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What is the role of surgery in potentially resectable N2 non-small cell lung cancer?
  1. Matthew Evison1,
  2. Fiona McDonald2,
  3. Tim Batchelor3
  1. 1Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
  2. 2Department of Clinical Oncology, The Royal Marsden Hospital NHS Foundation Trust, London, UK
  3. 3Department of Thoracic Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  1. Correspondence to Dr Matthew Evison, North West Lung Centre, University Hospital South Manchester, Manchester M23 0FN, UK; m.evison{at}nhs.net

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Key messages

  • The optimum treatment for potentially resectable stage III N2 non-small cell lung cancer (NSCLC) is multimodality treatment targeting the prevention of distant disease with systemic therapy and achieving local control through surgery, radiotherapy or both.

  • An approach of induction treatment followed by surgery and surgery followed by adjuvant treatment both appear justified, though there is evidence suggesting higher treatment completion rates with an induction approach.

  • When definitive chemoradiotherapy is the preferred treatment option this should be delivered concurrently in the context of adequate physiological reserve.

  • Single station versus multistation N2 disease should not be used as treatment defining factor.

  • Complex multimodality treatments require experienced and high-volume multidisciplinary teams and centres to minimise the risks from treatment and maximise benefits. Consideration should be given to dedicated regional stage III NSCLC services. 

Introduction 

Stage III/N2 non-small cell lung cancer (NSCLC) describes the metastatic spread of a primary tumour to the ipsilateral mediastinal lymph nodes. It is a heterogeneous disease stage ranging from unsuspected N2 disease only detected by intraoperative lymph node sampling during surgical resection of the primary tumour to conglomerate, bulky and invasive N2 disease that cannot be resected. For unresectable N2 NSCLC concurrent chemoradiotherapy is widely accepted as the standard of care in the context of appropriate physiological reserve.1–3 Between these two ends of the spectrum sit those patients with discrete and potentially resectable N2 disease. The optimal treatment strategy in this patient group is keenly debated and a number of guidelines from the UK, Europe and America have made recommendations.1–3 The aim of this article is to review these guidelines and provide an interpretation of their recommendations as a guide to clinicians involved in the care of patients with potentially resectable N2 NSCLC. A summary of the key randomised controlled trials (RCTs) in resectable N2 NSCLC that form the basis of these …

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