Clinical prognostic factors in surgically treated stage IIIA-N2 non-small cell lung cancer: analysis of the literature

Docetaxel and cisplatin as induction chemotherapy in patients with pathologically-proven stage IIIA N2 non-small cell lung cancer: a phase II study of the European organization for research and treatment of cancer (EORTC 08984)

The objective of this phase II study was to document activity and toxicity of docetaxel and cisplatin as induction chemotherapy in patients with stage IIIA N2 non-small cell lung cancer (NSCLC) before definitive local treatment. Forty-six chemotherapy-nai ve patients (median age 60 years) were included. Treatment consisted of 3 cycles of docetaxel (85 mg/m2 on day 1), followed by cisplatin (40 mg/m2/day on days 1 and 2) every 21 days. Grade 3-4 leukopenia and neutropenia occurred in 45.7% and 65.2% of the patients, respectively. Among 8 cases of febrile neutropenia (17.4%), one (2.2%) resulted in early death. Common grade 3-4 non-haematological toxicities were nausea (17.4%) and vomiting (13%). Eighty-five percent of the patients received three courses; six stopped prematurely due to toxicity, one due to protocol violation. Response rate was the primary endpoint of this study. Considering eligible patients (n=40), 18 responses (1 complete and 17 partial responses) were observed (response rate 45%; 95% Confidence interval (CI): 29.3%-61.5%). In stage IIIA-N2 NSCLC patients, docetaxel-cisplatin could be administered and demonstrated manageable toxicity with modest efficacy.

Prognostic relevance of response evaluation using [18F]-2-fluoro-2-deoxy-D-glucose positron emission tomography in patients with locally advanced non-small-cell lung cancer

PURPOSE

The objective of this study was to determine the accuracy of (early) response measurements using [18F]-2-fluoro-2-deoxy-D-glucose positron emission tomography (18FDG PET) with respect to survival of patients with stage IIIA-N2 non-small-cell lung cancer (NSCLC) undergoing induction chemotherapy (IC), with a comparative analysis of PET methods.

PATIENTS AND METHODS

In a prospective multicenter study, PET was performed in patients before IC and after one and three cycles. Computed tomography (CT) was performed before and after IC. Glucose consumption (metabolic rate of glucose [MRglu]) was measured using Patlak graphical analysis and correlated with simplified methods. Mediastinal lymph node (MLN) status was assessed visually. Cox proportional hazards analysis was used to determine the prognostic relevance of CT and PET measures of response with respect to survival.

RESULTS

Complete PET data sets were available in 47 patients. Median survival was 21 months. MLN status after IC by PET predicted survival (hazard ratio [HR], 2.33; 95% CI, 1.04 to 5.22; P = .04) in contrast with CT (HR, 1.87; 95% CI, 0.81 to 4.30; P = .14). Residual MRglu after IC proved to be the best prognostic factor (HR, 1.95; 95% CI, 1.28 to 2.97; P = .002). Multivariate stepwise analysis showed that PET identified prognostically different strata in patients considered responsive according to CT. Residual MRglu after one cycle selected patients with different outcomes (HR, 2.04; 95% CI, 1.18 to 3.52; P = .01). Simplified quantitative 18FDG PET methods were correlated with Patlak graphical analysis during and after therapy (r > or = 0.90).

CONCLUSION

18FDG PET has additional value over CT in monitoring response to IC in patients with stage IIIA-N2 NSCLC, and it seems feasible to predict survival early during IC. Simple semiquantitative and complex PET methods perform equally well.

Selective reporting biases in cancer prognostic factor studies

BACKGROUND

Nonreported and selectively reported information and the use of different definitions may introduce biases in the literature of prognostic factors. We probed these biases in a meta-analysis of a prognostic factor for head and neck squamous cell cancer (HNSCC) mortality that has drawn wide attention--the status of the tumor suppressor protein TP53.

METHODS

We compared results of meta-analyses that included published data plus unpublished data retrieved from investigators; published data; and only published data indexed with "survival" or "mortality" in MEDLINE/EMBASE, with or without standardized definitions. We also evaluated whether previously published meta-analyses on mortality predictors for various malignancies addressed issues of retrieval and standardized information. All statistical tests were two-sided.

RESULTS

For the 18 studies with 1364 patients that included published and indexed data, we obtained a highly statistically significant association between TP53 status and mortality. When we used the definitions preferred by each publication, the association was stronger (risk ratio [RR] = 1.38, 95% confidence interval [CI] = 1.13 to 1.67; P = .001) than when we standardized definitions (RR = 1.27, 95% CI = 1.06 to 1.53; P = .011). The addition of 13 studies with 1028 subjects that included published but not indexed data reduced the observed association (RR = 1.23, 95% CI = 1.03 to 1.47; P = .02). Finally, when we obtained data from investigators (11 studies with 996 patients) and analyzed it with all other data, statistical significance was lost (RR = 1.16, 95% CI = 0.99 to 1.35; P = .06). Among 18 published meta-analyses of 37 cancer prognostic factors, 13 (72%) did not use standardized definitions and 16 (89%) did not retrieve additional information.

CONCLUSIONS

Selective reporting may spuriously inflate the importance of postulated prognostic factors for various malignancies. We recommend that meta-analyses thereof should maximize retrieval of information and standardize definitions.

Prognostic Significance of Reversion-Inducing Cysteine-Rich Protein With Kazal Motifs Expression in Resected Pathologic Stage IIIA N2 Non–Small-Cell Lung Cancer

BACKGROUND

Reversion-inducing cysteine-rich protein with Kazal motifs (RECK) is a novel membrane-anchored matrix metalloproteinase inhibitor, and experimental studies have shown that RECK can suppress tumor progression through angiogenesis inhibition. We have already revealed that enhanced RECK expression is significantly correlated with a favorable prognosis in non-small-cell lung cancer (NSCLC). In this study, further analyses focused on pN2 disease were conducted to assess the clinical significance of RECK expression.

METHODS

A total of 118 patients with completely resected pathologic stage IIIA N2 NSCLC were retrospectively examined. RECK expression in the primary tumor, along with involved N2 nodes, was examined immunohistochemically.

RESULTS

RECK expression in the primary tumor was strong in 53 patients (44.9%) and was weak in the other 65 patients. The 5-year survival rate of patients with RECK-strong tumor (42.9%) was significantly higher than that of patients with RECK-weak tumor (23.1%; P = .017). Reduced RECK expression significantly correlated with a poor prognosis for patients with a single N2 node involved (P = .019), but not for patients with multiple N2 nodes involved (P = .440). A multivariate analysis confirmed that reduced RECK expression was an independent and significant factor to predict a poor prognosis (P = .031). RECK expression in involved N2 nodes was significantly higher than in primary tumors (P < .001).

CONCLUSIONS

RECK status was a novel prognostic factor in pathologic stage IIIA N2 NSCLC.

Long-term survival of surgically staged IIIA-N2 non-small-cell lung cancer treated with surgical combined modality approach: analysis of a 7-year prospective experience

BACKGROUND

The aim of this study was to analyse the outcome of surgically staged IIIA-N2 non-small-cell lung cancer (NSCLC) treated with induction chemotherapy followed by surgical exploration.

METHODS

Univariate and multivariate analyses were carried out on a prospective cohort of 131 mediastinoscopy-proven IIIA-N2 NSCLC patients. Three preoperative cycles of vindesine-ifosfamide-cisplatin (VIP) were given. Patients with at least stable disease (SD) were considered for surgery, or radical radiotherapy in selected cases.

RESULTS

The response rate after VIP was 54% (95% confidence interval 45% to 63%) and was important for the final outcome. The median and 5-year survival for the total group were 24 months and 21% (38 months and 30% in responders), respectively. Involvement of subcarinal nodes at diagnosis was the most important prognostic factor (P=0.022). Seventy-five patients were considered for surgery. Downstaging occurred in 34 of 70 resection specimens, with a pathological complete response in six. Median and 5-year survival in the surgical cohort were 45 months and 35%, respectively. Surgery was rewarding both in patients with a response and in those with SD, although the complete resection rate was significantly lower in the latter. On multivariate analysis, favourable prognostic factors were low pathological T-stage (P=0.001) and downstaging of mediastinal nodes in the resection specimen (P=0.008).

CONCLUSIONS

VIP induction chemotherapy followed by surgical exploration was rewarding in mediastinoscopy-proven stage IIIA-N2 NSCLC, both in cases of response and SD, despite a lower complete resection rate in the latter. Patients with subcarinal nodes at diagnosis (5-year survival 8.5%) or without nodal downstaging at post-induction surgery (13.7%) might preferably be treated with a non-surgical approach.

Prolonged survival in patients with resected non-small cell lung cancer and single-level N2 disease

OBJECTIVES

To test the hypothesis that patients with non-small cell lung cancer and single-level N2 metastases constitute a favorable subgroup of patients with mediastinal metastases, we analyzed the results of the Eastern Cooperative Oncology Group 3590 (a randomized prospective trial of adjuvant therapy in patients with resected stages II and IIIa non-small cell lung cancer) by site of primary tumor and pattern of lymph node metastases.

METHODS

Accurate staging was ensured by mandating either systematic sampling or complete dissection of the ipsilateral mediastinal lymph nodes. The overall survival of patients with left lung non-small cell lung cancer and metastases in only 1 of lymph node levels 5, 6, or 7 and right lung non-small cell lung cancer with metastases in only 1 of levels 4 or 7 was compared with that of patients with N1 disease originating in the same lobe.

RESULTS

The median survival of the 172 patients with single-level N2 disease was 35 months (95% confidence interval: 27-40 months) versus 65 months (95% confidence interval: 45-84 months) for the 150 patients with N1 disease (median follow-up 84 months, P =.01). However, among patients with left upper lobe tumors, survival was not significantly different between patients with N1 disease and patients with single-level N2 disease (49 vs 51 months, P =.63). The median survival of the 71 patients with single-level N2 metastases without concomitant N1 disease (skip metastases) was 59 months (95% confidence interval: 36-107 months) versus 26 months (95% confidence interval: 16-36 months) for the 145 patients with both N1 and N2 metastases (P =.001).

CONCLUSIONS

Survival of patients with left upper lobe non-small cell lung cancer and metastases to single-level N2 lymph nodes is not significantly different from that of patients with N1 disease. The presence of isolate N2 skip metastases is associated with improved survival when compared with patients with both N1 and N2 disease. Survival should be reported by the lobe of primary tumor and metastatic pattern to guide future clinical trial development, treatment strategies, and revisions of the TNM staging system.

Immunohistochemical expression of integrins and extracellular matrix proteins in non-small cell lung cancer: correlation with lymph node metastasis

PURPOSE

For patients with non-small cell lung cancer (NSCLC), the biggest threat to survival is metastasis. During metastatic cascade, tumor cells interact with extracellular matrix (ECM) through certain adhesion molecules such as integrins. The aim of this study was to analyze the distribution of the main integrins and ECM in a series of patients with NSCLC to assess their distribution and correlate with lymph node (LN) metastasis of NSCLC.

METHODS

Formalin-fixed and paraffin-embedded tissues of NSCLC with (n=45) or without (n=23) regional LN metastasis were obtained form 68 surgically treated patients. The expression of fibronectin, collagen type IV, tenascin and the integrin subunits (alpha2, alpha3, alpha4, alpha5 and beta1) was studied by immunohistochemistry. Chi-square and Fisher's exact tests were used to compare groups and parameters.

RESULTS

Extensive (>50% of section area) fibronectin and collagen type IV staining were seen in 22 and 55% of tumors, respectively, with focal areas of immunoreactivity seen in another 75 and 38% of tumors, respectively. Tenascin staining showed just focal areas of immunoreactivity in 21% of tumors. Interstitial collagen matrices were more frequently lost in LN metastasis (P=0.007). Integrins alpha2, alpha5 and beta1 expressions were present in 9, 12 and 26% of tumors, respectively. The expression of integrins alpha5 and beta1 was significantly associated with LN metastasis (P=0.04 and 0.005, respectively).

CONCLUSIONS

Increased expression of integrins alpha5 and beta1, and lost expression of collagen matrices significantly correlated with LN metastasis of NSCLC. These findings suggested that enhanced expression of integrins and disrupted collagen stroma in NSCLC might promote tumor cell survival and invasiveness.

Implications of microscopic satellites of the primary and extracapsular lymph node spread in patients with high-risk melanoma: pathologic corollary of Eastern Cooperative Oncology Group Trial E1690

PURPOSE

To correlate the presence of extracapsular spread (ECS) of regional nodal metastases, and micrometastasis near the primary tumor, with disease outcome in the intergroup study E1690 in relation to the impact of recombinant interferon-alfa (rIFN alpha)-2b.

PATIENTS AND METHODS

E1690 included 642 patients with American Joint Committee on Cancer stage IIB or III cutaneous melanoma. Patients were randomized into high- and low-dose rIFN alpha-2b treatment arms and an observation arm. Pathologic slides were reviewed for selected parameters from at least half of the subjects in all three arms. Evaluation of the primary tumor included notations regarding ulceration, mitotic activity, thickness, microscopic satellites (MS), and nodal ECS on a standardized pathology form. These data were collated in relation to relapse-free survival (RFS) and overall survival (OS) at 50 months' follow-up and studied using Cox regression analysis.

RESULTS

Ulceration, mitotic activity, thickness, and size of tumor-bearing lymph nodes did not show a statistically significant correlation with either OS or RFS across all treatment arms. The presence of MS was correlated with RFS (P =.0008) and OS (P =.05). ECS correlated with RFS (hazard ratio = 1.44, P =.032) but not OS (P =.11).

CONCLUSION

The presence of MS (in 6% [18 of 308 patients]) had a significant adverse impact on both RFS (P =.0008) and OS (P =.053). Ulceration, mitotic activity, thickness, and number of positive lymph nodes had no significant effect on OS in this subset study (univariate or multivariate Cox analysis). The presence of ECS in lymph nodes had a significant adverse effect on RFS (P =.032) but not on OS.

A randomized trial of systematic nodal dissection in resectable non-small cell lung cancer

PURPOSE

We conducted a randomized trial to investigate whether systematic nodal dissection (SND) is superior to mediastinal lymph nodal sampling (MLS) in surgical treatment of non-small cell lung cancer (NSCLC).

METHODS

The patients resectable clinical Stage I-IIIA NSCLC were randomly assigned to lung resection combined with SND or lung resection combined with MLS. After postoperative pathological re-staging, eligible cases were followed up until 30 November 2000. The Kaplan-Meier method was used for survival analysis. COX proportional hazards model was used for prognostic analysis.

RESULTS

Of the 532 patients who were enrolled in the study, 268 patients were assigned to lung resection combined with SND and 264 were assigned to lung resection combined with MLS. After surgical restaging only 471 cases were eligible for follow-up. The median survival was 59 months in the group given SND and 34 months in the group given MLS (P=0.0000 by the log rank test). There was significant difference in survival in Stage I (5-year survival 82.16 vs. 57.49%) and Stage IIIA (26.98 vs. 6.18%) by the log rank test and Breslow test. There was no significant yet marginal difference in survival by log rank test (10-year survival 32.04 vs. 26.92%, P=0.0523) but significant difference in survival by Breslow test (5-year survival 50.42 vs. 34.05%, P=0.0284) in Stage II. Types of mediastinal lymph node dissection, pTNM stage, tumor size and number of lymph node metastasis were four factors that influenced long-term survival rate by multivariate analysis.

CONCLUSIONS

As compared with MLS, lobectomy (pneumonectomy) combined with SND can improve survival in resectable NSCLC.

Building a better therapy for stage IIIA non-small cell lung cancer

What do clinicians know about stage IIIA lung cancer? They know accurate staging is critical and requires wide application of mediastinoscopy. They know that surgery and radiation alone each can cure a small subset of patients, and complete resection is of the utmost importance in surgically treated patients. They know that chemotherapy can increase the number of patients cured when combined with definitive radiation, and concurrent chemoradiotherapy seems superior to sequential. Neoadjuvant chemotherapy also seems to cure more patients than surgery alone, but more data are necessary. Trimodality therapy remains a promising but unproved approach in patients with stage IIIA disease. With the exciting new molecularly targeted agents, trials examining quad-modality therapy are just around the corner.

Gross tumor volume, critical prognostic factor in patients treated with three-dimensional conformal radiation therapy for non-small-cell lung carcinoma

PURPOSE

Three-dimensional conformal radiation therapy (3D-CRT) has recently become widely available with applications for patients with non-small-cell lung cancer (NSCLC). These techniques represent a significant advance in the delivery of radiotherapy, including improved ability to delineate target contours, choose beam angles, and determine dose distributions more accurately than were previously available. The purpose of this study is to identify prognostic factors in a population of NSCLC patients treated with definitive 3D-CRT.

METHODS AND MATERIALS

Between March 1991 and December 1998, 207 patients with inoperable NSCLC were treated with definitive 3D-CRT. Tumor targets were contoured in multiple sections from a treatment planning computed tomography (CT) scan. Three-dimensional treatment volumes and normal structures were reconstructed. Doses to the International Commission on Radiation Units and Measurements (ICRU) reference point ranged from 60 to 83.85 Gy with a median dose of 70 Gy. The median dose inhomogeneity was +/- 5% across planning target volume. Outcome was analyzed by prognostic factors for NSCLC including pretreatment patient and tumor-related factors (age, gender, race, histology, clinical stage, tumor [T] stage, and node [N] stage), parameters from our 3D-CRT system (gross tumor volume [GTV] in cm3), irradiation dose prescribed to isocenter, volume of normal lung exceeding 20 Gy (V20), and treatment with or without chemotherapy. The median follow-up time was 24 months (range, 7.5 months to 7.5 years).

RESULTS

One and two-year overall survival rates for the entire group were 59% and 41%, respectively. Overall survival, cause-specific survival, and local tumor control were most highly correlated with the GTV in cm3. On multivariate analysis the independent variable most predictive of survival was the GTV. Traditional staging such as T, N, and overall clinical staging were not independent prognostic factors. Patients receiving ICRU reference doses > or =70 Gy had better local control and cause-specific survivals than those treated with lower doses (p = 0.05). Increased irradiation dose did not improve overall survival.

CONCLUSIONS

GTV as determined by CT and 3D-CRT planning is highly prognostic for overall and cause-specific survival and local tumor control and may be important in stratification of patients in prospective therapy trials. T, N, and overall stage were not independent prognostic factors in this population of patients treated nonsurgically. The value of dose escalation beyond 70 Gy should be tested prospectively by clinical trial.

Overall survival and local recurrence of 406 completely resected stage IIIa-N2 non-small cell lung cancer patients: questionnaire survey of the Japan Clinical Oncology Group to plan for clinical trials

BACKGROUND

the group of completely resected stage IIIA-N2 non-small cell lung cancer patients (NSCLC) is considered to be heterogeneous in various aspects including survival and the recurrent pattern. In the present study, we attempted to clarify the factors which separate these patients into high and low risk groups based on the survival and local recurrence.

METHODS

a questionnaire survey on the survival and local recurrence of non-small cell lung cancer patients with pathological stage IIIA-N2 disease who underwent a complete resection from January 1992 to December 1993 was performed by the Japan Clinical Oncology Group as of July 1999. The information on the survival of 406 patients and that of local recurrence in 332 of them was available.

RESULTS

the 5-year survival of the 406 patients was 31.0%. In a univariate analysis, the age, clinical and pathological T status, number of N2 stations, pathological N1 disease, operative modality and postoperative radiotherapy were all found to be important prognostic factors. Clinical N2 disease marginally influenced the survival (P=0.07). In a multivariate analysis of these variables including clinical N2 disease, the survival was significantly worse in the case of multiple N2 stations (hazard ratio=1.741), the presence of pathological N1 disease (1.403), pathological T2 or 3 disease (1.399) and an age older than 65 (1.327). The rate of freedom from any local recurrence at the bronchial stump, or in the hilar, mediastinal or supraclavicular lymph nodes at 5 years was 64%. In a univariate analysis of the freedom from local recurrence, the clinical N status, pathological T status, pathological N1 disease and number of N2 stations were all found to be important prognostic factors. A multivariate analysis revealed the freedom from local recurrence to be adversely influenced by multiple N2 stations (hazard ratio=2.05), and the presence of either clinical N1 or 2 (1.733) disease. The 5-year survival and the rate of freedom from local recurrence at 5 years were 43 and 75% in patients with a single N2 station and 17 and 48% in those with multiple N2 stations, respectively.

CONCLUSIONS

the number of N2 stations (single vs. multiple N2 stations) was found to be a useful prognostic factor, which can separate completely resected stage IIIA-N2 patients into high and low risk groups regarding both the overall survival and local recurrence.

Lung cancer in patients under 50 years old

PURPOSE

The community based lung cancer registry was set up and the results were analysed to assess the differences in clinicopathological parameters and survival between patients under and over 50 years of age.

PATIENTS AND METHODS

The Pulmonary Outpatient Clinics supplied the data on 5404 lung cancer patients diagnosed in Poland in 1995. Data regarding demographic, smoking, histology, clinical stage, performance status, family history of cancer, therapy and survival were obtained.

RESULTS

At time of diagnosis 757 (14%) patients were under 50 years of age. In this group the frequency of females was higher as compared to this in the group of older patients (24.2% vs. 12.1%; P<0.001). Also the incidence of adenocarcinoma (12.6% vs. 7.6%; P<0.001) and small cell lung cancer (22.9% vs. 14.8%; P<0.001) were significantly higher in younger patients. Young patients had better performance status (55.4% vs. 46.6%; P<0.001) than old. The incidence of cancer in families of younger patients was higher both among the mothers (4.7% vs. 3.0%; P<0.001) and among the fathers (7.6% vs. 4.1%, P<0.001). Surgery or chemotherapy were more often applied to patients under 50 years in comparison to older ones (P<0.001). Young patients had better prognosis. Higher percentage of them survived one year (32.6% vs. 28.9%; P<0.049). In multivariate analysis, age over 50 at diagnosis, male gender, diagnosis of small cell lung cancer, advanced stage of the disease, bad performance status, and non-surgical therapy were independent negative prognostic factors.

CONCLUSION

Among young patients, overrepresentation of women, subjects with positive family history of cancer, with better performance status, with adenocarcinoma and small cell lung cancer were noticed. Young patients were treated more aggressively and had better prognosis than patients over 50 years of age.

Cost-effectiveness associated with the diagnosis and staging of non-small-cell lung cancer

OBJECTIVE

We evaluated how much time and money could be saved without compromising overall results in treating lung cancer.

SUBJECTS AND METHODS

We retrospectively evaluated 318 patients for T- and M-factors and 335 for N-factor. If bronchoscopy failed to diagnose a mass lesion believed to be malignant in x-ray computed tomography (CT), we proceeded to direct thoracotomy without needle or video-assisted biopsy. When mediastinal nodes were negative in CT, we proceeded to direct thoracotomy without mediastinoscopy. We searched routinely for distant metastasis with brain and abdominal CTs and bone scans.

RESULTS

Lesions suspected of malignancy in CT were pathologically malignant in 93%. A total of 82.8% of patients with CT-negative mediastinum were without metastasis. The remainder, with metastasis, had a postoperative 5-year survival of 23.5%. Brain CT scans were positive in only 2.2%, abdominal CT scans in 2.4%, and bone scans in 5.0%, for patients with a cT1/T2 non-cN2 lesion.

CONCLUSION

Brain and abdominal CT scans and bone scans may be omitted for cT1/T2 and non-cN2 lesions in CT. CT-negative mediastinum then leads to direct thoracotomy. The vast majority of patients may thus undergo surgery earlier with less physical and financial burden. The cost saving was calculated to be 59.4% per cT1/T2 non-cN2 patient, or US$666,815, for population evaluated based on cost-effectiveness.

Assessing the prognostic value of the extent of mediastinal lymph node infiltration in surgically-treated non-small cell lung cancer (NSCLC)

Although there have been several attempts in dividing N2 patients into several subgroups on the basis of different prognoses, the correct treatment for these patients is still a moot point. Even multimodal treatment, which is the most common therapy used, does not result in a consistent outcome. The aim of our study is to assess the prognostic value of the extent of mediastinal lymph node infiltration in surgically treated non-small cell lung cancer (NSCLC). From January 1990 to December 1997, 682 patients underwent surgery for NSCLC at the Thoracic Surgery Unit, University Hospital of Siena, 87 of which (12%) had mediastinal involvement. Studies on the number of lymph node stations show that those with one station involved tend to have a better 5-year survival rate with respect to the others. We studied the number of lymph node stations by using a new critique based on the percentage of lymph node infiltration. The percentage is obtained from a ratio of the number of involved nodes to the total number of nodes removed. The result was an improved 5-year survival ratio in patients with lymph node infiltration, lower than 50% with respect to the others, and the difference was significant (P=0.0001). It appears that surgery may be the most suitable option for treating those N2 patients that we consider to be in 'early N2 phase', in view of long term survival. Although an invasive technique like mediastinoscopy seems to be the appropriate indicator in selecting N2 patients, it does not allow the calculation of the ratio a priori.

Survival of patients with resected N2 non-small-cell lung cancer: evidence for a subclassification and implications

PURPOSE

Patients who suffer from non-small-cell lung cancer (NSCLC) with ipsilateral mediastinal lymph node involvement (N2) belong to a heterogeneous subgroup of patients. We analyzed the prognosis of patients with resected N2 NSCLC to propose homogeneous patient subgroups.

PATIENTS AND METHODS

The present study comprised 702 consecutive patients from six French centers who underwent surgical resection of N2 NSCLC. Initially, two groups of patients were defined: patients with clinical N2 (cN2) and those with minimal N2 (mN2) disease were patients in whom N2 disease was and was not detected preoperatively at computed tomographic scan, respectively.

RESULTS

The median duration of follow-up was 52 months (range, 18 to 120 months). A multivariate analysis using Cox regression identified four negative prognostic factors, namely, cN2 status (P <. 0001), involvement of multiple lymph node levels (L2+; P <.0001), pT3 to T4 stage (P <.0001), and no preoperative chemotherapy (P <. 01). For patients treated with primary surgery, 5-year survival rates were as follows: mN2, one level involved (mN2L1, n = 244): 34%; mN2, multiple level involvement (mN2L2+, n = 78): 11%; cN2L1 (n = 118): 8%; and cN2L2+ (n = 122): 3%. When only patients with mN2L1 disease were considered, the site of lymph node involvement according to the American Thoracic Society numbering system had no prognostic significance (P =.14). Preoperative chemotherapy was associated with a better prognosis for those with cN2 (P <.0001). Five-year survival rates were 18% and 5% for cN2 patients treated with and without preoperative chemotherapy, respectively.

CONCLUSION

This study has identified homogeneous N2 NSCLC prognostic subgroups and suggests different therapeutic approaches according to the subgroup profile.

Docetaxel (Taxotere) in the neo-adjuvant setting in non-small-cell lung cancer

BACKGROUND

There is a potential for neo-adjuvant chemotherapy to provide significant benefit in outcome for patients with locally advanced non-small-cell lung cancer (NSCLC). Patients with N2/T3 NSCLC have a poor prognosis when treated by surgery alone since micrometastases result in relapse in the majority of cases. The same is true of patients with N3/T4 disease treated only with radiotherapy. Systemic therapy is therefore required, and cisplatin-based induction chemotherapy prior to surgery or radiotherapy has been shown to improve survival when compared with surgery or radiotherapy alone. Docetaxel has been shown to have significant activity in stage IV NSCLC and ongoing phase III trials are comparing single agent docetaxel or doceatxel in combination with cisplatin or VP16 before local treatment to local treatment alone.

DESIGN

Patients with locally-advanced (stage IIIa or IIIb) NSCLC receive three cycles of docetaxel (100 mg/m2) followed by appropriate local therapy, or local therapy alone. Local therapy for stage IIIa patients is surgery (with or without radiotherapy depending on completeness of resection) and for stage IIIb patients curative intent radiotherapy. In another on-going study in stage IIIa NSCLC, docetaxel (75 mg/m2) is given in combination with cisplatin (40 mg/m2) followed by surgery. Patients must have histologically or cytologically confirmed NSCLC, have received no prior treatment for the disease and are suitable to undergo surgery or radical radiotherapy, as appropriate.

RESULTS

Initial results from the phase III comparative study show that single agent docetaxel in the neo-adjuvant setting is effective and associated with acceptable toxicity. Two hundred of the planned two hundred ninety-two patients have been accrued to the single-agent docetaxel neo-adjuvant study. In the first 49 evaluable patients in the docetaxel arm, 1 CR and 18 PR have been achieved (response rate 39%) and no patients receiving docetaxel neo-adjuvant therapy have progressed. All patients were able to receive the full doses of docetaxel.

CONCLUSION

The details of time-to-progression and survival in this study will eventually confirm the results from recent small trials of neo-adjuvant chemotherapy in locally-advanced NSCLC.

The impact of surgical adjuvant thoracic radiation for different stages of non-small cell lung cancer: the experience from a single institution

A retrospective analysis is performed of 223 patients receiving radiotherapy after complete surgery or microscopic-positive resection margins for non-small cell lung cancer. All patients received a total dose of 55 Gy. For 98 stage II (T1, T2N1), a 5-year survival rate of 37% was found. First failure analysis showed 15% (15/98) local and 39% (38/98) distant failures. Patients with hilar-positive lymph nodes had a 5-year survival rate of 32%, compared with 41% for lobar-positive nodes due to more distant failures. Patients with squamous histology had a better survival than non-squamous tumours. There were 48 patients with pN2 tumours. First failure analysis gave 23% (11/48) local and 39.5% (19/48) distant failures resulting in 35% 5-year survival. Patients with pT3N0 with microscopic-positive resection margins and pT3N1 tumours had 5-year survival rates of 21.5 and 17%. Postoperative radiotherapy should be advised in cases of positive hilar nodes, and in all cases of mediastinal-positive nodes. A combination schedule with chemotherapy seems necessary.