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The Significance of Upfront Knowledge When it Comes to N2 Disease in Non-Small Cell Lung Cancer
*Daniel C. Thomas, *Brian N. Arnold, *Joshua E. Rosen, *Michelle C. Salazar, *Frank C. Detterbeck, *Justin D. Blasberg, *Daniel J. Boffa, Anthony W. Kim
Yale School of Medicine, New Haven, CT

Objective: Determine the impact of unsuspected N2 disease (cN0/pN2) compared with known N2 disease (cN2/pN2) in pathologic stage IIIA non-small cell lung cancer (NSCLC) patients who underwent curative intent surgery, with the secondary objective to measure the impact of adjuvant therapy.
Design: Retrospective clinical oncology dataset analysis.
Setting: Commission on Cancer accredited facilities.
Patients: The National Cancer Data Base (NCDB) was queried for patients with pathologic stage IIIA NSCLC who underwent surgical resection from 2004-2011.
Intervention: Comparison of five-year overall survival of patients with unsuspected N2 disease versus those with known N2 disease after surgical resection using Kaplan-Meier analysis. The independent effect of unsuspected N2 disease on mortality was analyzed using a multivariable model.
Main Outcome Measures: Five-year overall survival.
Results: 3,271 patients with pathologic stage IIIA NSCLC underwent curative intent surgical resection with or without adjuvant chemotherapy or chemoradiation therapy. Unsuspected N2 disease accounted for 49% of patients, were more likely to be women, and have adenocarcinoma when compared to patients with known N2 disease (both p<0.01). Patients with unsuspected N2 disease were more likely to have T1 tumors (37% vs 32%, p<0.01) and be treated with adjuvant chemotherapy (48% vs 46%, p<0.01). Unsuspected N2 disease did not impact 5-year overall survival compared with known N2 disease (34% vs 31%, NS). Multivariable analysis identified older age, higher comorbidity score, and treatment with surgery alone as independently associated with increased mortality, while presence of unsuspected N2 disease was not associated.
Conclusions: Unsuspected N2 disease compared to known N2 disease is not associated with a detrimental 5-year survival when adjuvant therapy is employed. Adjuvant chemotherapy should be recommended when N2 disease is identified after surgical resection.


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