Abstract
Major pulmonary resection by VATS (video-assisted thoracoscopic surgery) has become a standard therapeutic approach, not only for early stage lung tumors but also for patients with locally advanced disease. However, while in cases of clinical N2 disease surgical resection after neoadjuvant therapy is an established treatment protocol, more uncertainty exists on whether the intraoperative discovery of unexpected N2 disease should lead to following through with surgical resection or aborting it in favor of pre-operative treatment. A literature review using the PICO framework was conducted to compare the short and long-term oncological outcomes of the different therapeutic strategies. Although survival outcomes appear to be only moderately superior in patients treated by neoadjuvant therapy followed by surgery compared with those undergoing adjuvant therapy, an important issue is that slightly more than 50% of the operated patients eventually undergo post-operative chemotherapy. Surgical morbidity is certainly responsible for this reduced treatment completion rate; therefore, favoring VATS over thoracotomy may improve the feasibility of adjuvant treatment protocols. Furthermore, there is now evidence that the thoroughness of lymphadenectomy and the complete resection rates are as satisfactory by VATS as by thoracotomy, resulting in equal oncological outcomes. Therefore, in light of the earlier functional recovery of patients operated on by VATS and their greater ability to withstand postoperative adjuvant therapies, considering the effectiveness of this treatment protocol compared to the detrimental effects of an exploratory surgery, we recommend that, in case of unexpected N2 involvement, the surgeon should proceed with a complete resection and systematic mediastinal lymphadenectomy through the same VATS approach.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Berry MF, D’Amico TA, Onaitis MW, Kelsey CR. Thoracoscopic approach to lobectomy for lung cancer does not compromise oncologic efficacy. Ann Thorac Surg. 2014;98:197–202.
Hanna WC, de Valence M, Atenafu EG, Cypel M, Waddell TK, Yasufuku K, et al. Is video-assisted lobectomy for non-small-cell lung cancer oncologically equivalent to open lobectomy? Eur J Cardiothorac Surg. 2013;43:1121–5.
Oparka J, Yan TD, Ryan E, Dunning J. Does video-assisted thoracic surgery provide a safe alternative to conventional techniques in patients with limited pulmonary function who are otherwise suitable for lung resection? Interact Cardiovasc Thorac Surg. 2013;17:159–62.
Zhang R, Ferguson MK. Video-assisted versus open lobectomy in patients with compromised lung function: a literature review and meta-analysis. PLoS One. 2015;10:1–12.
Nwogu CE, D’Cunha J, Pang H, Gu L, Wang X, Richards WG, et al. VATS lobectomy has better perioperative outcomes than open lobectomy: CALGB 31001, an ancillary analysis of CALGB 140202 (Alliance). Ann Thorac Surg. 2015;99:399–405.
Paul S, Altorki NK, Sheng S, Lee PC, Harpole DH, Onaitis MW, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: a propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg. 2010;139:366–78.
Swanson SJ, Meyers BF, Gunnarsson CL, Moore M, Howington JA, Maddaus MA, et al. Video-assisted thoracoscopic lobectomy is less costly and morbid than open lobectomy: a retrospective multiinstitutional database analysis. Ann Thorac Surg. 2012;93:1027–32.
Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomized controlled trial. Lancet Oncol. 2016;17:836–44.
Ramnath N, Dilling TJ, Harris LJ, Kim AW, Michaud GC, Balekian AA, Diekemper R, Detterbeck FC, Arenberg DA. Treatment of stage III non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e314S–40S.
Cerfolio RJ, Bryant AS. Survival of patients with unsuspected N2 (Stage IIIA) nonsmall-cell lung cancer. Ann Thorac Surg. 2008;86:362–7.
Watanabe A, Mishina T, Ohori S, et al. Is video-assisted thoracoscopic surgery a feasible approach for clinical N0 and postoperatively pathological N2 non-small cell lung cancer? Eur J Cardiothorac Surg. 2008;33:812–8.
Kim HK, Choi YS, Kim J, et al. Outcomes of unexpected pathologic N1 and N2 disease after video-assisted thoracic surgery lobectomy for clinical stage I non-small cell lung cancer. J Thorac Cardiovasc Surg. 2010;140:1288–93.
Lee DH, Kim JB, Keum DY, et al. Long term survival of patients with unsuspected N2 disease in non-small cell lung cancer. Korean J Thorac Cardiovasc Surg. 2013;46:49–55.
Bille A, Woo KM, Ahmad U, et al. Incidence of occult pN2 disease following resection and mediastinal lymph node dissection in clinical stage I lung resection. Eur J Cardiothorac Surg. 2017;51:674–9.
Berghmans T, Paesmans M, Meert AP, et al. Survival improvement in resectable non-small cell lung cancer with (neo) adjuvant chemotherapy: results of a meta-analysis of the literature. Lung Cancer. 2005;49:13–23.
Douillart JY, Rosell R, De Lena M, et al. Adjuvant vinorelbine plus cisplatin versus observation in patients with completely resected stage IB-IIIA non-small-cell lung cancer (Adjuvant Navelbine International Trialist Association [ANITA]): a randomised controlled trial. Lancet Oncol. 2006;7:719–27.
Zhang W, Wei Y, Jiang H, et al. Thoracotomy is better than thoracoscopic lobectomy in the lymph node dissection of lung cancer: a systematic review and meta-analysis. World J Surg Oncol. 2016;17:14–290.
Goldstraw P, Crowley J, Chansky K, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM classification of malignant tumors. J Thorac Oncol. 2017;12:1434–41.
Thomas M, Rube C, Hoffknecht P, et al. Effect of preoperative chemoradiation in addition to preoperative chemotherapy: a randomized trial in stage III non-small-cell lung cancer. Lancet Oncol. 2008;9:636–48.
Girard N, Mornex F, Douillard J, et al. Is neoadjuvant chemoradiotherapy a feasible strategy for stage IIIA-N2 non-small cell lung cancer? Mature results of the randomized IFCT-0101 phase II trial. Lung Cancer. 2010;69:86–93.
Katakami N, Tada H, Mitsudomi T, et al. A Phase 3 study of induction treatment with concurrent chemoradiotherapy versus chemotherapy before surgery in patients with pathologically confirmed N2 stage IIIA nonsmall cell lung cancer (WJTOG9903). Cancer. 2012;118:6126–35.
Pless M, Stupp R, Ris H, et al. Induction chemoradiation in stage IIIA/N2 non-small cell lung cancer: a phase 2 randomized trial. Lancet. 2015;386:1049–56.
Yang CJ, Gulack BC, Gu L, et al. Adding radiation to induction chemotherapy does not improved survival of patients with operable clinical N2 non-small cell lung cancer. J Thorac Cardiovasc Surg. 2015;150:1484–93.
Chen Y, Peng X, Zhou Y, et al. Comparing the benefits of chemoradiotherapy for resectable stage III A/N2 non-small cell lung cancer: a meta-analysis. World J Surg Oncol. 2018;16:8.
Albain KS, Swann RS, Rusch VR, et al. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small cell lung cancer. Lancet. 2009;374(9687):379–86.
Ferguson MK. Optimal management when unsuspected N2 nodal disease is identified during thoracotomy for lung cancer: cost-effectiveness analysis. J Thorac Cardiovasc Surg. 2003;126:1935–42.
Detterbeck F. What to do with “surprise” N2? Intraoperative management of patients with non-small cell lung cancer. J Thorac Oncol. 2008;3:289–302.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2020 Springer Nature Switzerland AG
About this chapter
Cite this chapter
Schiavon, M., Nicotra, S., Rea, F. (2020). N2 Disease Discovered at the Time of Vats Lung Resection: Resect or Abort?. In: Ferguson, M. (eds) Difficult Decisions in Thoracic Surgery. Difficult Decisions in Surgery: An Evidence-Based Approach. Springer, Cham. https://doi.org/10.1007/978-3-030-47404-1_16
Download citation
DOI: https://doi.org/10.1007/978-3-030-47404-1_16
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-47403-4
Online ISBN: 978-3-030-47404-1
eBook Packages: MedicineMedicine (R0)