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. 2021 Apr;10(4):1960-1968.
doi: 10.21037/tlcr-20-1210.

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

Markus Glatzer  1 , Pawel Leskow  2 , Francesca Caparrotti  3 , Olgun Elicin  4 , Markus Furrer  5 , Franco Gambazzi  6 , André Dutly  2 , Hans Gelpke  7 , Matthias Guckenberger  8 , Jürg Heuberger  9 , Rolf Inderbitzi  10 , Stefano Cafarotti  10 , Wolfram Karenovics  11 , Peter Kestenholz  12 , Gregor Jan Kocher  13 , Peter Kraxner  14   15 , Thorsten Krueger  16 , Francesco Martucci  17 , Christoph Oehler  18 , Mahmut Ozsahin  19 , Alexandros Papachristofilou  20 , Dirk Wagnetz  21 , Kathrin Zaugg  22 , Daniel Zwahlen  18 , Isabelle Opitz  23 , Paul Martin Putora  1   24
Affiliations

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

Markus Glatzer et al. Transl Lung Cancer Res. 2021 Apr.

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.

Keywords: Non-small cell lung cancer (NSCLC); decision-making; radiotherapy; stage III N2 lung cancer; surgery.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tlcr-20-1210). The series “Radiotherapy in thoracic malignancies” was commissioned by the editorial office without any funding or sponsorship. PMP received an educational grant from AstraZeneca (educational grant to the Institution); outside the submitted work, he also received research support and educational grants to the department from Celgene, Roche and Takeda. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Example of the simplified decision tree. LN, lymph nodes; OP, surgery; RT, radiotherapy.
Figure 2
Figure 2
demonstrates the overall majority recommendations for each parameter combination. LN, lymph nodes; OP, surgery; RT, radiotherapy.
Figure 3
Figure 3
Demonstrates the answers from the radiation oncologists for all combinations of simplified criteria. Single alphabetic letters: participating sites. LN, lymph nodes; OP, surgery; PP, patient’s preference; RT, radiotherapy.
Figure 4
Figure 4
Demonstrates the answers from surgeons for all combinations of simplified criteria. Single alphabetic letters: participating sites. LN, lymph nodes; OP, surgery; PP, patient’s preference; RT, radiotherapy.
See this image and copyright information in PMC

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