title: Survival Benefit of Surgery after Chemoradiotherapy for Stage III (N0-2) Non-Small-Cell Lung Cancer Is Dependent on Pathologic Nodal Response.
abstract: BACKGROUND
  The benefit of surgery (trimodality therapy [TMT]) after chemoradiotherapy (CRT) for patients with stage III non-small-cell lung cancer (NSCLC) is controversial, but nodal pathologic complete response (N-PCR) is accepted as a strong predictor of overall survival (OS). We compared the outcomes of patients treated with TMT versus CRT, focusing on the importance of N-PCR.
  
  
  METHODS
  Patients with stage III NSCLC treated with CRT or TMT from December 2004 through December 2012 were included; patients with N3 disease were excluded. Pathologic nodal response dichotomized surgical patients into N-PCR versus residual nodal disease (RND) groups. Actuarial OS, progression-free survival (PFS), and distant metastasis-free survival (DMFS) were compared between patients treated with CRT and TMT and between CRT and N-PCR/RND.
  
  
  RESULTS
  The cohort was composed of 138 patients (52% CRT and 48% TMT). The median OS was significantly higher after TMT than after CRT (81 versus 31.8 mo, p = 0.0068). This benefit was restricted to N-PCR (n = 50, 83.2 versus 31.8 mo, p = 0.0004), as RND (n = 19) experienced poor OS (16.1 mo). On multivariable analyses, N-PCR had superior OS (hazard ratio [HR], 0.38; p = 0.0012), PFS (HR, 0.42; p = 0.0005), and DMFS (HR, 0.42; p = 0.0007) compared with CRT. Conversely, there were trends for worse OS and PFS for RND versus CRT, although only inferior DMFS was significant (HR, 1.83; p = 0.04).
  
  
  CONCLUSIONS
  Surgical patients with complete nodal clearance experienced superior survival, but those with RND fared no better than CRT alone. Mediastinal response may play an important role in the decision to proceed with surgical resection after CRT for stage III NSCLC.
authors.affiliation: *Department of Radiation Oncology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California; †Department of Radiation Oncology, Roswell Park Cancer Institute, Buffalo, New York; ‡Department of Radiation Oncology, §Section of Medical Oncology, and ‖Department of Cardiothoracic Surgery, Rush University Medical Center, Chicago, Illinois.
authors.forename: Ellis
authors.initials: E
authors.lastname: Ziel
authors.forename: Gregory
authors.initials: G
authors.lastname: Hermann
authors.forename: Neilayan
authors.initials: N
authors.lastname: Sen
authors.forename: Philip
authors.initials: P
authors.lastname: Bonomi
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Liptay
authors.forename: Mary Jo
authors.initials: MJ
authors.lastname: Fidler
authors.forename: Marta
authors.initials: M
authors.lastname: Batus
authors.forename: William H
authors.initials: WH
authors.lastname: Warren
authors.forename: Gary
authors.initials: G
authors.lastname: Chmielewski
authors.forename: David J
authors.initials: DJ
authors.lastname: Sher
mesh_terms: D000368:Aged; D002289:Carcinoma, Non-Small-Cell Lung / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D059186:Chemoradiotherapy, Adjuvant; D015331:Cohort Studies; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D008297:Male; D009367:Neoplasm Staging; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome