whereas 130 (25.5%) had both LRR and DM. The hazard rate function for overall recurrence revealed a continuous increase between 0-18 months after surgery, consistent high level during 8-48 months and marked decline thereafter. And the DM displayed a hazard rate curve similar to that of overall recurrence. However, a double-peaked pattern of hazard rate was present in LRR and both LRR and DM. What's more, the peak recurrence frequency of DM differed by organs. A comparison of clinical and pathological factors revealed that patients with lower pT stage, single pN2 station and postoperative radiotherapy had a lower recurrence risk but similar pattern of recurrence.The recurrence risk of IIIA-N2 NSCLC after complete resection and adjuvant chemotherapy increased to a high level in 18 months and maintained continuously high till 48 months after surgery, which hinted necessity of intensive follow-up during this period of time. This follow-up strategy implied an individualized surveillance for N2 disease which was different from clinical routine, and should be verified in further studies.

Incorporating Surgery in treatment of Stage IIIA – N2 Non- Small Cell Lung Cancer

Stage IIIA-N2 Non-small cell lung cancer includes heterogenous group of patients with a poor 5-year survival ranging from 13% to 36% with surgery alone. Various randomized controlled trials established the role of multimodality treatment either including or excluding surgical resection. In a select group of non-bulky/ single station N2 disease, the better results have been achieved with induction chemotherapy or chemo-radiotherapy followed by surgery. 

Perioperative safety and feasibility outcomes of stage IIIA-N2 non-small cell lung cancer following neoadjuvant immunotherapy or neoadjuvant chemotherapy: a retrospective study.

BackgroundWe sought to determine the perioperative safety and feasibility outcomes of stage IIIA (N2) non-small cell lung cancer (NSCLC) following neoadjuvant immunotherapy or neoadjuvant chemotherapy.MethodsThe clinical details of patients who attended the Affiliated Hospital of Qingdao University between January 2019 and December 2020 were retrospectively evaluated. Eligible patients had pathologically proven stage IIIA (N2) NSCLC and were randomly prescribed neoadjuvant therapy. Those in the neoadjuvant immunotherapy group received two cycles of nivolumab (3 mg/kg) and those in the control group received neoadjuvant chemotherapy (1,000 mg/m2 gemcitabine and 80 mg/m2 cisplatin). All patients were scheduled to undergo surgery. The primary endpoint was the risk of major complications within 30 days of surgery and the secondary endpoints were interval to surgery and 30-day mortality.ResultsA total of 107 eligible patients were evaluated of whom 25 were allocated to the neoadjuvant immunotherapy group and 82 to the neoadjuvant chemotherapy group. The median interval to surgery was similar in the two groups at 29.2 days [95% confidence interval (CI), 27.1 to 31.4 days] in the immunotherapy group and 28.7 days (95% CI, 27.6 to 29.8 days) in the chemotherapy group (P=0.656). While treatment-related adverse events were reported in most patients, all 25 patients completed two cycles of neoadjuvant immunotherapy and 80 of 82 patients completed two cycles of neoadjuvant chemotherapy, although one patient in the latter group died within 30 days of surgery. There was no statistically significant difference between the groups in the probability of grade 3 or higher postoperative complications within 30 days after surgery (P=0.757).ConclusionsMost patients achieved the primary and secondary endpoints of the study. However, the major pathological response (MPR) showed statistically significant differences between the neoadjuvant immunotherapy and neoadjuvant chemotherapy groups.

[Clinical study on the effects of neoadjuvant chemotherapy on lymph node ratio, prognosis, and survival analysis of stage ⅢA-N2 non-small cell lung cancer].

Objective: To investigate the effect of neoadjuvant chemotherapy (NCT) on the lymph node ratio (LNR) of patients with stage ⅢA-N2 non-small cell lung cancer (NSCLC), and analyze the relationship between LNR and prognosis. Methods: The data of 128 patients with stage ⅢA-N2 NSCLC admitted to the Department of Cardiothoracic Surgery of the First Affiliated Hospital of Hebei North University from January 2013 to December 2018 were retrospectively collected. The patients were divided into two groups according to the treatment method. The patients in the observation group (64 cases) were treated with NCT and surgery, and the patients in the control group (64 cases) were treated with surgery. Lymph node metastasis and survival were observed in the two groups. Subgroups were divided according to LNR and N2 lymph node status, and survival analysis was performed for each subgroup. Univariate and multivariate analysis were conducted for the observation group. Results: The number of metastatic lymph nodes, the proportion of patients with positive lymph nodes, and the rate of lymph node metastasis in the observation group were lower than those in the control group,3.8±2.1 vs 4.9±2.4,92.2% vs 100%,19.1% vs 22.4% respectively (all P<0.05). Progression-free survival (PFS) and overall survival (OS) in the observation group were better than those in the control group (both P<0.05). Both the observation and control subgroups with low LNR had better PFS and OS than the subgroups with high LNR (both P<0.05). Patients in the observation group with non-multi-site N2 lymph node metastasis had better PFS and OS (both P<0.05). Univariate analysis of observation group showed that patients with low LNR had better 2-year PFS and OS(both P<0.05). Multivariate analysis showed that the higher the LNR, the greater the risk of death (HR=2.178,95%CI: 1.025-4.626,P=0.043) and progression (HR=2.130,95%CI: 1.123-4.038,P=0.021). Conclusion: NTC could improve the prognosis and reduce LNR of patients with stage ⅢA-N2 NSCLC, and LNR was expected to be a prognostic indicator.

Advances in multimodal treatment for stage IIIA-N2 non-small cell lung cancer (NSCLC)

Advances in multimodal treatment for stage IIIA-N2 non-small cell lung cancer (NSCLC)

Postoperative radiotherapy for patients with completely resected pathological stage IIIA-N2 non-small cell lung cancer: a preferential benefit for squamous cell carcinoma.

BackgroundThe beneficial effect of postoperative radiotherapy (PORT) on completely resected pathological IIIA-N2 (pIIIA-N2) non-small cell lung cancer (NSCLC) has been a subject of interest with controversy. The aim of the study was to distinguish the clinical efficacy of PORT on lung adenocarcinoma (LADC) and lung squamous cell carcinoma (LSCC) among pIIIA-N2 NSCLC.Patients and methodsBetween October 2010 and September 2016, 288 consecutive patients with completely resected pIIIA-N2 NSCLC at Beijing Chest Hospital were retrospectively analyzed, which consisted of 194 cases of LADC and 85 cases of LSCC. There were 42 (21.6%) patients treated with PORT in LADC cases and 19 (22.3%) patients treated with PORT in LSCC cases. The 5-year overall survival (OS), loco-regional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS) were calculated using the Kaplan-Meier method. The prognostic factors were determined using Cox’s regression model.ResultsAmong 194 cases of LADC, the 1-, 3-, and 5-year OS in the PORT group were 95.2%, 61.9% and 40.0%, respectively, while in the non-PORT group were 90.1%, 63.3% and 45.0% (p = 0.948). The use of postoperative chemotherapy (POCT) and smoking index ≥ 400 were both prognostic factors of 5-year rates of OS, LRFS and DMFS. On the other hand, among 85 cases of LSCC, the 1-, 3-, and 5-year OS in the PORT group were 94.7%, 63.2% and 63.2%, respectively, whereas in the non-PORT group were 86.4%, 48.5% and 37.1% (p = 0.026). In this group, only the use of PORT was a favorable prognostic factor for 5-year OS, LRFS and DMFS.ConclusionsDue to clinicopathological differences among completely resected pIIIA-N2 NSCLC, PORT may not be suitable to all patients. Our study distinguishes pIIIA-N2 LSCC from LADC by their positive responses to PORT.

Postoperative radiotherapy for pathological stage IIIA-N2 non-small cell lung cancer with positive surgical margins.

BackgroundThe aim of this study was to evaluate the efficacy of postoperative radiotherapy (PORT) in stage pIIIA‐N2 non‐small cell lung cancer (NSCLC) patients with positive surgical margins.MethodsBetween January 2003 and December 2015, patients who had undergone lobectomy or pneumonectomy plus mediastinal lymph node dissection or systematic sampling in our single institution were retrospectively reviewed. Those with pIIIA‐N2 NSCLC and positive surgical margins were enrolled into the study. The Kaplan‐Meier method was used for survival analysis, and the log‐rank test was used to analyze differences between the groups. Univariate and multivariate analyses using Cox proportional hazards regression models were performed to evaluate potential prognostic factors for OS. Statistically significant difference was set as P < 0.05.ResultsOf all the 1547 patients with pIIIA‐N2 NSCLC reviewed, 113 patients had positive surgical margins, including 76 patients with R1 resection and 37 with R2 resection. The median overall survival (OS) was 28.3 months in the PORT group and 22.6 months in the non‐PORT group (P = 0.568). Subset analysis showed that for patients with R1 resection, the median OS was 52.4 months in the PORT group which was nonsignificantly longer than that of 22.6 months in the non‐PORT group (P = 0.127), whereas PORT combined with chemotherapy could significantly improve OS, with a median OS of 52.4 months versus 17.2 months (P = 0.027). For patients with R2 resection, PORT made no significant difference in OS (17.6 vs. 63.8 months, P = 0.529).ConclusionsFor pIIIA‐N2 NSCLC patients with positive surgical margins, PORT did not improve OS, but OS was improved in those patients who underwent R1 resection combined with chemotherapy.Key pointsSignificant findings of the studySignificant findings of the study: Postoperative radiotherapy (PORT) has been recommended to treat patients with positive surgical margins. However, the existing evidence is controversial and high‐level evidence is lacking.What this study addsWhat this study adds: The PORT group had markedly, but not statistically significant, longer median OS compared with the non‐PORT group in patients with R1 resection. OS was significantly longer in the patients with R1 resection receiving adjuvant CRT than the surgery alone group.

Evaluation of Postoperative Radiotherapy Effect on Survival of Resected Stage III-N2 Non-small Cell Lung Cancer Patients

Objective: The role of postoperative radiotherapy (PORT) in resected stage IIIA-N2 non-small cell lung cancer (NSCLC) patients remains controversial. This study aimed to explore the effect of PORT on survival of resected stage IIIA-N2 NSCLC patients.Methods: Resected stage IIIA-N2 NSCLC patients aged 18 years or older were identified from the SEER (Surveillance, Epidemiology, and End Results) database from 2010 to 2015. Cox regression analysis was used to identify factors including PORT associated with survival time. A subgroup analysis of patients stratified by number of lymph node metastases was also performed. Overall survival (OS) and overall mortality were compared among the different groups.Results: A total of 3,445 patients were included in the study. Multivariate Cox analysis showed that PORT had no significant impact on survival of patients with <6 positive lymph node [hazard ratio (HR) = 1.012, P = 0.858, 95% CI: 0.886–1.156]. Postoperative chemotherapy (POCT) (HR = 0.605, P < 0.001, 95% CI: 0.468–0.783) and PORT (HR = 0.724, P = 0.007, 95% CI: 0.574–0.914) are both favorable prognostic factors for stage IIIA-N2 patients with ≥6 positive lymph nodes. In 2,735 patients who featured <6 number of positive regional lymph nodes, patients who received PORT had better survival and lower 3-years and 5-years overall mortality rate than patients who underwent surgery only (41 vs. 28 months, P < 0.015). There was no significant difference in the survival of postoperative patients who underwent POCT in view of whether received PORT (44 vs. 53 months, P = 0.176). A total of 710 patients who featured ≥6 number of positive regional lymph node metastasis were divided into two groups by PORT. PORT did not prolong survival for postoperative patients who did not receive chemotherapy (12 vs. 15 months, P = 0.632). PORT showed a significant advantage in influencing OS in patients who received PORT combined with POCT as compared with those who received POCT only (32 vs. 25 months, P = 0.006).Conclusions: For IIIA-N2 patients with <6 lymph node metastases, use of PORT can be encouraged to improve survival. For patients with ≥6 positive lymph nodes, PORT combined with POCT significantly improved OS and decreased overall mortality.

Pneumonectomy in stage IIIA-N2 non-small cell lung cancer

Pneumonectomy in stage IIIA-N2 non-small cell lung cancer