Role of Surgery in Combined Treatment at Stage III

Marmara University School of Medicine Dept of Thoracic Surgery

Role of Surgery in Combined Treatment at

Stage III

Asso.Prof.Hasan F.Batırel


• Stage III disease

• Role of surgery in Stage III NSCLC

• Results of studies

• Current problems and solutions

• Conclusion


Stage III Disease


Stage III Disease

• Stage III disease according to the 1997 system.

• IIIA ve IIIB

• Before 1997 different staging system and results in series (T3N0).


Which Stages?

Stage IIIA – T3N1, T1-3N2Stage IIIB – T4N0

Stage IIIB – T1-4N3


Stage IIIA


Role of Surgery in Stage III NSCLC


Evolution of Surgery

• 1982 Pearson – Cervical mediastinoscopy

• Poor survival in N2 + pations 9% 5 yr survival (Pearson – 1982), 16% (Naruke – 1988)

• So locoregional disease?


Multimodal Treatments

• Starting multimodality trials

• 2 small series (60 pts each) by Roth and Rosell 1994.

• Surgery + Adj / Neoadj Chemo + Surgery + Adj


The Type of Preoperative Treatment• Chemotherapy – CALGB 8935

Sugarbaker 1995.

• Chemoradiation – SWOG 8805 Albain 1995.


No role for surgery?

• Albain 2005 – INT 0139/RTOG 9309

• Van Meerbeck 2007 – EORTC 08941


Results of Studies


Pearson ve Naruke

Pearson 1982

• N2+ diagnosed preop, 5 yr survival 9% (n=79).

• N2+ found during surgery, 5 yr survival %24 (n=62).

Naruke 1988

• Clinical N2 disease, 5 yr survival 16% (n=345)


Roth and Rosell Studies

• 60 patients each

• T3N0 included in each series.

• Routine mediastinoscopy only in Roth study.

• Roth 36% vs 15% 5 yr survival.

• Rosell 17% vs 0% 5 yr survival.


Survival advantage continues at 7-8 year follow-up.


Type of Preoperative Treatment

• CALGB 8935 – Sugarbaker 1995, Neoadj Chemo + Surgery + Adj XRT Pathologic partial response 22%.

• SWOG 8805 – Albain 1995, Concurrent Neoadj CRT, Surgery, Pathologic complete response 21%, Lymph node clearance 59%.

• 3 year survival 23% ve 26%.


SWOG 8805

• Even in the case of radiologically and clinical stable disease %25 pathologic complete response!!!

• One of the most important findings to show the weaknesses of radiologic re-staging following neoadjuvant treatment…


Metaanalysis – Stage III

Neoadjuvant• Bergmans, Lung Cancer 2005.


INT – 0139 Albain – JCO 2005


INT – 0139 Compatison with Lobectomy


INT – 0139 Surgical Results


EORTC – 08941 – JNCI 2007• %90 partial response, %7 pathologic complete

response• %47 pneumonectomy


Issues with EORTC and INT studies

• The number of accrual is insufficient to show small differences.

• The percent of pneumonectomies is very high in the EORTC study.

• Long-term results of Intergroup study will be clinically important.


Pneumonectomy following Neoadjuvant Treatment

• Martin MSKCC 2001 Ann Thorac Surg - %11 (right side %26).

• Albain INT 0139 2005 JCO - %26 (right side %39).

• EORTC 08941 2007 JNCI - %7 (right side %5).


Survival in Patients with Lymph

Node Downstaging

• CALGB 8935 – J Surg Oncol 2006. N0 patients 47.8, N2 patients 8.2 months.

• Van Schil – EJCTS 2006. N0 patients 41, N2 patients 7 ay. Remediastinoscopy recommended.

• Bueno – Ann Thorac Surg 2000. N0 patients 21.3, N2 patients 15.9 months. 5 year survival 36% vs 9%.


Lymph Node and Primary Tumor Response


Recommendations


Current Problems and Solutions


Staging Following Neoadjuvant Treatment

• Remediastinoscopy,

VAMLA

• VATS

• Transbronchial USG

• PET


Pathologic Complete/Partial Response

• PET during neoadjuvant treatment?

• Concurrent Chemotx + RT

• Evaluation of complete response – Surgical specimen


Conclusions


• N2 Stage IIIA NSCLC Surgery following neoadjuvant treatment > Surgery alone.

• Persistence of N2 disease following neoadjuvant treatment – Surgery < Curative CRT

Lessons Learned During Evolution of Surgery – 1


Lessons Learned During Evolution of Surgery– 2

• Pneumonectomy required following neoadjuvant tx - Surgery < Curative CRT

• Lymph node downstaging, resectable with lobectomy – Surgery offers excellent long term local control and survival when compared with other modalities.


Conclusion

• The boundaries and role of surgery is becoming more apparent in Stage IIIA NSCLC.

• This patient group will probably be stratified to microscopic systemic and locally limited (not locally invasive) disease via molecular/pathologic markers.

• There is no doubt that surgery is the best treatment in locally limited disease.

Role of Surgery in Combined Treatment at Stage III

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