Lung Cancer.pdf

Surgical Treatment of Locally Advanced Non–Small Cell Lung Cancer 131
Although surgery in patients with T1–3N2 NSCLC can eliminate the
known disease in both the primary site and the lymph nodes, the presence
of mediastinal nodal disease is associated with a high risk of metastatic recurrence
following surgical resection (Mountain and Dresler, 1997). The
outcome of this group of patients is dictated more by the systemic disease
(N2 and micrometastatic) than by the local-regional problems, and consequently,
improved survival requires effective systemic treatment (chemotherapy)
as well as local-regional treatment (surgery or radiation therapy).
Multiple randomized trials have demonstrated that induction chemotherapy
with surgery (Roth et al, 1998; Rosell et al, 1999) or radiation therapy
(Schaake-Koning et al, 1992; Dillman et al, 1996; Sause et al, 2000) results in a
significant survival advantage, and this group of patients should therefore
be treated with systemic therapy as well as local-regional treatment for
maximal therapeutic benefit.
Patients with T1–3N2 Pancoast tumors have a very poor prognosis.
Several series have shown that N2 involvement in Pancoast tumors is associated
with no long-term survivors (Anderson et al, 1986; Attar et al,
1998). Therefore, except in a protocol setting, surgery is usually not performed
for T1–3N2 Pancoast tumors; patients with these lesions are
treated with chemotherapy and radiation therapy alone. It is important,
however, that the involvement of N2 nodes be documented pathologically
because enlarged nodes on CT do not always harbor neoplasm.
Selection of Therapy
Because of the mediastinal lymph node involvement, T1–3N2 tumors
have a high propensity to harbor occult micrometastatic disease, and thus
local-regional treatment alone (i.e., radiation therapy or surgery alone) is
associated with poor long-term survival rates, in the range of 10% to 20%
(Andre et al, 2000). The addition of induction chemotherapy to surgery or
radiation therapy is associated with an increase, albeit modest, in longterm
survival rates, to 15% to 30% (Roth et al, 1998; Rosell et al, 1999).
Chemotherapy is therefore essential in this group of patients. What has
not yet been defined completely, however, is the optimum local-regional
therapy (i.e., surgery or radiation therapy or both). In an effort to answer
this critical question, we have tried to enroll patients in a randomized intergroup
study (RTOG 93–09) evaluating chemoradiation versus chemoradiation
and surgery. However, accrual of patients to this study has been
very slow because of patients’ and physicians’ reluctance to rely on random
assignment to determine whether surgery is performed. In addition,
the advent of newer, less toxic chemotherapy combinations that can be
given concurrently with radiation therapy has made the traditional cisplatin,
etoposide, and concurrent radiation therapy delivered in the study
less interesting (Choy et al, 1994; Gressen and Curran, 2001).
Among patients with T1–3N2 non-Pancoast tumors who do not wish to
be treated on protocol, we try to identify those patients who have a good