Transcervical extended mediastinal lymphadenectomy for mediastinal restaging after induction therapy

Background: The aim of this study was to retrospectively evaluate long-term survival of stage IIIA-N2 non-small cell lung cancer patients operated after induction chemotherapy or chemoradiotherapy and negative mediastinal restaging with transcervical extended mediastinal lymphadenectomy (TEMLA).

Methods: From January 2007 to December 2013, 48 stage IIIA-N2 non-small cell lung cancer (NSCLC) patients (36 men, 12 women) underwent anatomic pulmonary resection after induction therapy and negative result of mediastinal restaging with TEMLA. Mean age was 58.3 years (range, 46-75 years). There were 28 squamous cell carcinomas, 13 adenocarcinomas, 1 mixed carcinoma and 6 non-small cell lung cancers. Neoadjuvant chemotherapy was given in 24 patients, chemoradiotherapy in 23 and chemotherapy with bradytherapy in 1 patient. All patients were followed-up until death or 60 months since pulmonary resection.

Results: There were 29 pneumonectomies, 2 lower bilobectomies and 17 lobectomies. 2 patients had R1 resection. After negative TEMLA, persistent metastatic N2 nodes were discovered in 5 patients (10.4%). The only complication after TEMLA was bilateral vocal cord paralysis observed in 1 patient (2.1%); 2 patients died in early postoperative period due to bronchial fistula (4.2%). Overall 5-year survival of patients operated after negative TEMLA was 39.5%. 5-year survival was not statistically different in patients who underwent lobectomy/bilobectomy and in patients who underwent pneumonectomy (47.4% vs. 34.5%). Five-year survival was lower in patients after chemoradiotherapy than in patients after chemotherapy alone (21.7% vs. 56.0%, P=0.022). 5-year survival was not statistically different in patients with true mediastinal downstaging and in patients with false negative TEMLA (41.9% vs. 20%, P=0.19).

Conclusions: Stage IIIA-N2 non-small cell lung cancer patients who underwent pulmonary resection after induction treatment and negative mediastinal restaging with TEMLA showed good long-term survival. In these patients aggressive surgery, including pneumonectomy, lead to satisfactory outcomes. However, prognosis of patients after induction chemoradiotherapy was worse.