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Stage III N2 non-small cell lung cancer treatment: decision-making among surgeons and radiation oncologists

Markus Glatzer, Pawel Leskow, Francesca Caparrotti, Olgun Elicin, Markus Furrer, Franco Gambazzi, André Dutly, Hans Gelpke, Matthias Guckenberger, Jürg Heuberger, Rolf Inderbitzi, Stefano Cafarotti, Wolfram Karenovics, Peter Kestenholz, Gregor Jan Kocher, Peter Kraxner, Thorsten Krueger, Francesco Martucci, Christoph Oehler, Mahmut Ozsahin, Alexandros Papachristofilou, Dirk Wagnetz, Kathrin Zaugg, Daniel Zwahlen, Isabelle Opitz & Paul Martin Putora

abstract

Background
Stage III N2 non-small cell lung cancer (NSCLC) is a very heterogeneous disease associated with a poor prognosis. A number of therapeutic options are available for patients with Stage III N2 NSCLC, including surgery [with neoadjuvant or adjuvant chemotherapy (CTx)/neoadjuvant chemoradiotherapy (CRT)] or CRT potentially followed by adjuvant immunotherapy. We have no clear evidence demonstrating a significant survival benefit for either of these approaches, the selection between treatments is not always straightforward and can come down to physician and patient preference. The very heterogeneous definition of resectability of N2 disease makes the decision-making process even more complex.

Methods
We evaluated the treatment strategies for preoperatively diagnosed stage III cN2 NSCLC among Swiss thoracic surgeons and radiation oncologists. Treatment strategies were converted into decision trees and analysed for consensus and discrepancies. We analysed factors relevant to decision-making within these recommendations.

Results
For resectable "non-bulky" mediastinal lymph node involvement, there was a trend towards surgery. Numerous participants recommend a surgical approach outside existing guidelines as long as the disease was resectable, even in multilevel N2. With increasing extent of mediastinal nodal disease, multimodal treatment based on radiotherapy was more common.

Conclusions
Both, surgery- or radiotherapy-based treatment regimens are feasible options in the management of Stage III N2 NSCLC. The different opinions reflected in the results of this manuscript reinforce the importance of a multidisciplinary setting and the importance of shared decision-making with the patient.
   
citation Glatzer M, Leskow P, Caparrotti F, Elicin O, Furrer M, Gambazzi F, Dutly A, Gelpke H, Guckenberger M, Heuberger J, Inderbitzi R, Cafarotti S, Karenovics W, Kestenholz P, Kocher G J, Kraxner P, Krueger T, Martucci F, Oehler C, Ozsahin M, Papachristofilou A, Wagnetz D, Zaugg K, Zwahlen D, Opitz I, Putora P M. Stage III N2 non-small cell lung cancer treatment: decision-making among surgeons and radiation oncologists. Transl Lung Cancer Res 2021; 10:1960-1968.
   
type journal paper/review (English)
date of publishing 4-2021
journal title Transl Lung Cancer Res (10/4)
ISSN print 2218-6751
pages 1960-1968
PubMed 34012806
DOI 10.21037/tlcr-20-1210