Video-assisted mediastinocopic lymphadenectomy (VAMLA) for restaging clinical N2-3 non-small cell lung cancer (NSCLC) after neoadjuvant treatment.

Abstract

Background: Reliable mediastinal restaging after neoadjuvant treatment to rule out persistent nodal disease is essential to select patients for resection. Main endpoints of this study are: to analyse the accuracy of video-assisted mediastinoscopic lymphadenectomy (VAMLA) and to determine the rate of persistent N2-3 in patients with clinical N2-3 (cN2-3) non-small cell lung cancer (NSCLC) after neoadjuvant treatment.

Methods: Prospective observational single-centre study of patients with NSCLC and histologically proven mediastinal involvement (cN2-3), treated with neoadjuvant therapy who underwent VAMLA for restaging. Patients with negative VAMLA underwent lung resection. Systematic nodal dissection (SND) was considered the reference test to confirm negative VAMLAs. Staging values were calculated based on pathologic findings using the standard formulas.

Results: From 2017 to 2023, 41 patients with cN2-3 NSCLC received neoadjuvant therapy and thereafter underwent VAMLA for restaging. Neoadjuvant treatments: concomitant cisplatin-based chemotherapy and radical radiotherapy (n=33), chemoradiotherapy and immunotherapy (n=2), chemotherapy (n=2), chemotherapy and immunotherapy (n=2), tyrosine kinase inhibitor and immunotherapy (n=1) and immunotherapy (n=1). VAMLA was feasible in all patients. Restaging values with VAMLA were: sensitivity, 1 [95% confidence interval (CI): 0.72-1]; negative predictive value (NPV), 1 (95% CI: 0.89-1); and diagnostic accuracy, 1 (95% CI: 0.91-1). Rate of persistent N2 of the whole series: 29% (12/41). Complication rate was 9.7%.

Conclusions: This preliminary series of patients with cN2-3 NSCLC treated with neoadjuvant treatment and restaged by VAMLA demonstrated high accuracy and high rate of persistent N2. VAMLA should be included in restaging algorithms to select patients with potentially resectable cN2-3 NSCLC.