Adequate Lymph Node Staging Is Fundamental to Comparative Study on Resectable Non–Small-Cell Lung Cancer
Authors: Tony S.K. Mok, Benny Zee, Alain Depierre, Virginie Westeel, Bernard Milleron, Denis Moro-Sibilot, Elisabeth Quoix, Denis Braun, Bernard Lebeau
Journal: Journal of Clinical Oncology (2002)

Article Tools SPECIAL DEPARTMENTS Article Tools OPTIONS & TOOLS Export Citation Track Citation Add To Favorites Rights & Permissions COMPANION ARTICLES No companion articles ARTICLE CITATION DOI: 10.1200/JCO.2002.20.10.2604 Journal of Clinical Oncology - published online before print September 21, 2016 PMID: 12011141 Adequate Lymph Node Staging Is Fundamental to Comparative Study on Resectable Non–Small-Cell Lung Cancer Tony S.K. MokxTony S.K. MokSearch for articles by this author , Benny ZeexBenny ZeeSearch for articles by this author Alain DepierrexAlain DepierreSearch for articles by this author , Virginie WesteelxVirginie WesteelSearch for articles by this author , Bernard MilleronxBernard MilleronSearch for articles by this author , Denis Moro-SibilotxDenis Moro-SibilotSearch for articles by this author , Elisabeth QuoixxElisabeth QuoixSearch for articles by this author , Denis BraunxDenis BraunSearch for articles by this author , Bernard LebeauxBernard LebeauSearch for articles by this author Show More The Chinese University of Hong Kong, Hong Kong, ChinaJ. Minjoz University Hospital, BesançonTenon University Hospital, ParisMichalon University Hospital, GrenobleUniversity Hospital, StrasbourgGeneral Hospital, BrieySaint-Antoine University Hospital, Paris, France https://doi.org/10.1200/JCO.2002.20.10.2604 First Page Full Text PDF Figures and Tables © 2002 by American Society of Clinical OncologyjcoJ Clin OncolJournal of Clinical OncologyJCO0732-183X1527-7755American Society of Clinical OncologyResponse15052002In Reply:The authors of these two letters made the same comment on the need for a mediastinoscopy before inclusion in a phase III trial of preoperative chemotherapy. We agree with their theoretical arguments. In our study,1 we made the choice of a pragmatic attitude because of the very conflicting opinions of investigators concerning systematic mediastinoscopy (especially in clinical stage I and II). Guidelines from the American Society of Clinical Oncology,2 American Thoracic Society, and European Respiratory Society3 recommend mediastinoscopy only in patients with clinical N2 evident on computed tomography (CT) scans (short-axis diameter > 1 cm). However, many institutions do not perform this procedure for each patient before surgery, as they claim that mediastinoscopy is inefficient for numerous mediastinal lymph node chains (sites 2L, 5L, 6L, 7, 8, 9L, and R). Therefore, the question we have addressed was: “Is preoperative chemotherapy useful in clinically resectable tumors?” This is a useful question to be answered for an everyday practice.Patients were randomized before receiving any treatment; therefore, the rate of minimal N2 (N0 to N1 on CT scan) and of false clinical N2 should be well balanced between the two groups of patients. In the control arm (primary surgery), sensitivity and specificity of CT scan were within the limits reported in the literature. This study was therefore correctly designed to answer the above-cited question. We clearly cannot make definitive conclusions from subgroup analyses on the interest of preoperative chemotherapy in N0, N1 disease on the one hand and in N2 disease on the other hand. However, it can be a sufficient argument for recommending the separate study of early stages and stage IIIa disease in upcoming trials of preoperative treatments.Mok and Zee think it is very likely that the risk of death during the treatment period is only increased in clinical N2 disease. They are correct, especially for postoperative deaths in N2 patients treated with chemotherapy. This point was presented during the 2001 annual meeting of the American Society of Clinical Oncology.4 Estimated risks of death in both randomized arms were not proportional over time. During the treatment period, which was the first 5 months, the relative risk was 2.28 (95% confidence interval, 0.84 to 6.23) for N2 disease and 0.81 (95% confidence interval, 0.31 to 2.14) for N0 to N1 non–small-cell lung cancer, but differences were not statistically significant in any group. Within the first 30 postoperative days and thereafter, there were four lethal complications in the control arm and 14 in the preoperative chemotherapy arm for N2 disease, and five and four, respectively, for N0 to N1 disease.REFERENCE1. Depierre A, Milleron B, Moro-Sibilot D, et al: Preoperative chemotherapy followed by surgery compared with primary surgery in resectable stage I (except T1N0), II, and IIIa non–small-cell lung cancer. J Clin Oncol 20:: 247,2002-253, Link, Google Scholar2. American Society of Clinical Oncology: Clinical practice guidelines for the treatment of unresectable non–small-cell lung cancer. J Clin Oncol 15:: 2996,1997-3018, Link, Google Scholar3. American Thoracic Society: Pretreatment evaluation of non-small-cell lung cancer. Am J Respir Crit Care Med 156:: 320,1997-332, Crossref, Medline, Google Scholar4. Breton JL, Westeel V, Milleron B, et al: Postoperative morbidity and mortality after neoadjuvant chemotherapy (NCT) for non small cell lung cancer (NSCLC) in the French phase III trial. Proc Am Soc Clin Oncol 20:: 311a,,2001 (abstr 1239) Google Scholar