[How to treat the relapse of NSCLC after surgery and chemotherapy? IFTC 0702 randomized phase III study]

BACKGROUND

As chemotherapy gains wider acceptance for the treatment of earlier stages of NSCLC, particularly in the adjuvant and neoadjuvant setting, physicians face a growing population of high performance status patients who have relapsed after their first-line chemotherapy. The type of second-line chemotherapy after initial adjuvant or neoadjuvant treatment with a platinum-based regimen remains largely undefined. The current study has been designed to compare the classical mono chemotherapy docetaxel with a docetaxel cisplatin doublet.

METHODS

Patients will be randomized in 2 arms. Arm: docetaxel cisplatin (cycles repeated every 21 days), 4 cycles followed by 2 cycles of docetaxel alone in case of objective response or stabilisation. Arm B: docetaxel alone (cycles repeated every 21 days), 4 cycles followed by 2 cycles of docetaxel alone in case of objective response or stabilisation.

EXPECTED RESULTS

300 patients will be randomized with a statistical hypothesis of a progression free survival of 3 months in the control arm and of 4.5 months in the experimental arm.

[What treatment for a patient of PS 2-3 with stage IV non-small cell lung cancer?]

Patients with poor performance status (PS) and advanced lung cancer have been underrepresented in clinical trials. As a consequence, the management of these patients in clinical practice is often empirical. Recent data indicate that patients with advanced non-small cell lung cancer (NSCLC) and a PS of 2 tend to benefit from first line chemotherapy with respect to symptom improvement and perhaps overall survival. Whether single-agent or combination chemotherapy is preferable remains debatable. In previously treated patients with NSCLC, EGFR tyrosine kinase inhibitors produced a substantial rate of clinical benefit and led to an improvement in survival compared with placebo in studies that included a significant percentage of patients with poor PS.

[Non-small cell lung cancer - from treatment of relapse to treatments for relapses]

Second line treatments of non-small cell lung cancer are currently largely used because of their effectiveness in terms of survival and quality of life. Three drugs are currently licensed for this indication (docetaxel, pemetrexed and erlotinib), and possibly others will follow in the years to come. A true therapeutic strategy can thus be applied in advanced non-small cell lung cancer. The questions which need to be resolved are the optimum choice of treatments (mono-chemotherapy? Poly-chemotherapy? Therapeutic biological?) related to the still poorly understood "characteristics" of patients and tumours, as well as the specific question as to whether patients who have received adjuvant chemotherapy and then relapse should receive "first line" or "second line" therapy?

Infections pulmonaires à Nocardia

INTRODUCTION

Nocardial pneumonias are due to a genus of aerobic, filamentous, partly acid-alcohol fast, mainly Gram positive, actinomycetes.

CASE REPORT

We report here two cases of nocardial pneumonia. The first was a 62 year old man with a history of fludaribine treatment and bone marrow transplant for lymphocytic leukaemia. During the investigation of pyrexia evidence of N. farcinica infection was found in the bronchial secretions. The second case was a man of 61 receiving long term corticosteroids and cytotoxic chemotherapy. Investigation of a pneumonia with pleural effusion found evidence, on culture of blood and pleural fluid, of disseminated infection with N. nova (cerebral, pleural, pulmonary and splenic).

CONCLUSION

Nocardiosis is a rare cause of pneumonia mainly occurring in immuno-compromised adults (corticosteroid therapy, HIV infection, transplantation, cancer or leukaemia). It should be suspected in the presence of pleuro-pulmonary symptoms associated with neurological and cutaneous signs, general deterioration and weight loss. The microbiology laboratory should be advised of this eventuality as soon as possible in order to optimise the search for the organism.

[Evaluation criteria for bronchial carcinoma. How to assess quality of life in lung cancer?]

The aim of medical treatment in lung cancer is often to a large extent palliative, due to advanced stage at the time of diagnosis. Evaluation of such treatment has usually been based on objective responses, global survival, survival at 1 or 2 years and the occurrence of toxicities, but also more recently on assessment of quality of life. Two Quality of Life questionnaires have been validated (FACT and QLQ C30). The different criteria of 'quality of life' are presented and also their difficulties in application and interpretation, due to potential problems of bias. In routine clinical practice, only the visual symptom scales are of use, in association with the wishes and understanding of patients which must remain at the centre of medical care allowing the patient being a partner in therapeutic decisions.

Cost-minimization analysis of a phase III trial comparing concurrent versus sequential radiochemotherapy for locally advanced non-small-cell lung cancer (GFPC-GLOT 95–01)

BACKGROUND

We conducted an economic analysis of a phase III clinical trial comparing sequential radiochemotherapy (RT-CT) with concurrent RT-CT in patients with locally advanced non-small-cell lung cancer.

PATIENTS AND METHODS

The trial was a randomized multicenter study comparing three cycles of chemotherapy (arm A) followed by radiotherapy against an RT-CT combination (two cycles of platinum etoposide) followed by two cycles of platinum-vinorelbine (arm B). The economic analysis adopted the payer's perspective and only included direct costs. Costs (euro, 1996-2003) were recorded until the cut-off date. A cost minimization analysis and a sensitivity analysis were carried out.

RESULTS

Data from 173 patients were used in the economic study. Protocol costs tended to be higher in arm B, while relapse costs were significantly higher in arm A. The total number of hospital days was higher in arm B. The average total cost per patient was euro16,074 in arm A and euro15,245 in arm B (P=0.15). The cost minimization analysis favored arm B. This advantage persisted in the sensitivity analysis.

CONCLUSIONS

Concurrent RT-CT was not the more costly strategy in this phase III trial, despite lengthier hospitalization for toxicity. Other studies of similar design are needed to confirm these results in future randomized trials.

[Gastropleural fistula presenting with a pyopneumothorax in pregnancy]

INTRODUCTION

Gastropleural fistula has only rarely been described in the literature, typically presenting with evidence of left-sided pleural infection.

CASE REPORT

The diagnosis may be suggested by the occurrence of chest pain and repeated vomiting with the diagnosis confirmed by microbiological examination of the pleural fluid and appropriate radiological investigations. The fistula occurs most frequently after abdominal or anterior thoracic surgery. Generally, surgical repair should be performed urgently but in the case that we describe occurring during pregnancy, surgery was delayed for 10 weeks until a caesarean section could be performed.

CONCLUSION

In the presence of left-sided basal pleuritic chest pain in the context of a possible gap in the diaphragm the diagnosis of gastropleural fistula should be considered. Treatment is usually a medico-surgical emergency.

Phase II trial of temozolomide and cisplatin followed by whole brain radiotherapy in non-small-cell lung cancer patients with brain metastases: a GLOT-GFPC study

BACKGROUND

Brain metastases (BM) considerably worsen the prognosis of non-small-cell lung cancer (NSCLC) patients. The usefulness and choice of chemotherapy remain uncertain in this indication since these patients are excluded from most clinical trials. We conducted a phase II study to determine the efficacy and tolerability of up-front chemotherapy with association of temozolomide and cisplatin in NSCLC patients with BM.

PATIENTS AND METHODS

Fifty NSCLC patients with BM received temozolomide (200 mg/m(2)/day for 5 days every 28 days) and cisplatin (75 mg/m(2) at day 1 of each cycle), up to six cycles, followed by whole brain radiotherapy (WBRT). An evaluation was carried out every two cycles and after WBRT. WBRT was performed earlier in case of progressive disease at any time or stable disease after cycle 4.

RESULTS

Eight objective responses were achieved (16%). Overall median survival was 5 months. Median time to progression was 2.3 months. Ten patients (20%) presented a grade 3/4 neutropenia and 11 patients (22%) presented a grade 3/4 thrombopenia.

CONCLUSION

This study demonstrates a lack of efficacy of up-front chemotherapy with association of temozolomide and cisplatin in these patients. Nevertheless, it supports the feasibility of chemotherapy before brain radiotherapy in NSCLC patients with BM.

Gemcitabine–docetaxel versus cisplatin–vinorelbine in advanced or metastatic non-small-cell lung cancer: a phase III study addressing the case for cisplatin

BACKGROUND

This multicenter, randomized, phase III study compared the efficacy, including progression-free survival (PFS), and safety of gemcitabine-docetaxel (GD) combination versus cisplatin-vinorelbine (CV) in the treatment of advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Chemonaive patients with stage IIIB or IV NSCLC were treated with GD (gemcitabine 1000 mg/m(2) days 1 and 8 plus docetaxel 85 mg/m(2) day 8, every 3 weeks for eight cycles) or CV (cisplatin 100 mg/m(2) day 1 plus vinorelbine 30 mg/m(2), days 1, 8, 15 and 22, every 4 weeks for six cycles).

RESULTS

A total of 311 patients were enrolled (155 GD and 156 CV). Neither PFS nor overall survival differed significantly between the two arms (median PFS 4.2 and 4 months; median survival 11.1 and 9.6 months; 1-year survival 46% and 42%, for GD and CV, respectively). For the GD arm compared with the CV arm, the hazard ratio for PFS was 1.04 [95% confidence interval (CI) 0.83-1.32], and for overall survival, it was 0.90 (95% CI 0.70-1.16). Objective response rates did not differ significantly (31% for GD, 35.9% for CV). Myelosupression, emesis and frequency of febrile neutropenia were less pronounced on the GD arm, whereas fluid retention and pulmonary events were more pronounced. The CV arm experienced a higher number of serious adverse events and a lower compliance with the protocol. There was no quality of life (QoL) difference between arms. Median time to definite impairment of health-related QoL was 153 and 168 days in GD and CV arms, respectively.

CONCLUSIONS

There was no advantage in PFS with GD compared with CV; however, the CV regimen had higher rate of toxic events, mainly myelosuppression. The herein, non-platinum-containing regimen could be considered as a rational alternative to the cisplatin-based doublet.

[Treatment of anemia and bone metastasis in metastatic non-small-cell lung cancer. A French survey]

Use of erythropoietin (EPO) for chemotherapy-induced anemia and biphosphonates (BP) for bone metastasis has increased steadily. However, there are no guidelines on their use in many situations such as non small cell lung carcinoma (NSCLC), which frequently alters quality of life markedly. Therefore, a multicentric survey was designed to assess the treatment of anemia and bone metastasis in chemotherapy-treated patients with non-small-cell lung carcinoma. Nine representative centers of the oncology working party of the French respiratory society (Groupe d'Oncologie de la Société de Pneumologie de Langue Française) participated. Inclusion criteria were stage IV NSCLC and at least one course of chemotherapy in the last 3 months. A total of 148 and 50 patients (pts) were included in the anemia and bone metastasis surveys, respectively. Anemia was present in 60.8% of patients, and was not treated in 75%; 15 patients received EPO (10.1%). Independent predictors of EPO use were presence of anemia-related symptoms, hemoglobin level, age and center: the rate of prescription in patients with anemia varied from 13 to 73% between centers. BP were administered in 38% of patients with bone metastasis. Independent predictors of BP use were calcium serum level, pain, and center with a rate of prescription ranging from 0 to 80% between centers. This study reveals that, in France, most patients with anemia are not treated, EPO being seldom prescribed. The use of both EPO and BP is highly variable between centers. Guidelines on the use of these supportive treatments could help improve the care for lung cancer patients receiving chemotherapy.

[Treatment of lung cancer in the elderly]

Elderly patients form an increasing proportion of the lung cancer population. However, they are poorly represented in clinical trials. The published studies are generally phase II trials on highly selected small numbers of patients. Applying these trials to clinical practice is therefore difficult and this is compounded by the fear of increased treatment toxicity in elderly patients. In the event of organ failure (respiratory, cardiac or other organ failure), where conventional therapy is not possible, there are a number of alternative options: radiotherapy for inoperable limited non-small-cell-lung cancer, chemotherapy without platinum for those with more extensive disease or with analogues of platinum for small-cell-lung-cancer. Finally, adjunctive therapy with haematopoietic-cell growth factors or cytoprotectors may allow full doses of treatment to be delivered whilst limiting toxicity. More studies in elderly patients, with larger numbers, are needed to develop more rational therapeutic strategies. We present here some studies of reference and the most recent publications on this subject.

[Second-line chemotherapy in non-small cell lung cancer]

The progress in first-line chemotherapy in non-small cell lung cancer with efficient and often well-tolerated combinations has progressively led to the proposal of second-line chemotherapy for the patients. Docetaxel provides significantly enhanced survival compared with palliative treatments. Various phase II studies with vinorelbine, gemcitabine and paclitaxel have been reported. Pemetrexed has demonstrated identical enhanced survival as docetaxel, but with improved tolerance. An epothilone B analog is under study in clinical trials.

Expérience française du géfitinib dans le cancer bronchique non à petites cellules

INTRODUCTION

Gefitinib (Iressa, ZD 1839; AstraZeneca) is a selective Epidermal Growth Factor receptor tyrosine kinase inhibitor. In two randomized phase II trials (IDEAL 1 and IDEAL 2), it has demonstrated an activity against NSCLC, showing partial response and symptoms improvement rates respectively in about 20% and 40% of patients. Multivariate analyses revealed that being a woman, a non-smoker and having an adenocarcinoma was associated with response rate.

METHODS

We describe a retrospective study of patients receiving Gefitinib as a third line compassionate treatment of NSCLC.

RESULTS

We enrolled 37 patients (29 men, 8 women). Tumors included 25 adenocarcinoma, 4 squamous cell carcinoma, 7 large cell carcinoma, and 1 neuroendocrine carcinoma. Partial response rate was 8.1%, and stable disease rate 27.0%. The 3 responders were all non-smoker women, with an histological type of adenocarcinoma. Symptoms improvement was observed in 59.5% of patients. Main toxicities were diarrhoea and skin reactions. We observed that responding patients had more adverse drugs-related reactions than stable or non-responding patients.

CONCLUSIONS

Gefitinib is a meaningful active therapy in NSCLC with a favorable toxicity profile. We suggest that being a woman, a never-smoker and having an adenocarcinoma may be clinical predictive factors of response to Gefitinib.

Lessons from the ("Iressa" Expanded Access Programme: gefitinib in special non-small-cell lung cancer patient populations

Some subgroups of patients with advanced/metastatic non-small-cell lung cancer (NSCLC) are frequently considered ineligible for the aggressive, platinum-based combination chemotherapy that is the recommended treatment. Elderly patients may have a poorer tolerance of chemotherapy due to impaired organ function and frequent comorbidities; patients with poor performance status (PS; ⩾2 due to NSCLC and/or coexisting illnesses) are often considered unfit for chemotherapy; other patients may be unable or unwilling to endure the toxicity or inconvenience of chemotherapy. These patient groups may benefit from novel, relatively nontoxic treatment modalities. Gefitinib (‘Iressa’, ZD1839) 250 mg day⁻¹ is well tolerated and has proven antitumour and symptom improvement activity in patients with previously treated NSCLC. Phase II trials (IDEAL 1 and 2) of gefitinib in advanced/metastatic NSCLC included 70 out of 425 (16.5%) patients with PS ⩾2, and their response rate, clinical benefit rate and rates of adverse events were similar to those of the overall trial population. In addition, many patients with advanced/metastatic NSCLC with poor PS or advanced age have received gefitinib 250 mg day⁻¹ in an Expanded Access Programme (EAP). Observations from the EAP support those of IDEAL 1 and 2, and indicate that gefitinib 250 mg day⁻¹ warrants further investigation in these patient groups.

GLOB-1: a prospective randomised clinical phase III trial comparing vinorelbine-cisplatin with vinorelbine-ifosfamide-cisplatin in metastatic non-small-cell lung cancer patients

BACKGROUND

The standard doublet, vinorelbine-cisplatin, was compared with a triplet of vinorelbine-ifosfamide-cisplatin, in terms of survival, in patients with advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

From February 1998 to June 1999, 259 chemonaïve patients entered the study and were randomised to receive either vinorelbine-cisplatin (NP; vinorelbine 30 mg/m(2) on days 1, 8 and 15 with cisplatin 80 mg/m(2) on day 1) or vinorelbine-ifosfamide-cisplatin (NIP; vinorelbine 25 mg/m(2) on days 1 and 8, ifosfamide 3 g/m(2) on day 1 and cisplatin 75 mg/m(2) on day 1), with both regimens being repeated every 3 weeks. All patients had stage IV or relapsed disease and a performance score of 0 or 1.

RESULTS

The overall response rate was 34.6% for NP and 35.7% for NIP. Median and 1-year survival rates were 10.0 months and 38.4% for NP, and 8.2 months and 33.7% for NIP, respectively. A median of four cycles was administered in each arm. The major World Health Organization grade 3-4 toxicities for NP and NIP, respectively, were: neutropenia (20.3% compared with 9% of cycles), anaemia (4.1% compared with 5% of cycles), nausea and vomiting (22.2% compared with 19.4% of patients) and alopecia (5.6% compared with 29.8% of patients). Four toxic deaths occurred in the NP arm and eight in the NIP arm.

CONCLUSIONS

The different schedules of vinorelbine in the two arms led to a greater survival in the NP arm without impairing the tolerance profile, although this is not statistically significant. This confirms that the two-drug combination NP is a reference treatment for metastatic NSCLC. The role of three-drug combinations remains questionable in this subset of patients.

[Treatment of bronchial carcinoma in the elderly]

Elderly patients form an increasing proportion of the lung cancer population. However, they are poorly represented in clinical trials. The published studies are generally phase II trials on highly selected small numbers of patients. Applying these trials to clinical practice is therefore difficult and this is compounded by the fear of increased treatment toxicity in elderly patients. In the event of organ failure (respiratory, cardiac or other organ failure), where conventional therapy is not possible, there are a number of alternative options: radiotherapy for inoperable limited non-small-cell-lung cancer, chemotherapy without platinum for those with more extensive disease or with analogues of platinum for small-cell-lung-cancer. Finally, adjunctive therapy with haematopoietic-cell growth factors or cytoprotectors may allow full doses of treatment to be delivered whilst limiting toxicity. More studies in elderly patients, with larger numbers, are needed to develop more rational therapeutic strategies. We present here some studies of reference and the most recent publications on this subject.

[Isolated pleurisy revealing ovarian hyperstimulation syndrome]

Ovarian hyperstimulation is a rare but serious iatrogenic complication following induction of ovulation cycles. Release of vasoactive substances by the stimulated ovaries leads to leakage of intravascular fluid into the extracellular and serous spaces due to enhanced capillary permeability. Pleural effusion is a classical finding in the most severe forms, often associated with ascitis and signs of hemoconcentration. We report the case of a women who presented pleural effusion as the sole inaugural sign of ovarian hyperstimulation.

Rhabdomyosarcoma arising in mediastinal teratoma in an adult man: a case report

We report a case of rhabdomyosarcoma which occurred in a mediastinal teratoma in a 44-year-old man. Presentation symptoms were chest pain, hoarseness and a cough. Diagnosis was fortuitous, performed by the histological and immunohistochemical study of a mediastinal tumour biopsy specimen that showed embryonal carcinoma and yolk sac tumour components associated with the rhabdomyosarcoma. After cisplatin-based chemotherapy (bleomycin-etoposide-cisplatin), surgical resection of the residual mediastinal tumour was performed. Histological and immunohistochemical study of this tumour confirmed the presence of mature teratoma and embryonal rhabdomyosarcoma. Evolution was marked by a local extension of the mediastinal tumour, occurrence of multiple metastases and bone marrow involvement. The patient died 8 months after diagnosis despite chemotherapy and radiotherapy. A review of the literature reveals that the development of rhabdomyosarcoma in primary mediastinal teratomas is unusual in adults. The diagnostic, therapeutic and prognostic implications of such an association are reviewed.

Carboplatin-etoposide combination in small cell lung cancer patients older than 70 years: a phase II trial

BACKGROUND

No standard treatment is defined for elderly patients with small cell lung cancer (SCLC). Carboplatin and etoposide are highly active agents against SCLC. In this study, we evaluated the activity and toxicity of a combination of these two agents.

PATIENTS AND METHODS

Thirty-four untreated patients with limited or extensive SCLC and median age of 73.9 years entered the study. Chemotherapy consisted of carboplatin i.v. on day 1 (AUC 5 using Calvert's formula) and etoposide 100 mg/m(2) given orally on days 1-5, every 4 weeks, and thoracic irradiation was given to limited disease patients after chemotherapy.

RESULTS

The overall response rates was 59% (95% CI: 43-76). The median survival for all patients was 37 weeks (range 3-76 weeks). The toxicity was mainly haematological with grade 3-4 neutropenia in 59% of courses, febrile neutropenia in 15% of courses, and toxic death in 9% of patients.

CONCLUSION

The results of this regimen are disappointing with worse response and survival, and more haematological toxicity than expected and previously reported, despite the use of Calvert's formula. Possible explanations are the use of etoposide per os rather than i.v., the frequent comorbidities of older patients and the inclusion of patients with poor prognosis factors.

The role of chemotherapy in early stage of non-small cell lung cancer

Despite surgery, resectable NSCLC (stage I, II, and IIIA N2) has a quite poor prognosis: about 50% of patients will die during the first 2 years by metastatic disease and only 36% are alive at 5 years after diagnosis. Postoperative radiotherapy is not effective in case of complete resection (PORT meta-analysis). The role of perioperative chemotherapy is still questionnable. Cambridge meta-analysis has shown a little benefit of cisplatin based postoperative chemotherapy. Several randomised trials are completed like Alpi Trial or ANITA or still in progress. Results would be available in 2 or 3 years. Several phase II trials of preoperative chemotherapy have demonstrated that preoperative chemotherapy is feasible, with high response rate, very few progression (mainly metastatic progression without local progression) and no increase of mortality and morbidity. Two small phase III trials have demonstrated that preoperative chemotherapy can dramatically increase survival compared with surgery alone, in case of N2 disease. The MIP trial of Depierre has studied two or four cycles of MIP regimen in perioperative setting in stage IB, II or IIIA, compared to surgery alone (TRT in case of N2 disease). After 3 years of survey there is a trend in favor of MIP in case of stage IB and II (23% increase of 3 years survival) but not in case of N2. The toxicity of MIP is a possible explanation of such poor results in N2 patients despite a high response rate (64%). Some other trials are in progress in the world. Surgery is also questionnable in case of resectable N2 disease. Several trials comparing chemo radiotherapy to chemo (+/- radiotherapy)+surgery are in progress in U.S. and Europe.

[Standards, Options and Recommendations for the management of stage I or II primary bronchial cancers treated exclusively with radiotherapy]

CONTEXT

The 'Standards, Options and Recommendations' (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French cancer centres and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.

OBJECTIVES

To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for the management of stage I and II non small cell lung carcinoma treated by radiotherapy alone.

METHODS

Data were identified by searching Medline and personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to independent reviewers, and to the medical committees of the 20 French cancer centres.

RESULTS

The main recommendations for the management of stage I and II non small cell lung carcinoma treated by radiotherapy alone are: 1) The curative external irradiation with a continual course is an alternative to surgery only in the case of medically inoperable tumors or because the patient refuses surgery; 2) The external irradiation of the primary tumor only without the mediastinum could be proposed in peripheral stage IA. In proximal stage IA and IB, external irradiation should be carried out only as part of prospective randomised controlled trials comparing a localised irradiation of the primary tumor with a large irradiation of the mediastinum and the primary tumor. The treated volume must include the macroscopic tumoral volume with or without the microscopic tumoral volume and with a security margin from 1.5 to 2 cm; 3) There is a benefit to delivering a total dose in the primary tumor higher than 60 Gy in so far as the proposed irradiation, taking into account the respiratory function, does not increase the likelihood of severe adverse events due to radiation; and 4) The change in fractionation, the radiochemotherapy combination, the endobronchial brachytherapy with high dose rate alone or with external irradiation could be proposed only as part of prospective controlled trials for tumors classified as stage IB or II.

[Standards, options and recommendations for the management of locally advanced non small cell lung carcinoma]

CONTEXT

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of the French Cancer Centres (FNCLCC), the 20 French Cancer Centres and specialists from French Public Universities, General Hospitals and Private Clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.

OBJECTIVES

To develop clinical practice guidelines according to the definitions of the Standards, Options and Recommendations project for the management of locally advanced non small cell lung carcinoma.

METHODS

Data were identified by searching Medline and the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to independent reviewers and to the medical committees of the 20 French Cancer Centres.

RESULTS

The main recommendations are: 1) The management of the locally advanced non small cell lung carcinoma has two main goals: firstly to obtain local control of the disease (or to at least delay local progression in order to improve the survival or relapse free survival), and secondly to prevent the development of metastases. 2) There is a consensus that locally advanced non small cell lung carcinoma should be irradiated. External beam radiotherapy should be of optimal quality and delivered at a minimal dose of 60 Gy by standard fractionation. For patients with a poor life expectancy, this can be delivered as a split-course or hypofractionated scheme. 3) Treatment for patients with a performance status of 0-1 should consist of short duration induction chemotherapy (with a least two drugs one of which must be cisplatin), combined sequentially with conventional radiotherapy. 4) Surgery is contraindicated in extensive N3 disease. Combined radio-chemotherapy (adjuvant or neoadjuvant) is not indicated outside clinical trials. Surgery is justified in stage N2 disease as good local control can be achieved. T4-N0 disease should be treated surgically with curative intent.