Which patients should be operated on after induction chemotherapy for N2 non–small cell lung cancer? Analysis of a 7-year experience in 175 patients

Objective: The role of surgery in patients with N2 non–small cell lung cancer is debated. The aim of this studywas to evaluate the results of surgical resection after induction chemotherapy.Methods: We retrospectively reviewed the cases of patients with N2 non–small cell lung cancer who underwentneoadjuvant chemotherapy followed by resection between 2001 and 2007. They all had tumors deemed resectable.Results: One hundred seventy-five patients entered the study. Most of them received 2 or 3 cycles of chemotherapy(81%), in all cases platinum-based regimens. Chemotherapy response rate was 62%. Operations included 96lobectomies/bilobectomies and 79 pneumonectomies. Complete resection rate was 94%, and perioperative mortalitywas 4.5%. A pathologic mediastinal downstaging was found in 39% of patients. Overall median survivaltime and 5-year survival were 34.7 months and 30%, respectively. Survival was affected by clinical response(median survival time 51 months and 5-year survival 42% for responders versus 19 months and 10% for nonresponders)and by nodal downstaging (51 months and 45%versus 25%and 22%). In the group of responders,nondownstaged patients showed satisfying survival (median survival time 30 months, 5-year survival 30%). Inthe group of nonresponders, survival was unsatisfactory when a lobectomy was performed (median survival time20 months, 5-year survival 13%) and poor in case of pneumonectomy (15 months and 6%). Multivariate analysisfound 4 factors significantly affecting survival: clinical response, nodal downstaging, number of chemotherapycycles, and histopathologic response.Conclusions: Surgery after chemotherapy could be effective for selected patients with N2 non–small cell lungcancer. Survival for responders is satisfactory, even in case of persistent N2 disease. Prognosis for nonrespondersis disappointing.