title: Surgery on unfavourable persistent N2/N3 non-small-cell lung cancer after trimodal therapy: do the results justify the risk?
abstract: OBJECTIVE
  Persistent mediastinal lymph node metastasis after neoadjuvant therapy is a significant negative indicator for survival. Even though there is still no consensus on the matter, some authors advocate a thorough restaging prior to surgery and deny surgery in cases of persistent N2 because of the poor outcome. We analysed our results after trimodal therapy in pN2/N3 stage III non-small-cell lung cancer (NSCLC) and persistent mediastinal lymph node metastasis after neoadjuvant chemoradiotherapy.
  
  
  METHODS
  We conducted a retrospective cohort analysis of 167 patients who received trimodal therapy for stage III NSCLC. Progression-free interval and survival were calculated. T-stage, N-stage, ypT-stage, ypN2/3-stage and surgical procedure were tested as risk factors.
  
  
  RESULTS
  Eighty-three patients with potentially resectable initial pN2/3 underwent 44 pneumonectomies and 76% extended resections. Thirty-five patients showed persistent mediastinal lymph node metastasis after trimodal therapy. Treatment-related comorbidity after an operative therapy was 58%. Hospital mortality was 2.4%. The ypT- and ypN2/N3 stages were significant risk factors and, in the case of persistent mediastinal lymph node metastasis, median progression-free period was 17 months and median survival time was 21 months.
  
  
  CONCLUSIONS
  Persistent but resectable N2/N3 after chemoradiotherapy in stage III NSCLC is the least favourable subgroup of patients in neoadjuvant approaches. If surgery can be carried out with curative intent and low morbidity, completing trimodal therapy is justified, with an acceptable outcome.
authors.affiliation: Department of Thoracic Surgery, Schillerhöhe Hospital, Gerlingen, Germany. vrsteger@gmx.de
authors.forename: Volker
authors.initials: V
authors.lastname: Steger
authors.forename: Tobias
authors.initials: T
authors.lastname: Walker
authors.forename: Migdat
authors.initials: M
authors.lastname: Mustafi
authors.forename: Karoline
authors.initials: K
authors.lastname: Lehrach
authors.forename: Thomas
authors.initials: T
authors.lastname: Kyriss
authors.forename: Stefanie
authors.initials: S
authors.lastname: Veit
authors.forename: Godehard
authors.initials: G
authors.lastname: Friedel
authors.forename: Thorsten
authors.initials: T
authors.lastname: Walles
mesh_terms: D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000556:secondary / Q000628:therapy*; D059186:Chemoradiotherapy, Adjuvant / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D018572:Disease-Free Survival; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000628:therapy*; D008207:Lymphatic Metastasis; D008297:Male; D020360:Neoadjuvant Therapy / Q000009:adverse effects / Q000401:mortality; D009367:Neoplasm Staging; D018579:Patient Selection; D011013:Pneumonectomy / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome