指南：潜在可切除N2非小细胞肺癌管理

Etienne H, Battilana B, Spicer J, Werner RS, Opitz I. Defining resectability: When do you try to take it out? JTCVS Open. 2024 Mar 29;19:338-346. doi: 10.1016/j.xjon.2024.03.012. PMID: 39015436; PMCID: PMC11247203.

Definition of Resectability
The aim of any curative intent surgery for primary lung cancer is to achieve a complete resection, otherwise known as an R0 resection.13 According to the International Association for the Study of Lung Cancer (IASLC), complete resection is defined as:

• En bloc resection of the tumor with microscopically free margins;
• Systematic lymph node dissection or lobe-specific systematic nodal dissection;
• No extracapsular nodal extension of the tumor;
• The highest mediastinal lymph node negative for tumor; and
• Pleural and pericardial cytology negative.
  

Table 1. Summary of UK, European, and American guidelines on the management of potentially resectable N2 non–small cell lung cancer (NSCLC)∗

Guideline	Definition of resectable	Recommendations	Notes
BTS and SCTS7 (2010)	Nonfixed lymph nodes Nonbulky lymph nodes Single-zone N2 disease Reasonable chance of: Complete resection, clear pathological margins	Consider surgery as part of multimodality treatment in nonfixed, nonbulky, single-zone N2 NSCLC Further research into the role of surgery in nonfixed, nonbulky, multizone N2 NSCLC	Significant weight placed on IASLC staging database outcomes despite lack of comparator group and lack of clinical N2 Guidelines consider evidence for adjuvant chemotherapy more robust than preoperative chemotherapy
ACCP8 (2013)	Discrete lymph nodes Easily measurable and defined lymph nodes Free from major structures, such as the great vessels and trachea	Definitive CRT or induction therapy (chemotherapy or CRT) followed by surgery Surgery followed by adjuvant chemotherapy not recommended	Does not support the concept that surgery can only be justified in patients with minimal N2 disease Preoperative chemotherapy better than surgery alone in all NSCLC (small studies) and therefore surgery plus adjuvant chemotherapy is not recommended
ESMO9 (2017)	Minimal, nonbulky N2 disease Single-station N2 disease	Definitive CRT, induction chemotherapy followed by surgery or induction CRT followed by surgery	Paramount importance of an experienced and high-volume multidisciplinary team and treatment centers able to minimize risk and complications from multimodality treatment highlighted
NICE10 (2019)	None provided	Consider CRT followed by surgery	CRT followed by surgery improves PFS and might improve survival compared with CRT alone
NCCN11 (2023)	Single lymph node smaller than 3 cm	Definitive CRT or induction chemotherapy followed by surgery or induction CRT followed by surgery Maintenance durvalumab following cCRT	Benefit from preoperative chemotherapy is similar to that of postoperative chemotherapy and either approach is justified

BTS, British Thoracic Society; SCTS, The Society for Cardiothoracic Surgery in Great Britain and Ireland; IASLC, International Association for the Study of Lung Cancer; ACCP, American College of Chest Physicians; CRT, chemoradiotherapy; ESMO, European Society of Medical Oncology; NICE, National Institute for Health and Care Excellence; NCCN, National Comprehensive Cancer Network; PFS, progression-free survival; cCRT, concurrent chemoradiotherapy.

∗ This table, under the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), was duplicated and updated from a previous table.12