Surgical treatment for N2 non-small cell lung cancer

Because the control of the local tumor and possible distant micrometastases is essential for curing N2 non-small cell lung cancer, multimodality approaches have been considered the preferred treatment for patients with N2 non-small cell lung cancer, including radiotherapy, surgery and chemotherapy. Although induction treatment followed by surgery has been shown to offer a possible survival benefit in select patients with N2 non-small cell lung cancer, randomized phase III trials have failed to demonstrate an advantage of induction treatment followed by surgery over definitive chemoradiotherapy. However, in patients with resectable N2 non-small cell lung cancer, induction chemoradiotherapy followed by surgery has been shown to contribute to improved outcomes in the subgroup of patients who underwent lobectomy. Therefore, induction chemoradiotherapy followed by surgery may be a viable option in a select subset of patients. Recently, the use of immune checkpoint inhibitors after concurrent chemoradiotherapy has been shown to demonstrate a survival advantage in patients with unresectable N2 non-small cell lung cancer, suggesting that the advent of immune checkpoint inhibitors has led to an increase in therapeutic options. In this review, we outline some clinical trials of induction treatment followed by surgery for N2 non-small cell lung cancer and describe our experience in the perioperative management and surgical treatment with induction chemoradiotherapy followed by surgery as well as discuss future perspectives.