Treating the N2 disease patient: more uncertainties than real facts

Many times we faced the decision about what to do with an N2 patient that has gone through chemo-radiation therapy. Despite many publications in favor and against it, it’s not clear what lung resection surgery adds in terms of survival to this group of patients. To complicate more things, there is not an ideal test to distinguish those patients with residual N2 disease from those that had a complete response. For what I learnt and heard in different meetings there are two different positions regarding how to proceed: one is to do whatever it takes in terms of invasive restaging to make sure that there is not residual disease in the mediastium. The other is to consider the response by images and go ahead and resect those patients with acceptable response. What is an acceptable response is very subjective sometimes. I usually stick to this later option. Re-mediastinoscopy is not usual in my practice and we rely in what CT and/or PET-CT shows. We discuss these cases in a multidisciplinary meeting among thoracic surgeons, clinical oncologists, pulmonologists and radiologists. If the conclusion is that there has been a response to induction treatment we offer the patient to do the lung resection and dissect the mediastinum. But, what about if a pneumonectomy is needed? There is some evidence in the trial that Albain and cols. presented in ASCO 2005 that pneumonectomy is associated with worse survival due to high mortality of pneumonectomy after chemoradiation therapy. This doesn’t mean it shouldn’t be done, but we need to be very careful about these results and be very honest with our patients about what can be expected.

N2 disease patients are a very heterogeneous group of people and every patient should be considered individually. Of outmost importance is the expertise of a group of doctors dedicated to the care of this disease and tailor a treatment made for each individual patient.

What is your approach to these patients?

Sebastian

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