[New therapeutic strategies and current research in inoperable locally advanced non small-cell lung cancers (stage IIIB)]

Treatment of patients with inoperable locally advanced non small-cell lung cancer (NSCLC) remains disappointing with less of 5% of patients alive at 5 years. Both initial local control and circumvention of concomitant undetectable metastatic chemoresistant cells are the critical targets for the oncologists in charge of this disease. Results of a recent meta-analysis including 22 randomized studies comparing standard treatment (i.e. radiotherapy) to sequential chemoradiotherapy have undoubtabely well defined the role of cisplatine-containing chemotherapy in stage IIIB NSCLC, even if the 5 year survival benefit remains modest. However, high complete response rates and prolonged overall survival were observed with combinations of new promising chemotherapy regimens and new fractionated radiation schedules in several phase II studies. These results have to be corroborated by prospective randomized trials. Integration of more aggressive and more toxic strategies such as radical surgery in these initial inoperable locally advanced NSCLC are evaluating. Around these conventional therapies, the stage IIIB NSCLC represent a favoured target to elaborate innovative therapeutic approaches based on emergence of biotherapies as recombinant cytokines, antitumoral vaccine and gene therapy programs. The contribution of these new therapeutic options opens new directions in the therapeutic strategy and leads to hope a new promising era in the management and outcome of patients with these tumors.

Lung resection for recurrence after pneumonectomy for metastases

Resection of pulmonary recurrences after pneumonectomy for metastases is exceptional. Nevertheless in carefully selected patients surgery on the residual lung might be successfully performed. From January 1987 to February 1996, 5 patients underwent metastasectomy on single lung after pneumonectomy performed for the same metastatic disease. There were 3 male and 2 female with a mean age of 38 years at the time of surgery on single lung. All patients had a FEV1 > 40%. One patient (n degree 1) had 2 consecutive operations (wedge resections) on the right lower lobe followed 17 months later by right inferior lobectomy for metastases of soft tissue sarcoma. Three patients had only an operation on the residual lung (patient n degree 2 had 2 wedge resections for carcinoma; patient n degree 3 had 7 wedge resections for carcinoma; patient n degree 4 had 6 wedge resections for osteogenic sarcoma). The last patient (n degree 5) had 2 wedge resections on the right upper lobe and a large wedge resection on the right lower lobe for metastases of malignant corticosurrenaloma using a cardiopulmonary femoro-femoral by-pass without cardiac arrest. She postoperatively developed a right lower lobe venous infarction treated subsequently with a completion right lower lobectomy. She died in the postoperative course from cardiorespiratory insufficiency. The other patients had an uneventful postoperative course. Two patients (n degree 2 and n degree 4) died of their disease 14 and 12 months respectively after the surgery on the residual lung; by contrast 2 patients (40%) (n degree 1 and n degree 3) are still alive without recurrences 36 and 27 months after the last resection. In selected patients aggressive surgery for metastases on the residual lung can be successfully performed but the benefits in terms of long-term disease-free survival remain to be determined.

[Optimization of combined radiotherapy and chemotherapy in treatment of non-small cell lung carcinoma]

PURPOSE

To report the results of CEBI 140 and 142 trials. These trials were aimed at improving the local control in stage III non-small cell carcinoma with concomitant chemotherapy and radiotherapy in the CEBI 140 trial, and with concomitant chemotherapy and radiotherapy followed by local excision in the CEBI 142 trial.

MATERIAL AND METHODS

Thirty-four patients presenting with stage III non-small cell lung carcinoma were included into the CEBI 140 trial from December 1989 to December 1992. Patients were treated with a combination of daily cisplatin (6 mg/m2 per day, 144 mg/m2 in total), vindesine once a week (2.5 mg/m2, 15 mg/m2 in total) and bifractionated radiotherapy (60 Gy/48 fractions/6 weeks) followed by two cycles of cisplatin 120 mg/m2 (at d18 and d45 after completion of radiochemotherapy) and three cycles of vindesine (6 mg/m2 at d24, d31, and d38 after completion of radiochemotherapy). Twenty-eight patients presenting with stage IIIB non-small cell carcinoma-were included into the CEBI 142 trial since January 1993. Patients received a combination of cisplatin (100 mg/m2 at d1 and d24, 200 mg/m2 in total), vinblastine (4 mg/m2 at d1 and d24, 8 mg/m2 in total), 5-fluorouracil in continuous infusion (1,000 mg/m2 from d1 to d3, and from d24 to 26, 6,000 mg/m2 in total) and bifractionated radiotherapy (two series of 21 Gy/14 fractions/9 days, 11 days apart) followed by a new evaluation and surgical excision.

RESULTS

In the CEBI 140 trial, all patients received a complete course of radiotherapy, but the dose of cisplatin was decreased in 27% of the cases, and the dose of vindesine in 88%. There were two toxicity-related deaths. Three months after completion of the protocol, there were 50% of complete responders. The overall survival rates at 1, 2 and 3 years were 53, 33, and 11%, respectively, and disease-free survival rates 21 11, and 11%, respectively. In the CEBI 142 trial the immediate tolerance was good. Twenty-one patients (75%) underwent surgical resection. Four tumors could not be resected. Resection was histologically incomplete in one case, and complete in the 16 remaining cases. With a median follow-up of 14 months, ten patients were alive and disease-free.

CONCLUSION

Preliminary results of the CEBI 142 trial are encouraging. More patients and longer follow-up are needed for definitive conclusion. It would be of interest to implement a randomized trial comparing the CEBI 142 scheme and classical radiation therapy.

Phase I study of a recombinant adenovirus-mediated gene transfer in lung cancer patients

BACKGROUND

Despite vigorous efforts at curbing tobacco consumption and aggressive combined-modality treatment programs, both the incidence of and the mortality from lung cancer have remained virtually unchanged in the last 10 years. More effective innovative therapies are clearly needed. The direct transfer into tumor cells of tumor suppressor genes or toxic gene products that specifically promote tumor cell death and spare nonmalignant cells is a potentially novel anticancer treatment approach that should be investigated.

PURPOSE

On the basis of compelling preclinical data, we initiated a phase I study involving six patients with inoperable lung cancer and an endobronchial lesion accessible by bronchoscopy. Our purpose was to evaluate the feasibility, tolerance, and clinical, biologic, and immunologic effects of the intratumoral administration of a recombinant, replication-deficient adenovirus (rAd.RSV beta-gal), using the Rous sarcoma virus promoter to drive transcription of the Escherichia coli lacZ marker gene that encodes for the bacterial enzyme beta-galactosidase (beta-gal).

METHODS

From June 1994 through April 1995, six patients (five males and one female) were enrolled in the trial. A single dose of recombinant virus suspension containing 10(7) or 10(8) plaque-forming units (PFU) was injected intratumorally into two successive cohorts of three patients. Eligible patients received concomitant chemotherapy. Patients were kept under isolation conditions from 3 days before the injection was given until virus excretion was undetectable. Biopsy specimens of the tumor and surrounding mucosa were collected on the 8th day and at 1, 2, and 3 months after injection. They were analyzed by cell culture, polymerase chain reaction (PCR), and beta-gal expression for the presence of recombinant adenovirus. So that the risk of virus recombination or complementation could be minimized, wildtype adenovirus carriers among the hospital staff (identified by PCR) were excluded from contact with patients who were potentially excreting recombinant virus.

RESULTS

beta-gal was expressed in tumor biopsy specimens of three patients (one who received the 10(7) PFU dose level and two who received 10(8)). Bronchoalveolar lavage specimens collected immediately after injection were positive for recombinant adenovirus when analyzed in culture and by PCR. All biologic fluids were negative for recombinant virus as judged by PCR after day 12, with the exception of bronchoalveolar lavage specimens (positive PCR up to 90 days in two of three patients treated with 10(8) PFU). The blood samples obtained from the three patients treated with 10(8) PFU showed positive PCR results immediately after virus injection. Patients were kept in isolation for a median of 17 days. The most common toxic effects were moderate bleeding (occurring in two patients) during bronchoscopy and fever (seen in four patients). Endoscopic and clinically objective antitumor responses were seen in four patients, including one patient who showed a complete response by pathologic evaluation. The median survival for the patients was 12.5 months (range, 3-16+ months). Throughout the study, hospital staff remained negative for recombinant adenovirus infection.

CONCLUSIONS

This ongoing phase I study has demonstrated that a recombinant adenovirus-mediated marker gene, such as rAd.RSV beta-gal, can be safely introduced into humans and that the gene product is expressed by lung tumor cells of the host.

Cancer resection on the residual lung after pneumonectomy for bronchogenic carcinoma

BACKGROUND

After pneumonectomy for bronchogenic carcinoma, the residual lung may be the site of a new lung cancer or metastatic spread.

METHODS

From 1989 to 1995, 13 patients with carcinoma on the residual lung after pneumonectomy for lung cancer were operated on. Three segmentectomies and 7 simple wedge resections were performed, 2 patients had multiple wedge resections, and 1 patient had an exploratory thoracotomy. Nine patients had a primary metachronous bronchogenic carcinoma, 3 had metastases from bronchogenic carcinoma, and no definite conclusion was reached in 1 case.

RESULTS

No postoperative mortality was observed. Four patients had postoperative complications. The mean postoperative hospital stay was 14 days. Seven patients are alive, including 5 patients without evidence of disease. Six patients died of their disease, all with pulmonary recurrences. The overall median survival was 19 months, with a probability of survival at 3 years (Kaplan-Meier) of 46% (95% confidence interval, 22% to 73%).

CONCLUSIONS

Limited pulmonary resection for lung cancer after pneumonectomy for bronchogenic carcinoma is feasible with very low morbidity. In highly selected patients, surgical resection might prolong survival.

Lung volume reduction in patients with severe diffuse emphysema. A retrospective study

BACKGROUND

For most authors, surgery of emphysema is restricted to resection of large bullae, whereas resection of small bullae or lung volume reduction is generally considered to have poor results.

STUDY OBJECTIVE

To report our experience of lung volume reduction in patients with severe emphysema without large bullae.

PATIENTS

Thirteen patients were operated on from 1982 to 1992. Before surgery, they all had severe diffuse emphysema with a dyspnea grade 4 or 5 and mean FEV1 values of 18 +/- 5% of predicted. Seven patients had a PaCO2 greater than 42 mm Hg. On radiologic evaluation, they had either small bullae or, most often, areas of destroyed lung.

INTERVENTION

The surgical procedure was unilateral in 11 patients and bilateral in 2.

MEASUREMENTS AND RESULTS

Postoperative assessment included dyspnea grading, FEV1 measurements, and blood gas analysis followed at 6- to 12-month intervals. There was no perioperative mortality and the morbidity was limited. At 6, 12, 18, 24, and 36 months postoperatively, a symptomatic improvement was observed in 92%, 85%, 54%, 31%, and 31% of the patients, respectively, with FEV1 increasing by at least 20% in 92%, 46%, 46%, 31%, and 24% of the patients, respectively.

CONCLUSION

Our data show that lung volume reduction may result in symptomatic and spirometric improvement in patients with severe emphysema without large bullae.

Surgery for lung metastases from colorectal cancer: analysis of prognostic factors

PURPOSE

To identify prognostic factors of improved survival after resection of isolated pulmonary metastases (PM) from colorectal cancer.

PATIENTS AND METHODS

A retrospective analysis of the records of all patients with PM from colorectal cancer who underwent thoracic surgery with curative intent before December 1992 at a single surgical center was performed. Univariate (log-rank) and multivariate (Cox's model) analyses of survival were used to identify significant prognostic factors.

RESULTS

Eighty-six patients with PM from colon (n = 49) or rectal (n = 37) cancer underwent 102 thoracic operations, which included 21 bilateral and 10 incomplete resections. The 5- and 10-year probabilities of survival (Kaplan-Meier) after the first thoracic operation were 24% (95% confidence interval [CI], 15% to 35%) and 20% (95% CI, 13% to 31%), respectively. Sex, age, site of the primary tumor (colon or rectum), disease-free interval (DFI), and previous resection of hepatic metastases were found not to be statistically significant prognostic factors. Complete resection, a limited number ( < two) of PM, and a normal prethoracotomy serum carcinoembryonic antigen (CEA) level were predictors of a longer survival duration by univariate analysis, but only complete resection (P = .024) and preoperative CEA level (P = .001) were identified as independent prognostic factors by multivariate analysis. The estimated 5-year survival rate of patients with a normal prethoracotomy CEA level was 60%, as compared with 4% in cases with elevated ( > 5 ng/mL) CEA level.

CONCLUSION

Besides resectability, the prethoracotomy serum CEA level appears the most reliable predictor of survival in patients with isolated PM from colorectal cancer.

Virtual tracheo-bronchial endoscopy: educational and diagnostic value

The use of Helical CT significantly improves image quality of examinations in a number of clinical settings. It is particularly suited to the study of the tracheo-bronchial tree as a result of new ways of image processing (developed by GEMS research) which can produce virtual endoscopic images without the use of an endoscope. We present our initial anatamo-radiological findings and their educational value as well as our thoughts on potential future clinical applications.

Concurrent cisplatin-vindesine and hyperfractionated thoracic radiotherapy in locally advanced nonsmall cell lung cancer

PURPOSE

Local failure is a major problem in locally advanced nonsmall cell lung cancer. The main objective of this Phase II trial was to test the feasibility of a combined concurrent radiotherapy and chemotherapy approach in an attempt to improve local control.

METHODS AND MATERIALS

From December 1989 to December 1992, 34 patients were included. The treatment schedule consisted of hyperfractionated radiotherapy (60 Gy in 48 fractions and 6 weeks with two daily sessions of 1.25 Gy), cisplatin (6 mg/m2 every day of radiotherapy), and vindesine (2.5 mg/m2 once weekly). After a 3-week rest period, two full cycles of cisplatin (120 mg/m2 on weeks 10 and 14) and vindesine (2.5 mg/m2 on weeks 11, 12, and 13) were given. Treatment evaluation with thoracic computed scan, bronchoscopy, and bronchial biopsies was performed 3 months after completion of radiation therapy. Failure rates were estimated using a competing risk approach.

RESULTS

The complete response rate was 50%. Local failure rates at 1 and 3 years were 53 and 56%, respectively. Distant metastases rates at 1 and 3 years were 26.5 and 29%. Overall survival rates at 1, 2, and 3 years were respectively 53, 33, and 12%. Severe esophagitis was observed in three patients (9%). Lethal toxicity was observed in two patients.

CONCLUSION

This Phase II trial confirms the feasibility of this type of approach with specific dose reduction and suggests that it may improve local control compared to conventional approaches.

[Pulmonary emphysema: surgical indications]

Surgery for pulmonary emphysema, with the exception of lung transplantation, is limited at present to resection of the emphysematous areas. The resection of a unique bulla within an otherwise healthy parenchyma can be indicated in case of complications but rarely in asymptomatic patients. When the bullae are large (i.e. volume greater than one-third of the hemithorax) in a patient suffering from diffuse emphysema, bullectomy is the ideal indication. Mortality varies from 0 to 10%, essentially due to infection or acute respiratory failure. In most patients, the subjective improvement in terms of dyspnea and the objective improvement as measured by spirometry remains significative up to 5 years after surgery. Inversely, surgical resection is classically considered to be contraindicated in patients with small poorly-limited bullae. Recent data would however question this idea since subjective and objective improvement after reduction of the lung volume is still present 1 year after surgery in most patients, even those with severe obstruction. The mechanism is probably related to increased elastic recoil. Even if only temporary improvement can be achieved for a few years, the persisting course of emphysema would suggest that volume reduction should always be entertained as an alternative before lung transplantation.

Total vertebrectomy for en bloc resection of lung cancer invading the spine

We describe a technique of total vertebrectomy for en bloc resection of a non-small cell lung cancer with vertebral invasion through a combination of thoracic and enlarged posterior approaches, and present our entire experience of total and partial vertebrectomy for tumors invading vertebral bodies or the costovertebral angle.

[Lung metastases from colorectal cancer: results of surgery]

OBJECTIVES

Surgery has become a recognized therapeutic means in selected patients with isolated pulmonary metastases, with a 5-year survival rate of about 35%, but specific studies on the results and prognosis of surgery for pulmonary metastases from colorectal cancer remain relatively rare.

METHODS

Between 1980 and 1991, 65 patients (34 men, 31 women, mean age 58.2 years) underwent 81 thoracic operations with curative intent (including 15 bilateral operations and 7 incomplete resections) for pulmonary metastases from colorectal cancer.

RESULTS

The 5- and 10-year probabilities of survival (Kaplan-Meier) after the first thoracic operation were 27% and 22% respectively. The site of the primary tumor (colon or rectum), the disease-free interval, previous resection(s) of hepatic metastases, and the size of pulmonary metastases were not found to the have a statistically significant influence on prognosis. On the other hand, the quality of resection (complete or incomplete) (p < 0.001), the number of resected pulmonary metastases (p = 0.016), and the preoperative carcino-embryonic antigen level (p < 0.001) were found to be highly significant prognostic factors.

CONCLUSION

Complete resection of pulmonary metastases from colorectal cancer seems to prolong survival in a significant number of patients, and the results from this study should help to select those who may benefit from this treatment.

Surgery for pulmonary metastases. Who are the 10-year survivors?

BACKGROUND

Surgical resection of pulmonary metastases (PMs) has been shown to produce approximately a 35% 5-year survival rate, but specific data about late survival are not available in the literature.

METHODS

A retrospective review and survival analysis of 186 adult patients who underwent surgery for PMs at a single center before June 1984 is presented.

RESULTS

Of the 186 patients who had surgery, of whom 34 (18%) had an incomplete resection, the 10-year survival rate (Kaplan-Meier) was 23% (95% CI, 16-30%), and 36 patients, with PMs from nine different primary sites, were still at risk at 10 years. Two patients died of their primary disease more than 10 years after the first thoracotomy, and two are alive with uncontrolled disease. Thirty-one patients are currently alive and disease free. Comparison between the 36 10-year survivors and the 150 nonsurvivors revealed that only the percentage of incomplete resections and the mean number of resections per patient were significantly different between the two groups (P < 0.001); the histologic type of the primary tumor, the disease-free interval, and the number of resected PMs at the first thoracotomy were not found to be statistically significant prognostic factors.

CONCLUSIONS

The 23% 10-year survival and the high rate of disease free 10-year survivors in this study constitute support for complete resection as an efficient therapeutic approach in patients with isolated PMs. Relevant criteria to select more precisely those patients who will benefit from resection remain to be developed.

Surgical resection of pulmonary metastases. Up to what number?

Specific results on the surgical resection of a large number of pulmonary metastases (PM) are currently unavailable, and the risk-benefit ratio of this aggressive approach may appear questionable. A systematic review of the records of 456 adult patients who underwent thoracic surgery for PM between 1979 and 1990 led to the identification of 44 patients who underwent at least one resection of eight or more PM (range eight to 110), of whom 33 (75%) had PM from osteogenic or soft tissue sarcoma. These 44 patients underwent a total of 77 operations, of which 47 (61%) were bilateral and nine (12%) incomplete resections. The 3- and 5-yr probabilities of survival after the first resection of eight or more PM were 36 and 28%, respectively, and were not significantly different from those of the 412 other patients who underwent surgery for PM over the same period. In this small group of patients, only the quality of resection (complete or incomplete) was found to be a highly significant prognostic factor (p < 0.01). A critical analysis of the reported data supports the view that, at least in patients with osteogenic or soft tissue sarcoma, the prognostic value of the number of PM seems to be more dependent on associated resectability than on the number per se and that, after careful preoperative patient selection, PM that can be resected should be resected, whatever their number.

Tracheal malacoplakia

Malacoplakia is a rare granulomatous disease well described in the urinary tract but which rarely involves the lung. We report for the first time, to our knowledge, tracheal localization of this unusual disorder. The larynx and probably kidneys were also involved. Differential diagnosis, physiopathology, and treatments are discussed.

[Preventive bronchial omentoplasty and myoplasty in pulmonary resection. Technical aspects and results]

Extended pulmonary resections with complete dissection of mediastinal lymph nodes, and the growth in neoadjuvant therapies, led us to define preventive methods to promote uncomplicated bronchial healing. Nineteen patients were operated on in conditions of high risk of impaired bronchial healing. They underwent bronchial revascularization either by omentopexy (12), or intercostal pedicle flap (7). 10/12 preventive omental pedicle flaps permitted correct healing, 7 preventive intercostal pedicle flaps permitted only 3 good results. This short series confirmed experimental data, and encouraged us to increase preventive bronchial omentopexy.