Affiliations: Ospedale Cardinale G. Massaia Asti, Italy,
European Institute of Oncology, Milan, Italy
Correspondence to: Maria Serra, MD, SOC Pneumologia, Ospedale Civile di Asti, Corso Dante, 202–14100 Asti, Italy; e-mail: firstname.lastname@example.org
We read with great interest the recent study by Milleron et al1on the evaluation of complete response (CR) by clinical investigators and an evaluation committee (EC) in patients treated using neoadjuvant chemotherapy for non-small cell lung cancer (NSCLC). The study was carried out using the database of the well-known French randomized trial2 and showed a low sensitivity of CR diagnosis by investigators (31.6%) and EC (15.8%). Specificity, positive and negative predictive values, and accuracy were very high for both investigators and EC, leading to the conclusion that investigator assessment was highly predictive of pathologic CR. Moreover, the study showed that clinical CT scan-based assessment, for both investigators or EC, underestimated the frequency of CR after induction chemotherapy in resected NSCLC.
This study has some methodologic biases that may severely weaken the reported message: (1) a lack of homogeneity in clinical staging: mediastinoscopy or mediastinotomy was not routinely used in IIIA patients to confirm histologic N2 disease before enrolment onto the trial; (2) absence of a homogeneous surgical treatment: in the original article,2 a complete lymph node dissection was performed in 59 patients (40.4%) of the preoperative chemotherapy arm; a lymph node sampling in 56 patients (38.4%), and 31 patients (21.2%) received neither a dissection nor a sampling (calculation based on data from Table 3 of Depierre et al2). Therefore, limitation in their staging technique and surgical procedure may explain the discrepancy between pathologic CR and investigators and EC.
Surgery should be indicated, when it is reasonably possible, in every case in which an induction therapy has been administered even if an objective clinical response to the therapy has not been evidenced. In fact, the most-used imaging technique (CT scan) hardly distinguishes among neoplastic tissue, fibrosis, and necrosis, and more accurate procedures, such as positron emission tomography scanning, do not reliably predict pathologic response to preoperative chemotherapy in NSCLC in either the primary tumor or the draining lymph nodes.3This clinical behavior has been confirmed by the high resectability rate obtained in those patients who were judged to be resectable and then operated on.4
In conclusion, this study underlines that the radiologic evaluation did not reflect the pathologic staging. In the light of the recent experiences, we think that patients showing a radiologic major response (CR or partial response) after induction treatment for NSCLC should undergo complete surgical resection to eradicate the tumor and to improve survival.
All of the authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
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