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Outcome of surgery versus radiotherapy after induction treatment in patients with N2 disease: systematic review and meta-analysis of randomised trials
  1. P J McElnay1,
  2. A Choong2,
  3. E Jordan3,
  4. F Song4,
  5. E Lim5
  1. 1Department of Cardiothoracic Surgery, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
  2. 2Specialty Registrar in Vascular Surgery, Imperial College Healthcare NHS Trust, London, UK
  3. 3Library Services, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  4. 4Faculty of Health, University of East Anglia, Norwich, UK
  5. 5Imperial College London and The Academic Division of Thoracic Surgery, Royal Brompton Hospital, London, UK
  1. Correspondence to E Lim, Imperial College London and The Academic Division of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK; e.lim{at}


Objective Chemoradiotherapy is often considered the ‘standard of care’ for patients with N2 disease. The aim was to evaluate survival outcomes of patients with N2 disease in multimodality trials of chemotherapy, radiotherapy and surgery.

Methods Systematic review and meta-analyses (random and fixed effects) were performed. Searches of Medline and Embase (1980–2013) were conducted. Abstracts from thoracic scientific meetings were searched. Reference lists of all relevant studies were reviewed. All studies of patients with N2 disease who received induction chemotherapy or chemoradiotherapy and randomised to surgery or radiotherapy were included. No language restrictions were imposed. The main outcome was overall survival.

Results 805 publications were identified. 519 and 281 were excluded because they were not primary results from randomised trials (or did not include N2 disease) or did not compare surgery with radiotherapy, respectively. The final six trials consisted of 868 patients. In four trials, patients received induction chemotherapy and in two trials patients received induction chemoradiotherapy. The HR comparing patients randomised to surgery after chemotherapy was 1.01 (95% CI 0.82 to 1.23; p=0.954) whereas for patients randomised to surgery after chemoradiotherapy was 0.87 (0.74 to 1.02; p=0.078). The overall HR of all pooled trials was 0.92 (0.81 to 1.04; p=0.179).

Conclusions In trials where patients received surgery as part of bimodality (with chemotherapy) or trimodality (with chemoradiotherapy) treatment, overall survival was not significantly better than radiotherapy (with chemotherapy) or combination chemoradiotherapy alone.

  • Thoracic Surgery
  • Lung Cancer
  • Lung Cancer Chemotherapy
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