Delphi for management of N2 non-small cell lung cancer

Mediastinal lymph node involvement is a prognostic factor in patients with localized NSCLC. Both ipsilateral and subcarinal nodal involvement are classified as N2 disease. However, there is no universally agreed-upon approach for diagnosing and treating this condition. The aim of this study is to elaborate an institutional N2 consensus. A multidisciplinary expert panel at Hotel Dieu de France provided informed consent to participate in the modified Delphi process. Twelve basic statements were started by a steering committee of three independent reviewers on the basis of international consensus, medical literature and personal experience. In the first round, physicians answered an open-ended questionnaire that was analyzed thematically. In the second round, the participants rated the generated statements and added their comments. In the third round, the participants rated their agreement via a 6-point Likert scale. Consensus was defined as ≥80 % agreement (A+ or A) with a statement. Nineteen physicians completed the three rounds. A full consensus was reached in eleven statements. Preoperative mediastinal staging is mandatory in patients with resectable N2 disease. It should be considered in patients with a high SUVmax (maximum standardized uptake value) (≥3), proximal or apical tumors and high carcinoembryonic antigen levels. Surgery is performed in the absence of neoadjuvant treatment depending on a single station with nonbulky disease and stage T3 invasive/T4 disease. In patients with N2 disease at several stations, radio chemotherapy is the main treatment, followed by durvalumab in patients with good general status. In pN2 patients, postsurgical treatment is based on the condition of the surgical resection margin. These findings will help physicians in multidisciplinary discussions agree on clinical decisions.