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Point and Counterpoint |

POINT: Is N2 Disease a Contraindication for Surgical Resection for Superior Sulcus Tumors? YesN2 Disease and Sulcus Tumors? Yes

Nichole T. Tanner, MD, MSCR, FCCP; Gerard A. Silvestri, MD, FCCP
Author and Funding Information

From the Ralph H. Johnson Veterans Affairs Hospital (Dr Tanner), Health Equity and Rural Outreach Innovation Center; and the Division of Pulmonary and Critical Care, Allergy and Sleep Medicine (Drs Tanner and Silvestri), Medical University of South Carolina.

CORRESPONDENCE TO: Nichole T. Tanner, MD, MSCR, FCCP, Division of Pulmonary and Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, 96 Jonathan Lucas St, Ste 812-CSB, Charleston, SC 29425; e-mail: tripici@musc.edu


CONFLICT OF INTEREST: N. T. T. has received grant funding from the CHEST Foundation OneBreath Initiative, American Cancer Society, Olympus Corporation of the Americas, and Cook Medical Inc and consulting fees from Integrated Diagnostics Inc; Cook Medical Inc; Veran Medical Technologies, Inc; and Olympus Corporation of the Americas. None declared (G. A. S.).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(6):1373-1375. doi:10.1378/chest.15-1194
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Nearly 36,000 Americans a year present with locally advanced stage IIIA lung cancer,1 with an overall 5-year survivorship of 19%.2 Superior sulcus tumors (SSTs) are either stage IIB (T3N0), IIIA (T3N1-2 or T4N0-1), or IIIB (T4N2), with only a slightly better 5-year survival rate (25%-30%). With such a grim outlook, physicians are inclined to extrapolate the available literature in an effort to provide the best chance for cure. The concept of surgery after induction therapy for SSTs posits that if you could get a response from chemoradiotherapy that shrinks the tumor away from critical structures in the apex of the lung near the brachial plexus and vertebral column, surgery could add benefit and potentially cure the patient. However, a closer look at the available evidence does not support this approach in patients with SSTs and N2 disease. Unfortunately, no level 1 evidence supports the use of induction therapy in patients with stage IIIA (N2) non-small cell lung cancer (NSCLC) without superior sulcus involvement, and only feasibility data support its use in those with Pancoast tumors with N0-1 disease. Furthermore, to our knowledge, induction therapy has never been tested in patients with SSTs with N2 disease and, therefore, cannot be recommended.

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