When we have patients who have a mediastinoscopy that’s positive, in other words we’ve found mediastinal lymph nodes that are involved with cancer, the decision comes down to what’s the best approach. Usually, when patients have what we call locally advanced lung cancer, which is lung cancer that has significantly involved those lymph nodes, that’s reserved for a concurrent chemotherapy plus radiation approach, and surgery is usually not indicated. But we do have patients whose lymph nodes were slightly involved, either with microscopic deposits or only a couple of lymph node areas that were involved, and in those patients we will give them upfront chemotherapy or chemotherapy plus radiation therapy at a moderate dose, and then reassess them after they’ve had their therapy. If their tumor has responded to the therapy, in other words on the PET scan and CT it’s smaller and the lymph nodes are less active, then we may consider a resection in those people.
The very best scenario is for patients that we do that, but then we go in and operate, that they’ve actually had their tumor completely sterilized by the therapy. I tell my patients that we use the lung mass as a measure of their response to the chemotherapy in their body, and the reason is that people don’t die from lung cancer in their chest after we operate on them, they die of lung cancer that’s out in their body and if there’s microscopic cancer out in their body, I’m not helping them by taking the lung mass out. I usually say the horses are out of the barn, and it really doesn’t care what I do to the barn, the horses are gone. If the tumor in the chest has been sterilized, there’s a very good chance that denotes that all of the tumor in their body is sterilized.
So when we resect patients who’ve had upfront treatment, if their tumor is completely dead or almost all dead from the therapy, that denotes very good outcome for the patients and they’re the ones that we have that are long-term survivors, and we do have patients that are long-term survivors after they’ve had chemotherapy plus or minus radiation and surgery.