The role of surgery in N2 lung cancer

Enduring challenge in the treatment of nonsmall cell lung cancer with clinical stage IIIB: results of a trimodality approach

BACKGROUND

Stage IIIb (T4/N3) non-small-cell lung cancer (NSCLC) is considered an inoperable disease and treatment is an enduring challenge. Surgery after induction therapy seems to improve locoregional control. We report the results of a phase II prospective trimodality trial (chemotherapy and concomitant radiotherapy plus surgery) in patients with stage IIIb NSCLC.

METHODS

From November 1992 to June 2000, 39 patients (37 men and 2 women, mean age 65 years) with clinical stage IIIb (34 T4N0 to 2, 4 T2 to 3N3, 1 T4N3, excluding T4 for malignant pleural effusion) entered the study. They received intravenous infusions of cisplatin 20 mg/m(2) and 5-fluorouracil 1,000 mg/m(2) (days 1 to 4 and 25 to 28) combined with a total dose of 50.4 Gy radiotherapy delivered over 4 weeks (1.8 Gy daily). Upon clinical restaging responders underwent surgery.

RESULTS

All patients were available for clinical restaging. No complete response was observed. Twenty-one patients had partial response (53.8%), 16 had stable disease (41%), and 2 had progressive disease (5.2%). Hematologic toxicity was moderate. Twenty-two patients (56.4%), 21 with partial response and 1 with stable disease, underwent surgery with no perioperative death. A radical resection was possible in 21 cases. Nine lobectomies, 3 bilobectomies, and 9 pneumonectomies were performed. Complications occurred in 5 patients (23.6%). Fourteen of the patients who underwent surgery (66.6%) showed a pathologic downstaging. A complete pathologic response was obtained in 9 cases (49%). Overall 5-year survival (Kaplan-Meier) was 23%. Resected versus non-resected patients showed a significant difference: 38% versus 5.6% (p = 0.028, log rank).

CONCLUSIONS

This trimodal approach for stage IIIb NSCLC appears safe and effective. It provides good therapeutic results with acceptable morbidity in surgical cases.

Potential for reduced toxicity and dose escalation in the treatment of inoperable non-small-cell lung cancer: a comparison of intensity-modulated radiation therapy (IMRT), 3D conformal radiation, and elective nodal irradiation

PURPOSE

To systematically evaluate four different techniques of radiation therapy (RT) used to treat non-small-cell lung cancer and to determine their efficacy in meeting multiple normal-tissue constraints while maximizing tumor coverage and achieving dose escalation.

METHODS AND MATERIALS

Treatment planning was performed for 18 patients with Stage I to IIIB inoperable non-small-cell lung cancer using four different RT techniques to treat the primary lung tumor +/- the hilar/mediastinal lymph nodes: (1) Intensity-modulated radiation therapy (IMRT), (2) Optimized three-dimensional conformal RT (3D-CRT) using multiple beam angles, (3) Limited 3D-CRT using only 2 to 3 beams, and (4) Traditional RT using elective nodal irradiation (ENI) to treat the mediastinum. All patients underwent virtual simulation, including a CT scan and (18)fluorodeoxyglucose positron emission tomography scan, fused to the CT to create a composite tumor volume. For IMRT and 3D-CRT, the target included the primary tumor and regional nodes either > or =1.0 cm in short-axis dimension on CT or with increased uptake on PET. For ENI, the target included the primary tumor plus the ipsilateral hilum and mediastinum from the inferior head of the clavicle to at least 5.0 cm below the carina. The goal was to deliver 70 Gy to > or =99% of the planning target volume (PTV) in 35 daily fractions (46 Gy to electively treated mediastinum) while meeting multiple normal-tissue dose constraints. Heterogeneity correction was applied to all dose calculations (maximum allowable heterogeneity within PTV 30%). Pulmonary and esophageal constraints were as follows: lung V(20) < or =25%, mean lung dose < or =15 Gy, esophagus V(50) < or =25%, mean esophageal dose < or =25 Gy. At the completion of all planning, the four techniques were contrasted for their ability to achieve the set dose constraints and deliver tumoricidal RT doses.

RESULTS

Requiring a minimum dose of 70 Gy within the PTV, we found that IMRT was associated with a greater degree of heterogeneity within the target and, correspondingly, higher mean doses and tumor control probabilities (TCPs), 7%-8% greater than 3D-CRT and 14%-16% greater than ENI. Comparing the treatment techniques in this manner, we found only minor differences between 3D-CRT and IMRT, but clearly greater risks of pulmonary and esophageal toxicity with ENI. The mean lung V(20) was 36% with ENI vs. 23%-25% with the three other techniques, whereas the average mean lung dose was approximately 21.5 Gy (ENI) vs. 15.5 Gy (others). Similarly, the mean esophagus V(50) was doubled with ENI, to 34% rather than 15%-18%. To account for differences in heterogeneity, we also compared the techniques giving each plan a tumor control probability equivalent to that of the optimized 3D-CRT plan delivering 70 Gy. Using this method, IMRT and 3D-CRT offered similar results in node-negative cases (mean lung and esophageal normal-tissue complication probability [NTCP] of approximately 10% and 2%-7%, respectively), but ENI was distinctly worse (mean NTCPs of 29% and 20%). In node-positive cases, however, IMRT reduced the lung V(20) and mean dose by approximately 15% and lung NTCP by 30%, compared to 3D-CRT. Compared to ENI, the reductions were 50% and >100%. Again, for node-positive cases, especially where the gross tumor volume was close to the esophagus, IMRT reduced the mean esophagus V(50) by 40% (vs. 3D-CRT) to 145% (vs. ENI). The esophageal NTCP was at least doubled converting from IMRT to 3D-CRT and tripled converting from IMRT to ENI. Finally, the total number of fractions for each plan was increased or decreased until all outlined normal-tissue constraints were reached/satisfied. While meeting all constraints, IMRT or 3D-CRT increased the deliverable dose in node-negative patients by >200% over ENI. In node-positive patients, IMRT increased the deliverable dose 25%-30% over 3D-CRT and 130%-140% over ENI. The use of 3D-CRT without IMRT increased the deliverable RT dose >80% over ENI. Using a limited number of 3D-CRT beams decreased the lung V(20), mean dose, and NTCP in node-positive patients.

CONCLUSION

The use of 3D-CRT, particul mean dose, and NTCP in node-positive patients. The use of 3D-CRT, particularly with only 3 to 4 beam angles, has the ability to reduce normal-tissue toxicity, but has limited potential for dose escalation beyond the current standard in node-positive patients. IMRT is of limited additional value (compared to 3D-CRT) in node-negative cases, but is beneficial in node-positive cases and in cases with target volumes close to the esophagus. When meeting all normal-tissue constraints in node-positive patients, IMRT can deliver RT doses 25%-30% greater than 3D-CRT and 130%-140% greater than ENI. Whereas the possibility of dose escalation is severely limited with ENI, the potential for pulmonary and esophageal toxicity is clearly increased.

Operative results of clinical stage I non-small cell lung cancer

BACKGROUND

Clinical stage (c-stage) I non-small cell lung cancer (NSCLC) is generally indicated for surgery, however, surgical exploration sometimes reveals advanced disease, thus resulting in incomplete resection.

PATIENTS AND METHODS

A total of 645 consecutive patients were investigated in which 347 were diagnosed to have c-stage IA in 347 and 298 were diagnosed to have IB disease. All cases underwent operation and were investigated for resectability and the cause of an incomplete resection.

RESULTS

The c-Stage IA patients included 16.6% of T3/4 and 10.4% of N2 whereas clinical stage IB patients included 14.4% of T3/4 and 18.8% of N2/3. A complete resection was performed in 594 patients (91%). In 347 c-stage IA patients, the complete resection rates were 93% in adenocarcinomas (235/252), 100% in squamous cell carcinomas (76/76), and 89% in others (17/19). In 298 c-stage IB patients, the complete resection rates were 86% in adenocarcinomas (141/164), 90% in squamous cell carcinomas (90/100), and 94% in others (31/33). The 5-year survival rates of the c-stage IA and IB patients who underwent a complete resection were 66.4 and 48.3%, respectively. However, the same rates were 18.4 and 14.7% for c-stage IA and IB patients who underwent an incomplete resection. The reasons for an incomplete resection in 54 patients were malignant pleurisy in 38 (70.4%), extranodal invasion of mediastinal nodal metastasis in ten (19%), an incomplete bronchial margin in three (5.6%), and ipsilateral pulmonary metastases in two (3.7%), and ipsilateral adrenal metastasis in one (1.3%). In 13% of the c-stage IB adenocarcinomas, pleural metastasis was discovered during thoracotomy.

CONCLUSIONS

Pleural dissemination was the most frequent cause of an incomplete resection, and its prevalence was high in c-stage IB adenocarcinomas.

Gemcitabine, paclitaxel, and cisplatin as induction chemotherapy for patients with biopsy-proven Stage IIIA(N2) nonsmall cell lung carcinoma

BACKGROUND

The objective of the current study was to define the activity and tolerability, as well as the influence on resectability, of the combination of gemcitabine, paclitaxel, and cisplatin (GTP) as induction chemotherapy for patients with Stage IIIA(N2) nonsmall cell lung carcinoma (NSCLC).

METHODS

Forty-nine chemotherapy-naïve patients (median age, 61 years; World Health Organization performance status, 0-1) with biopsy-proven Stage IIIA(N2) disease received 1000 mg/m(2) gemcitabine, 125 mg/m(2) paclitaxel, and 50 mg/m(2) cisplatin on Days 1 and 8 of every 3 weeks until reevaluation for surgery or definitive radiotherapy.

RESULTS

Grade 3-4 neutropenia was the most common hematologic toxicity, occurring in 32.7% of patients; however, only 1 case of febrile neutropenia was reported. Grade 3-4 thrombocytopenia occurred in 12.2% of patients but was not associated with bleeding. Severe nonhematologic toxicities were uncommon; the only Grade 4 nonhematologic toxicity was diarrhea, which occurred in 4% of patients. One patient died after the first course of therapy, but this event was found to be unrelated to treatment. Thirty-six patients (73.5%) achieved an objective response, and an additional 4 patients had stable disease with clearance of mediastinal lymph nodes. Overall, 29 patients underwent thoracotomy and 27 (55%) underwent complete resection. Mediastinal nodes were free of tumor in 35% of all cases, and 8 pathologic complete responses (16%) were reported. Median survival was 23 months, with a 1-year survival rate of 85%.

CONCLUSIONS

GTP is highly active as an induction chemotherapy regimen for Stage IIIA(N2) NSCLC and yields good toxicity results. The use of GTP in combination with radiotherapy and new biologic drugs should be explored.

Prognostic significance of bcl-2 expression in resected pN2 non-small cell lung cancer

AIMS

The prognosis of non-small cell lung cancer with pathologic mediastinal lymph node involvement (pN2) is poor, we wished to study the expression of p53, bcl-2 by immunohistochemistry in a series of such patients.

METHODS

Clinicopathologic factors were investigated in relation to prognosis in 60 patients with resected pN2 non-small cell lung cancer.

RESULTS

The 5-year survival rate was 21.7%. Positive staining for p53, and bcl-2 was found in 29/60 and 12/60, respectively. Patients with bcl-2 positive tumor had a more favorable survival than those with bcl-2 negative tumor (P=0.0054). The expression of p53 was not related to patients' survival. Multivariate analysis showed that Bcl-2 expression and single N2 station were independent prognostic factors.

CONCLUSIONS

Patients with bcl-2 positive tumors may comprise a favorable prognostic subgroup in pN2 non-small cell lung cancer.

Independent predictive value of the overall number of metastatic N1 and N2 stations in lung cancer

OBJECTIVE

The number of metastatic N2 stations is a known prognostic factor in patients with non-small-cell lung cancer (NSCLC). However, involvement of N1 stations as well as that of N2 stations seems to be important in the prognosis of these patients. We therefore attempt to clarify the significance of the total number of metastatic stations in pathologic N1 and N2 NSCLCs.

METHODS

Patients with either pathologic N1 (n = 51) or N2 (n = 96) NSCLC who had undergone major pulmonary resection with complete mediastinal dissection were included in this retrospective study. All positive nodes were characterized by location according to the TNM classification system. The hilar station was included with the N2 stations.

RESULTS

The total number of metastatic stations in patients with N2 disease ranged from 1 to 8 (average 2.5), whereas that in patients with N1 disease ranged from 1 to 3 (average 1.2). The incidence of multiple-station metastasis (> or = 3 metastatic stations) among N2 patients (35%) was significantly higher than that among N1 patients (2%) (p < 0.001). Multivariate analysis of survival showed pathologic N1 status (relative risk = 0.443, p = 0.013) and < or = 2 metastatic stations (relative risk = 0.515, p = 0.020) to be significant and independent prognostic factors. Age, sex, cell type, resected lobe, and pathological T status were statistically insignificant determinates of survival.

CONCLUSIONS

The total number of metastatic stations (< or = 2 vs > or = 3) is an independent prognostic indicator in patients with completely resected pathologic N1 or N2 NSCLC. The number of metastatic stations will be useful as a stratification factor in prospective clinical trials of these patients.

The significance of tumour markers as an indication for mediastinoscopy in non-small cell lung cancer

OBJECTIVE

The purpose of this study was to verify the significance of tumour markers as indicators for mediastinoscopy in non-small cell lung cancer.

METHODOLOGY

In the past 4 years, 205 patients with non-small cell lung carcinoma (NSCLC) underwent surgical resection at Chiba Cancer Center, Chiba, Japan. The correlation between the serum levels of eight tumour markers (CEA, AFP, CA19-9, SCC, NSE, CA125, CYFRA, ProGRP) and the presence of N2 disease was analysed. Univariate and multivariate analyses were performed to determine the relationship between both marker levels and clinical findings and N2 disease.

RESULTS

In multivariate analysis, positive CEA was significantly associated with the diagnosis of N2 disease. We also demonstrated that when CA125, CYFRA and ProGRP were positive, they were individually significantly associated with N2 disease. However, CEA was superior to the other markers and equivalent to a combination of various tumour markers.

CONCLUSION

It was concluded that evaluation of CEA in addition to CT is of use in the diagnosis of N2 disease in NSCLC patients and should be used as an indication for mediastinoscopy.

Postsurgical change in the tracheal bifurcation angle after upper lobectomy: radiographic evaluation

RATIONALE AND OBJECTIVES

The purpose of this study was to evaluate postsurgical changes in the tracheal bifurcation angle on chest radiographs after upper lobectomy and to determine whether bronchial repositioning after upper lobectomy mimics that in upper lobe collapse.

MATERIALS AND METHODS

The authors selected 81 patients who had undergone upper lobectomy with complete mediastinal and subcarinal lymph node dissection and in whom chest radiographs had been obtained before operation and at four postoperative intervals. The interbronchial angle and the subcarinal angle were measured on the preoperative and postoperative radiographs and compared statistically.

RESULTS

The average interbronchial angle and subcarinal angle during any postoperative period were significantly smaller than those before lobectomy (P < .001). These average angles decreased gradually during the postoperative periods.

CONCLUSION

The tracheal bifurcation angle was decreased on follow-up chest radiographs in most patients who underwent upper lobectomy with mediastinal lymph node dissection. This finding may be useful for establishing a history of this surgical procedure on the basis of chest radiographs.

Proposta de metodização da linfadenectomia mediastinal na cirurgia do câncer de pulmão

OBJETIVO: Estabelecer uma padronização anatômica da linfadenectomia mediastinal como complementação à cirurgia do câncer de pulmão. MÉTODO: 1 - Foram enviados para vinte e dois cirurgiões torácicos brasileiros, questionários sobre linfadenectomia mediastinal. 2 - Realizou-se extensa revisão bibliográfica sobre a anatomia dos linfáticos do mediastino e descrições das técnicas de dissecação linfática mediastinal. 3 - Procedeu-se à dissecação do mediastino em cinco cadáveres não formolizados. 4 - Estabelecido os limites anatômicos de cada loja linfonodal foram realizadas vinte e sete fotografias de cada uma das referidas lojas antes e após a dissecação. RESULTADOS: Não houve consenso entre os cirurgiões que responderam ao questionário quanto a realização ou não e quanto à forma de realizar a linfadenectomia do mediastino na cirurgia do câncer pulmonar, significando que a técnica merece uma metodização. Movidos por esta necessidade e baseados na análise dos itens 2, 3 e 4 acima relacionados, propusemos uma metodização da linfadenectomia mediastinal de forma objetiva, definindo claramente os limites anatômicos de cada loja ganglionar no mediastino direito e esquerdo e especificando aquelas a serem abordadas de acordo com o sítio primário da lesão no lobo pulmonar. CONCLUSÃO: É possível definir claramente uma metodização técnica de fácil execução da linfadenectomia mediastinal, baseado em critérios anatômicos.

Non-small cell lung cancer staging techniques and endoscopic ultrasound: tissue is still the issue

Non-small cell lung cancer (NSCLC) in the United States will continue to be a major public health issue, particularly as our elderly population grows. As surgery offers the best hope of cure for NSCLC, staging of NSCLC is critical because it directly impacts on the management of lung cancer. Cost, quality of life, safety, and accuracy of various staging methods all influence the clinical outcome. Staging of NSCLC is evolving due to the emergence of new and improved technologies. The objective of this article is to review the current methods used in staging of NSCLC. Currently, positron emission tomography and endoscopic ultrasound (EUS) show promise in identifying patients that may benefit from surgery. Histologic confirmation via EUS-guided fine-needle aspiration, however, may still be necessary to accurately stage the mediastinum.

Changes in hemodynamics in patients who underwent extended mediastinal lymphadenectomy through median sternotomy for primary lung cancer

OBJECTIVES

Extended bilateral mediastinal lymphadenectomy (ND3alpha) through median sternotomy for lung cancer has been reported to show longer survival compared to that after ipsilateral mediastinal lymphadenectomy (ND2a) through posterolateral thoracotomy for node-positive lung cancer. However, a high incidence of morbidity or mortality has also been found. The present prospective study was conducted to clarify the influence of this procedure on the hemodynamics as one of the factors influencing postoperative course.

METHODS

Between December 1999 and January 2001, at the Nippon Medical School Hospital, 10 patients underwent pulmonary resection with ND2a through a posterolateral thoracotomy, while another 10 patients underwent pulmonary resection with ND3alpha through median sternotomy. Changes in the hemodynamics were evaluated preoperatively and at 6, 12, 24 and 48 hours postoperatively.

RESULTS

Those who underwent ND3alpha showed higher peripheral vascular resistance for 24 hours postoperatively resulting from the longer surgery and increased blood loss, than those who underwent ND2a. The pulmonary capillary wedge pressure was elevated in those who underwent ND3alpha comparing to that in those who underwent ND2a. Stroke index decreased in patients who underwent NDalpha comparing to that in those who underwent ND2a. Even though the right ventricular ejection fraction showed minimal change, both the ventricular stroke work indices were depressed at 48 hours postoperatively in patient who underwent ND3alpha.

CONCLUSION

ND3alpha was concluded to have affected the cardiopulmonary circulation, compared to ND2a, and to be more invasive than ND2a. To perform ND3alpha, preoperative patient selection is an important factor to archive the advantage of increased survival by this procedure.

Heterogeneity of stage IIIA non-small cell lung cancers (NSCLC) and evaluation of late results of surgical treatment

AIMS

The aim of the study was assessment of the heterogeneity of stage IIIA non-small cell lung cancers (NSCLC) and the late results of surgical treatment.

METHODS

The study group consisted of 83 consecutive patients discharged between 1988 and 1992 undergoing radical operative treatment for stage IIIA NSCLC. Squamous cell carcinoma was diagnosed in 54 (65.1%) patients, adenocarcinoma in 23 (27.7%), large cell carcinoma in 2 (2.4%) and mixed (i.e. adenoid-squamous type) in 4 (4.8%). In respect of pTNM staging, 19 (22.9%) patients had T3N1M0, 35 (42.2%) had T2N2M0 and 29 (34.9%) had T3N2M0.

RESULTS

Overall, 13.3% of patients with stage IIIA NSCLC survived 5 years following the operation and 8.7% survived 10 years. Analysis of follow-up study indicated that this group was heterogenic. In T3N1M0 group 26.3% survived 5 years following the operation, in T2N2M0 group 14.3%, in T3N2M0 group 3.5% (P = 0.015). Of 23 patients with N2 disease and no metastases in hilar lymph nodes ('skip' metastases), 26.1% survived 5 years, whereas none of 41 patients with metastases spreading by continuity survived (P = 0.0015). If mediastinal lymph node metastases were diagnosed in one level, 25% patients survived 5 years, but if two or more levels were affected, 2.3% only (P = 0.0214): 85.7% of patients with well-differentiated (G1) cancer survived 5 years and 62.0% 10 years, whereas among those with moderately differentiated (G2) tumours, 11.8% and 8.8%, respectively. No patient survived 5 years after resection of poorly differentiated (G3) cancer (P < 0.001).

CONCLUSIONS

(1) Patients operated for stage IIIA NSCLC are a heterogeneous group, which makes it difficult to predict late results. (2) Patients operated for stage IIIA NSCLC have a better prognosis if metastases are discovered in level one mediastinal lymph nodes, particularly in the superior part of mediastinum, or if 'skip' metastases (pulmonary hilus unaffected) are discovered, as compared to those with N2 disease. (3) Poor histologic differentiation of the tumour is a bad prognostic factor.

The management of the patient undergoing combined modality therapy for locally advanced non-small cell lung cancer

Multimodality management of locally advanced non-small cell lung cancer is commonplace. Locally advanced disease is defined as patients with stage IIIA, IIIB (without pleural effusions), and Pancoast tumors. Improvements in the median and landmark survival rates of patients have been accomplished by integration of chemotherapy, radiotherapy, and surgery. Although the optimal sequencing and number of modalities remains to be established, the safe treatment of patients requires cooperation of the specialties (joint clinics and tumor boards). The toxicities of chemoradiotherapy are esophagitis, pneumonitis, and myelosuppression. These complications are a function of the dose and fractionation scheme of radiotherapy and the dose, schedule, and specific chemotherapy agents used. The use of modern techniques, including three-dimensional conformal radiotherapy, limitation of field size, and aggressive treatment of symptoms reduces toxicity and the number of treatment breaks, and allows delivery of planned therapy in many patients. In appropriate patients, surgery may be successful after induction chemotherapy or chemoradiotherapy. In addition to exclusion of medically inappropriate patients, patients with persistent mediastinal adenopathy after induction therapy are not likely to benefit from resection. Therefore, mediastinal sampling must be repeated after chemoradiotherapy and before surgery.

Treatment of stage IIIA non-small cell lung cancer

Stage IIIA non-small cell lung cancer represents a relatively heterogeneous group of patients with metastatic disease to the ipsilateral mediastinal (N2) lymph nodes and also includes T3N1 patients. Presentations of disease range from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky multistation nodal disease. Controversy abounds as to the optimal treatment of the various stage IIIA subsets, which is fueled by a lack of meaningful, large randomized trials. Multimodality therapy of some type appears to be preferable in stage IIIA patients.

Neoadjuvant and adjuvant therapy of non-small cell lung cancer

Though surgery offers the best chance of cure for patients with non-small cell lung cancer (NSCLC), many patients who undergo complete tumor resection will die of recurrent disease. Chemotherapy and radiotherapy have been employed both individually and in combination in an effort to prevent local recurrence and extrathoracic metastatic disease. However, the administration of neoadjuvant or adjuvant therapy remains controversial. Phase II and III trials with traditional radiotherapy schedules and cytotoxic drugs have produced conflicting results. Novel approaches utilizing long-term administration of less toxic drugs and targeted biologic therapies are promising.

[Preoperative chemotherapy and chemoradiotherapy for non-small-cell bronchial cancers]

The very disappointing results obtained by surgery in resectable non-small-cell lung cancer have led to a high active clinical research concerning pre- or postoperative treatment. Preoperative treatment has several distincts goals: to increase survival for patients suitable for surgery, to limit surgery or transform borderline or non resectable cancer into resectable tumors. Available datas on preoperative treatments for non-small-cell lung cancer provide from three types of therapeutics trials: 1/Some phase II studies of neoadjuvant chemotherapy have demonstrated that the neoadjuvant approach was feasible, and didn't compromise surgery. 2/Phase II trials of neoadjuvant chemoradiotherapy, performed for the majority on more extensive cancers, have demonstrated that this approach was also feasible at the expense of higher but still tolerable toxicity. 3/Phase III randomised published trials exclusively deal with preoperative chemotherapy with different results: two of them concerned a small number of patients presenting with non-small-cell lung stage IIIA cancer: they are positive. The third concerned 373 patients presenting with stage I, II, IIIA cancer: the three-year survival was increased by 11%, but this difference is not yet significant. The benefit essentially appeared for stage I and II. One trial comparing preoperative chemotherapy and radiochemotherapy has been reported, concluding to the superiority of the association. These observations suggest that the clinical research should now be different for stages I and II, and stage IIIA.

Use of technetium-99m tin colloid for sentinel lymph node identification in non-small cell lung cancer

BACKGROUND

To test the reliability of sentinel lymph node identification in non-small cell lung cancer, sentinel nodes were localized with a radioactive colloid in patients undergoing surgery.

METHODS

Forty-six patients with non-small cell lung cancer undergoing curative resection with mediastinal lymph node dissection were examined. The day before surgery, technetium-99m ((99m)Tc) tin colloid was injected into the peritumoral region. At operation, the radioactivity of the lymph nodes was counted with a handheld gamma counter before (in vivo) and after (ex vivo) dissection. Lymph nodes with an ex vivo radioactive count more than 10 times the background value were identified as sentinel nodes. The correlation between the in vivo and ex vivo results was examined.

RESULTS

Lymphoscintigraphy revealed that it took longer than 6 hours for sufficient (99m)Tc tin colloid to reach the sentinel nodes. Sentinel nodes could be identified in 40 patients (87%). Patients whose sentinel nodes could not be identified had a significantly lower ratio of forced expiratory volume in 1 second to forced vital capacity than did those with identifiable sentinel nodes (P =.03). No false-negative sentinel nodes were detected in 14 patients with N1 or N2 disease (0%). In the hilar lymph node stations, the lobar lymph nodes were most frequently identified as sentinel nodes (as often as 85% of the time). Fourteen patients (35%) had sentinel nodes in the mediastinum, the distribution of which depended on the lobe. In vivo and ex vivo counting showed 88% concurrence for the identification of sentinel nodes in mediastinal lymph node stations.

CONCLUSION

The identification of sentinel nodes with (99m)Tc tin colloid is a reliable method of establishing the first site of nodal metastasis in non- small cell lung cancer. Sentinel nodes could be hardly identified in patients with a low ratio of forced expiratory volume in 1 second to forced vital capacity because of such conditions as chronic obstructive pulmonary disease. In vivo identification of sentinel nodes in the mediastinum could be useful approach to guide mediastinal lymph node sampling or dissection.

Incidental surgical findings of a phase I trial of weekly gemcitabine and concurrent radiotherapy in patients with unresectable non-small cell lung cancer

OBJECTIVE

to report the surgical facts of unresectable patients with locally advanced non-small cell lung cancer (NSCLC) treated in a phase I trial with concurrent weekly gemcitabine and radiotherapy who achieved a clinical downstaging so as to re-enter resectability.

MATERIALS AND METHODS

from 3/99 to 11/00, 30 patients (ten stage IIIa, 16 IIIb and four IV) with histologically proven, unresectable NSCLC, were enrolled in this phase I trial. Gemcitabine was given weekly for 5 consecutive weeks as a 30-min intravenous infusion, at least 4 h before radiotherapy. Starting dose: 100 mg/m(2). Maximum tolerated dose (MTD): 350 mg/m(2). Radiotherapy total dose: 50.4 Gy (1.8 Gy/day) on primitive tumour and involved lymph nodes.

RESULTS

27 out of 30 patients (90%) were evaluable for clinical restaging (three patients who decided to continue their treatment elsewhere have been excluded). A major clinical response (partial+complete response) was observed in 17 out of 27 cases (62.9%). Clinical complete response rate was 3.7% (1/27) while partial response rate was 59.2% (16/27). Nine patients (33.4%) showed a clinical stable disease and one a disease progression (3.7%). Fourteen patients re-entered resectability and were operated upon: seven lobectomies; four bilobectomies; two pneumonectomies and one explorative thoracotomy. Mean operation duration time was 112 min; mean blood loss was 390 cc. Thirty-day morbidity and mortality were nil. Mean post-operative hospital stay was 6.8 days. A slight increase in operational technical difficulty was encountered. Definitive histology showed a pathologic downstaging of 71.4% (10/14). In four patients, only microscopic neoplastic remnants were found.

CONCLUSIONS

combined treatment with weekly gemcitabine and concurrent radiotherapy is feasible. In patients with advanced NSCLC who achieved a good clinical response and therefore were judged to be resectable, surgery was possible without any increase in thirty-day morbidity and mortality. Satisfactory pathologic results were obtained.

Use of Postoperative Radiotherapy for Node-Positive non—small-Cell Lung Cancer

The appropriate patient selection for adjuvant radiotherapy after primary surgical therapy of non-small-cell lung cancer (NSCLC) is unclear. Four thousand thirteen patients diagnosed from 1988-1995 in 9 registry areas of the Survival, Epidemiology, and End Results program who received primary surgical therapy for pathologic stage T1-3 N1/2 M0 NSCLC were identified. County-level and patient-specific variables associated with the use of postoperative radiotherapy (PORT) were studied by multivariate logistic regression analysis. Prognostic factors for cause-specific survival (CSS) and overall survival (OS) were determined by Cox multivariate analysis. Overall, 58% of node-positive patients received PORT. Use of PORT was independently associated with younger age, more advanced nodal disease, no prior cancer, less extensive surgery than pneumonectomy, and patient residence close to a radiotherapy facility. In multivariate analysis of the entire node-positive population, there were no differences in OS or CSS with the use of PORT. In the patients with N2 disease, PORT was associated with improved OS (5-year OS: 16% without PORT, 22% with PORT; P = 0.001) and CSS (5-year CSS: 25% without PORT, 30% with PORT; P = 0.02). Additionally, patients with = 4 nodes involved also had an improved survival in association with PORT (5-year OS: 11% without PORT, 18% with PORT; P = 0.001; 5-year CSS: 17% without PORT, 25% with PORT; P = 0.009). Therefore, recognizing the inherent limitations of a retrospective, registry-based analysis, patients with more advanced nodal disease appear to have an improved survival with the use of PORT.

Diagnosis and management of early lung cancer

Bronchogenic carcinoma remains the leading cause of cancer deaths in the United States. Approximately 80% of newly diagnosed cases are non-small cell lung cancer (NSCLC); 80% of these present with disseminated or locally advanced disease. Unfortunately, only 10% are potentially surgically curable patients with early-stage disease (T1N0/T2N0). Most patients with early-stage disease are asymptomatic, with their lung cancer detected as a result of non-cancer related procedures. Studies have shown that chest radiography as a screening modality resulted in a higher discovery of early disease, but did not translate to a significant reduction in lung cancer mortality. Recent work on low-dose helical CT, however, has renewed interest in the challenge of detecting early-stage lung cancer.

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.

Induction chemotherapy followed by concurrent chemotherapy and definitive high-dose radiotherapy for patients with locally advanced non-small-cell lung cancer (stages IIIa/IIIb): a pilot phase I/II trial

BACKGROUND

Overall prognosis of patients with locally advanced non-small-cell lung cancer (LAD-NSCLC) is still unfavourable. Different attempts to improve treatment results have been made using combinations of chemotherapy and radiotherapy. The aim of this pilot phase I/II investigation was to test the feasibility and toxicity of a definitive multimodality protocol in patients with irresectable NSCLC stages IIIA (N2) and IIIB.

PATIENTS AND METHODS

Thirty LAD-NSCLC patients (stages IIIA/IIIB: 3/27; median age: 54 years, range 34-70; male/female: 17/13) who were consecutively enrolled onto our ongoing neoadjuvant multimodality protocol from October 1996 to February 1999 remained inoperable after induction treatment. Three cycles of cisplatin/etoposide (PE) were followed by hyperfractionated accelerated radiotherapy (HF-RTx: 1.5 Gy bid up to a total dose of 45 Gy in 3 weeks) concurrent with one cycle of PE. Definitive local treatment was completed with a small volume boost of 20 Gy (qd), adding up to a total dose of 65 Gy to the primary. Patients were routinely offered prophylactic cranial irradiation (PCI; 30 Gy; 2 Gy qd).

RESULTS

Overall toxicity of the definitive CTx/RTx protocol-the main endpoint of this investigation-turned out to be acceptable (oesophagitis grade 3/4: 6/4 patients; pneumonitis grade 3/4: 0/1 patients; no treatment-related deaths). Actuarial survival at 2 years was 31% with a loco-regional control rate of 21%.

CONCLUSIONS

This regimen turned out to be feasible with acceptable toxicity and will serve as a reference arm in a planned randomised trial in stage IIIB NSCLC, testing the value of surgery in this setting: preoperative induction CTx/RTx followed by surgery versus definitive CTx/RTx.

Phase I trial of weekly gemcitabine and concurrent radiotherapy in patients with inoperable non-small-cell lung cancer

PURPOSE

To report the evidence of a phase I trial planned to determine the maximum-tolerated dose (MTD) and related toxicity of weekly gemcitabine (GEM) and concurrent radiotherapy in patients with non--small-cell lung cancer (NSCLC). In addition, the response to treatment was evaluated and reported.

PATIENTS AND METHODS

Thirty-six patients with histologically confirmed NSCLC deemed unresectable because of advanced stage were observed and treated according to a combined chemoradiation protocol with GEM as chemotherapeutic agent. GEM was given weekly for 5 consecutive weeks as a 30-minute intravenous infusion concurrent with radiotherapy (1.8 Gy/d; total dose, 50.4 Gy). The initial dose was 100 mg/m(2). Pulmonary, esophageal, cardiac, hematologic, and skin toxicities were assessed. The dose of GEM was increased by 50 mg/m(2) up to a dose of 250 mg/m(2); an additional increase by 25 mg/m(2) up to the MTD was planned and realized. Three patients were enrolled for each dose level.

RESULTS

Dose-limiting toxicity was identified for the 375-mg/m(2) level with two episodes of grade 2 esophagitis and two of grade 3 pulmonary actinic interstitial disease. The weekly dose of GEM 350 mg/m(2) was well tolerated.

CONCLUSION

A weekly GEM dose of 350 mg/m(2) concurrent with radiotherapy was well tolerated. Promising results regarding response to treatment were observed and reported.

Preoperative concurrent chemoradiotherapy for stage IIIA non-small cell lung cancer

Thirty-one patients with stage IIIA non-small cell lung cancer (NSCLC) were treated with preoperative concurrent chemoradiotherapy (CCRT) followed by surgery. The treatment protocol could not be completed in eight patients. The acute hematologic toxicities of grade III or IV occurred in 48.4%, (15/31) after the first chemotherapy cycle, and in 39.1% (9/23) after the second cycle. The most common non-hematologic toxicity was radiation esophagitis. Surgery was attempted in 23 patients and successful in 22 patients (resection rate = 71.0%. Pathologic complete response and down-staging were achieved in 13.6% (3/22) and 68.2% (15/22). The median survival period, 2-year overall survival, local control and disease-free survival rates of all 31 patients and of 22 patients who underwent surgery were 19 months, 37.2%, 49.1%, 35.5%, and 19 months, 43.2%, 51.8%, 25.6%, respectively. On the basis of our observations, preoperative CCRT followed by surgery for stage IIIA NSCLC has resulted in outcomes comparable with those in previous reports.

Preoperative chemotherapy followed by surgery compared with primary surgery in resectable stage I (except T1N0), II, and IIIa non-small-cell lung cancer

PURPOSE

To evaluate whether preoperative chemotherapy (PCT) could improve survival in resectable stage I (except T1N0), II, and IIIA non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

A randomized trial compared PCT to primary surgery (PRS). PCT consisted of two cycles of mitomycin (6 mg/m(2), day 1), ifosfamide (1.5 g/m(2), days 1 to 3) and cisplatin (30 mg/m(2), days 1 to 3), and two additional postoperative cycles for responding patients. In both arms, patients with pT3 or pN2 disease received thoracic radiotherapy.

RESULTS

Three hundred fifty-five eligible patients were randomized. Overall response to PCT was 64%. There were two preoperative toxic deaths. Postoperative mortality was 6.7% in the PCT arm and 4.5% in the PRS arm (P =.38). Median survival was 37 months (95% confidence interval [CI], 26.7 to 48.3) for PCT and 26.0 months (95% CI, 19.8 to 33.6) for PRS (P =.15). Survival differences between both arms increased from 3.8% (95% CI, 1.3% to 25.1%) at 1 year to 8.6% (95% CI, 2.64% to 24.4%) at 4 years. A quantitative interaction between N status and treatment was observed, with benefit confined to N0 to N1 disease (relative risk [RR], 0.68; 95% CI, 0.49 to 0.96; P =.027). After a nonsignificant excess of deaths during treatment, the effect of PCT was significantly favorable on survival (RR, 0.74; 95% CI, 0.56 to 0.99; P =.044). Disease-free survival time was significantly longer in the PCT arm (P =.033).

CONCLUSION

Although impressive differences in median, 3-year, and 4-year survival were observed, they were not statistically significant, except for stage I and II disease.

Characteristics and prognosis of resected T3 non-small cell lung cancer

BACKGROUND

T3 tumors can be divided into several subgroups depending on the type of anatomical structure invaded: chest wall, mediastinal pleura, or main bronchus. The aim of this study was to analyze the characteristics and prognosis of each subgroup of T3 tumors.

METHODS

The results of surgical treatment were retrospectively analyzed for 261 patients with T3 non-small cell lung cancer invading either the mediastinal pleura or parietal pericardium by direct extension (mediastinal pT3, n = 68), or main bronchus (bronchial pT3, n = 68), or chest wall (chest wall pT3, n = 125) that were operated on between 1984 and 1996. Complete resection including radical mediastinal lymph node dissection was intended in all patients. One patient had segmentectomy, 91 had lobectomy (34.9%), and 169 had pneumonectomy (64.8%). One hundred and fifty-eight patients received adjuvant radiation therapy and 7 patients received both adjuvant chemotherapy and radiation therapy. Actuarial survival curves were drawn using the Kaplan-Meier method and risk factors for late death were identified.

RESULTS

In-hospital mortality was 6.1%. Follow-up was 98% complete. Global 5-year survival was 28%, with survival being not significantly different among the three subgroups: 34.9%, 30.6%, and 22.5% (p = 0.19) in the bronchial pT3, mediastinal pT3, and chest wall pT3 subgroups, respectively. Resection margins were microscopically invaded in 33 patients (12.6%). Seventy-four patients had N1 involvement (28.4%) and 78 patients had N2 involvement (29.8%). N0 involvement was more prevalent in the chest wall pT3 subgroup, whereas N1 involvement was more prevalent in the bronchial pT3 subgroup and N2 involvement was more prevalent among patients with mediastinal invasion. Pathologic factors influencing the 5-year survival were tumor size (p = 0.03) and N involvement (p = 0.003). Histology, type of surgical resection (lobectomy versus pneumonectomy), and use of adjuvant therapy did not influence survival significantly.

CONCLUSIONS

Five-year survival was not significantly different among the three subgroups of pT3 non-small cell lung cancer, although bronchial pT3 tumors tended to have a better prognosis and chest wall pT3 tumors tended to have a worse prognosis. The pathologic characteristics of each pT3 subgroup seems different. Further research is warranted to explore the pathologic and biological factors influencing prognosis for each pT3 subgroup.

A phase II study of induction chemotherapy with gemcitabine (G) and cisplatin (P) in locally advanced non-small cell lung cancer: interim analysis

BACKGROUND

Gemcitabine-cisplatin (GP) combination is one of the most active and well tolerated regimens in advanced non-small cell lung cancer (NSCLC). The aim of this study is to evaluate the activity and toxicity of the GP regimen as a 21-day schedule in patients (pts) with stage IIIAN2-IIIB NSCLC.

PATIENTS AND METHODS

From October 1997 to July 2000, 47 pts entered the study: 43 were eligible (40 men and three women); median age was 61 years (range 45-73); ECOG PS 0-1; histology was squamous (20 pts), adenocarcinoma (12 pts), large cell (five pts), and undifferentiated (six pts); stage was IIIAN2 (14 pts, 32.56%), and IIIB (29 pts, 67.44%). Malignant pleural effusion or superior vena cava syndrome was criteria of exclusion. Induction treatment consisted of three cycles of GP (G 1250 mg/m(2) i.v. on days 1 and 8, and P 100 mg/m(2) on day 8 every 3 weeks). Responding and stable pts underwent surgery (S) and/or radiotherapy (RT).

RESULTS

Following a minimum of two cycles, 39 pts were evaluable for response and 42 for toxicity. Two pts had complete responses (CR; 5.2%), 24 had partial response (PR; 61.5%), eight had stable disease (SD; 20.5%), and five had progressive disease (PRO; 12.8%). WHO grades 3 and 4 anaemia, neutropenia and thrombocytopenia were observed in two, four and two pts, respectively; non-haematological toxicity was moderate. After induction, stable and responding pts received either RT (18 pts) or S+RT (13 pts). Among the 16 resected pts, a radical complete resection was possible in 13 cases (81.3%), whereas tumour down-staging was observed in nine pts (56.2%).

CONCLUSION

GP, as a 3-week neoadjuvant schedule, appears a safe and active regimen.

Results of induction chemotherapy followed by surgical resection in patients with stage IIIA (N2) non-small cell lung cancer: the importance of the nodal down-staging after chemotherapy

OBJECTIVE

Chemotherapy of stage IIIA non-small cell lung cancer (NSCLC) using second generation, cisplatin-based combinations has shown to improve the results; however, the distant relapses remain the major problem. Encouraging results in the treatment of stage IV NSCLC with newer agents (gemcitabine, placlitaxel) has encouraged us to use them in stage III. The aim of this study was to assess feasibility and efficacy of induction chemotherapy with cisplatin and gemcitabine followed by surgery for patients with stage IIIA (N2) NSCLC.

METHODS

From February 1996 to December 1999, 36 consecutive patients with mediastinoscopically staged N2 NSCLC received three cycles of cisplatin (80 mg/m(2), day 2) and gemcitabine (1200 mg/m(2), day 1+8) followed by surgery in responding patients. Patients with stable disease or even local progression received radiotherapy. All patients had clinical N2 disease (mediastinal lymph nodes metastasis) observed on CT scan.

RESULTS

No major complications of the chemotherapy occurred. Twenty-five patients (70%) had a clinical partial response and were surgically explored, with 18 complete resections (70%). There were no in-hospital deaths, although four (16%) major complications: bronchopleural fistula (two), respiratory insufficiency (one), oesophagospleural fistula (one). In the total group of 36 patients, 3-year survival was 20%. So far, no patient without surgery has survived longer then 27 months; median survival was 8 months. In the group of the 25 patients who underwent surgery 3-year survival was 30%, with a median survival of 21 months. The difference is significant (P=0.0027). In the surgical group, the survival of patients with down staged disease (56%) was greater than that of patients with persistent N2 disease (44%) after chemotherapy (3-year survival of 59 and 0%, respectively; P=0.0013).

CONCLUSION

induction chemotherapy with cisplatin and gemcitabine resulted in major tumour regression in a large percentage of patients with clinical N2 disease. In responding patients both the complete respectability rate and survival were higher when compared to historical controls. Survival was significantly better in patients down-staged to a mediastinal negative disease.

Induction chemotherapy with gemcitabine and cisplatin in stage III non-small cell lung cancer

The necessity of improving the long-term survival of patients with locally advanced non-small cell lung cancer (NSCLC) points out on the one hand the limit of surgery alone and, on the other hand, the need of combined modality therapy, in which the role of chemotherapy to control distant metastases is prominent. Recent experiences support the efficacy of neoadjuvant chemotherapy with or without radiotherapy. Phase II studies show response rates of 50-80% and median survival longer than 2 years. Phase III studies suggest that neoadjuvant chemotherapy improves survival and objective responses, and induces higher percentages of complete resections compared with surgery alone or chemotherapy and radiotherapy. The gemcitabine-cisplatin regimen has proved its efficacy in NSCLC advanced disease with response rate greater than 40% in phase II and III trials. Representing one of the regimens most used in Europe, its activity has been investigated also in the neoadjuvant setting. Phase II studies have reported an average response rate greater than 60%, complete surgical resections in 60-70% of the cases, and 1-year survival of about 60%. A modern tendency is to use neoadjuvant chemotherapy in very early stages of NSCLC. Gemcitabine-cisplatin regimen has been used as a randomised clinical trial (chemotherapy for early stages trial, CHEST) to compare the efficacy of surgery alone versus surgery plus preoperative chemotherapy in early-stage disease (T2-3N0, T1-2N1, T3N1), and to evaluate the progression free survival.

Surgical treatment of stage III non-small cell lung cancer

The resectability of NSCLC is determined by its stage. The surgical treatment in stage I and II NSCLC remains a golden standard. Stage IIIA NSCLC constitutes a non-homogenous group, and many patients are potentially non-resectable. The patients in stage IIIA NSCLC also constitute a non-homogenous group. The patients in stage T3N1 usually undergo surgical resection, but many patients with N2 disease are disqualified from surgical treatment due to the negative prognostic factors. The negative prognostic factors comprise: (1) metastases to upper paratracheal (no 2), anterior paratracheal (no 3), and subcarinal (no 7) lymph nodes; (2) metastases to multiple mediastinal lymph nodes; (3) occurrence of the so called 'bulky disease'; (4) capsular lymph node invasion. The occurrence of one of these negative prognostic factors disqualifies the patient with N2 disease from radical surgical treatment. In more advanced cases, i.e. stage IIIB, and stage IV NSCLC, patients are rarely operated. It regards the patients in stage T4 N1, and in M1 disease with a single metastasis (mainly to CNS) accompanied by the stage I, or II, of the primary focus. In these cases N2 disease always constitutes the contraindication to the surgical treatment. Multidisciplinary approach in the treatment of NSCLC is supposed to improve the results of the treatment of NSCLC.

Randomized phase III trial of radiation treatment +/- amifostine in patients with advanced-stage lung cancer

PURPOSE

This multicenter trial investigated whether daily pretreatment with amifostine (A) could reduce the incidence of acute and late lung toxicity and esophagitis without affecting antitumor efficacy of radiation in advanced lung cancer.

PATIENTS AND METHODS

Radiotherapy (XRT) patients (n = 146) received a daily fraction of 2 Gy/5 days/week to a total of 55-60 Gy +/- amifostine 340 mg/m(2) administered daily 15 min before irradiation. Acute and late toxicities were graded from 0 to 4 according to the Radiation Therapy Oncology Group/European Organization for the Research and Treatment of Cancer system.

RESULTS

Ninety-seven patients were evaluated 2 months post-XRT for the incidence of pneumonitis; 43% (23/53) of patients in the XRT arm and 9% (4/44) in the A + XRT arm experienced > or = Grade 2 pneumonitis (p < 0.001) [corrected]. Forty-nine percent (26/53) of patients in the XRT arm and 16% (7/44) in the A+XRT arm demonstrated changes representative of > or = Grade 2 lung damage (p < 0.001). At 6 months, fibrosis was present in 53% (19/36) receiving XRT vs. 28% (9/32) receiving A+XRT (p < 0.05). Incidence of esophagitis > or = Grade 2 during Week 4 was 42% (31/73) in the XRT arm vs. 4% (3/73) in the A+XRT arm (p < 0.001). Among 97 patients evaluable for response 2 months after XRT, complete or partial response was present in 76% (40/53) of patients in the XRT arm and 75% (33/44) in the A+XRT arm (p = 1.0).

CONCLUSION

Amifostine reduces the incidence of pneumonitis, lung fibrosis, and esophagitis in radiotherapy patients with lung cancer without compromising antitumor efficacy.

T2 tumors larger than five centimeters in diameter can be upgraded to T3 in non-small cell lung cancer

OBJECTIVE

Among the TNM criteria, tumor size is a well-assessed factor in the prognosis of small tumors. A 3-cm cutoff point separates T1 from T2 tumors, whereas a size larger than 3 cm is not ascribed any prognostic value. Instead, N2 is considered to be the worst prognostic factor for intrathoracic extended disease.

METHOD

The prognosis of 545 patients with non-small cell lung cancer larger than 3 cm in diameter (T2, T3, and T4) was studied. These tumors were completely resected by pneumonectomy (n = 126) or lobectomy (n = 411) or were partially resected (n = 8). Survivals were compared according to the following factors: tumor size (3.1-5 cm, 5.1-7 cm, >7 cm), nodal status, age, sex, histologic type, degree of pleural involvement, operative procedure, stage, and T factor. For the multivariate analysis, the Cox proportional hazard model was used with the same variables.

RESULTS

The univariate analysis showed that age, sex, degree of pleural involvement, operative procedure, tumor size, nodal status, and stage were all significant prognostic factors. Further comparison of survival between different tumor sizes (< or =5 cm vs >5 cm) in the same nodal category demonstrated a significantly poor prognosis for larger tumors in N0 (P =.00374) and N2+N3 (P =.0157), but not in N1 (P =.3452). T2 tumors (n = 349) were divided, according to size, into T2a (n = 238) and T2b (n = 111), and survival was compared with those in T3 and T4. The 5-year survivals were 51.3%, 35.1%, 47.8%, and 25.3%, respectively. The difference between T2a and T2b was statistically significant (log-rank P =.0170, Breslow P =.0055).

CONCLUSIONS

A tumor size of more than 5 cm in diameter was indicative of a poor prognosis in non-small cell lung cancer, because patients with T2b tumors had a significantly different survival from that of patients with T2a tumors, and the survival curve was located between those for patients with T3 and T4 tumors. Consequently, T2b might be upgraded to at least T3.

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.

Completely resected stage IIIA non-small cell lung cancer: the significance of primary tumor location and N2 station

BACKGROUND

The number of N2 stations (single vs multiple N2 stations) is an important prognostic factor in patients with completely resected stage IIIA-N2 non-small cell lung cancer. However, the significance of both the N2 station(s) actually involved and the primary tumor location remains unclear.

METHODS

The database was built with the use of a questionnaire survey on the survival of patients with pathologic stage IIIA-N2 non-small cell lung cancer completely resected between January 1992 and December 1993. The survey was performed by the Japan Clinical Oncology Group as of July 1999. The data include information on the survival and N2 stations of 402 patients.

RESULTS

A frequently metastasized single N2 station was the lower pretracheal station in primary tumors in the right upper lobe, the subaortic station in the left upper lobe, and the subcarinal station in the right middle or lower lobe and the left lower lobe. In multiple N2 stations, the frequency of metastasis of the N2 station observed in a single N2 station was as high as 72% to 89%, and one or two other frequently metastasized stations were added to each group. Regarding the survival of patients with a primary tumor in each lobe except for the left lower lobe, a single N2 station resulted in a significantly better survival than did multiple N2 stations. Furthermore, the overall survivals classified according to each primary site showed a significant difference among the four primary sites (P =.04).

CONCLUSIONS

The primary tumors in each lobe showed a prevalence of N2 station(s). The number of N2 stations is a good prognosticator except in patients with a primary tumor in the left lower lobe. In addition, the site of a primary tumor itself is also considered to influence the survival of the patients.

Risk of death from intercurrent disease is not excessively increased by modern postoperative radiotherapy for high-risk resected non-small-cell lung carcinoma

PURPOSE

Some studies report a high risk of death from intercurrent disease (DID) after postoperative radiotherapy (XRT) for non-small-cell lung cancer (NSCLC). This study determines the risk of DID after modern-technique postoperative XRT.

PATIENTS AND METHODS

A total of 202 patients were treated with surgery and postoperative XRT for NSCLC. Most patients (97%) had pathologic stage II or III disease. Many patients (41%) had positive/close/uncertain resection margins. The median XRT dose was 55 Gy with fraction size of 1.8 to 2 Gy. The risk of DID was calculated actuarially and included patients who died of unknown/uncertain causes. Median follow-up was 24 months for all patients and 62 months for survivors.

RESULTS

A total of 25 patients (12.5%) died from intercurrent disease, 16 from confirmed noncancer causes and nine from unknown causes. The 4-year actuarial rate of DID was 13.5%. This is minimally increased compared with the expected rate for a matched population (approximately 10% at 4 years). On multivariate analysis, age and radiotherapy dose were borderline significant factors associated with a higher risk of DID (P =.06). The crude risk of DID for patients receiving less than 54 Gy was 2% (4-year actuarial risk 0%) versus 17% for XRT dose > or = 54 Gy. The 4-year actuarial overall survival was 34%; local control was 84%; and freedom from distant metastases was 37%.

CONCLUSION

Modern postoperative XRT for NSCLC does not excessively increase the risk of intercurrent deaths. Further study of postoperative XRT, particularly when using more sophisticated treatment planning and reasonable total doses, for carefully selected high-risk resected NSCLC is warranted.

The role of positron emission tomography with 18F-fluoro-2-deoxy-D-glucose in respiratory oncology

In the past 5 yrs, positron emission tomography (PET) with 18F-fluoro-2-deoxy-D-glucose (FDG) has become an important imaging modality in lung cancer patients. At this time, the indication of FDG-PET as a complimentary tool to computed tomography in the diagnosis and staging of nonsmall cell lung cancer has gradually gained more widespread acceptance and also reimbursement in many European countries. This review focuses on the data of FDG-PET in the diagnosis of lung nodules and masses, and in locoregional and extrathoracic staging of nonsmall cell lung cancer. Emphasis is put on the potential clinical implementation of the currently available FDG-PET data. The use of FDG-PET in these indications now needs further validation in large-scale multicentre randomized studies, focusing mainly on treatment outcome parameters, survival and cost-efficacy. Interesting findings with 18F-fluoro-2-deoxy-D-glucose-positron emission tomography have also been reported for the evaluation of response to radio- or chemotherapy, in radiotherapy planning, recurrence detection and assessment of prognosis. Finally, a whole new field of application of positron emission tomography in molecular biology, using new radiopharmaceuticals, is under extensive investigation.

Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor

BACKGROUND

Visceral pleura invasion (VPI) by non-small cell lung cancer is a factor of poor prognosis. A tumor of any size that invades the visceral pleura is classified as T2. Few studies have been conducted concerning the prognostic significance of VPI relative to other staging factors.

METHODS

Between April 1984 and December 1996, 1,281 patients with T1 (n = 430) and T2 (n = 851) non-small cell lung cancer underwent curative surgical resection. Adjuvant radiation therapy was performed in 455 patients. There were 176 women and 1,105 men aged 30 to 86 years (mean, 60.9 years). Five hundred nineteen pneumonectomies, 742 lobectomies, and 20 segmentectomies were performed. In all patients, a complete mediastinal lymph node dissection was performed. International staging was stage IA and B (n = 697); stage II A and B (n = 247), and stage III A (n = 337). The patients were divided into two groups according to the existence of VPI (group I without, group II with). Both groups were compared with regard to the size of the tumors, histology, associated lymph node involvement, survival rates, and cause of death. Univariate and multivariate analyses were conducted.

RESULTS

VPI (group II) was identified in 19.1% of the resected specimens: group I, n = 1036; group II, n = 245. The VPI was present in only 10% of non-small cell lung cancer 3 cm or less in size, reaching 33% of patients with non-small cell lung cancer larger than 5 cm (p = 0.0001). Squamous non-small cell lung cancer were significantly less accompanied by VPI (13.5%) than the other histologic categories. The VPI was associated with a higher frequency of N2 involvement (group I = 24.6%, group II = 33.4%, p = 0.01) and N2 involvement was more extensive (two or more N2 involved stations: group I = 8.2%, group II = 15.6%, p = 0.003). Actuarial survival rates were 51.8% at 5 years and 33.8% at 10 years in group I (median, 66 months), and 34.6% at 5 years and 27.9% at 10 years in group II (median, 30 months) (p = 0.000002). Long-term survival rates significantly decreased for larger tumors. Even in patients with N2 stage tumors, the difference of survival curves between the two groups was statistically significant. Cancer-related deaths were more frequent in group II and were mainly caused by distant metastases. By multivariate analysis, visceral pleura invasion proved to be a significant independent factor of poor prognosis.

CONCLUSIONS

The VPI is a factor of poor prognosis. Its frequent association with extensive N2 involvement supports the hypothesis that exfoliated tumor cells are drained through the pleural lymphatics by the mediastinal lymphatic pathways and then into the bloodstream. The VPI is an important prognostic factor and, as such should stimulate more studies to better select the patients who could benefit from adjuvant therapy.

[Surgery and combined therapy for non-small cell lung cancer with invasion of the mediastinal nodes. A retrospective study]

OBJECTIVE

To analyze the survival of patients classified N2M0 (N2 cytology/histology)with non-small cell lung cancer treated by surgical resection of the primary tumor, lymphadenectomy and neo-adjuvant therapy.

PATIENTS AND METHODS

Among 1,043 consecutive patients with lung cancer treated between 1990 and 2000, 155 were classified N2M0 by histology. Of 130 patients undergoing thoracotomy, excision of the primary pulmonary tumor and lymphadenectomy were performed in 116. Among the 116 N2M0patients undergoing surgical resection, 23 were diagnosed N2c(c3)by mediastinoscopy and/or mediastinotomy and received induction chemotherapy (CT) with mitomycin/ifosfamide/cisplatin (3 cycles)and 93 were diagnosed N2pM0 after examination of samples of mediastinal lymph tissue taken during thoracotomy; for 19 of these patients,earlier surgical exploration of the mediastinum had been negative. The patient diagnosed N2p after thoracotomy also received CT and/or radiotherapy (RT). N2p patients who received induction CT also received RT. Those who were negative after lymphadenectomy and severely ill patients received no adjuvant therapy of any type.

RESULTS

Mean survival of resected patients (23/49) diagnosed N2(C3) by mediastinoscopy/mediastinotomy and who received induction CT was 18 months. Survival at 1, 2 and 5 years was 80%, 45% and 30%, respectively. No postoperative deaths occurred in this group. One patient developed a bronchopleural fistula. Nine patients showed no signs of residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients (93/106) diagnosed N2p after thoracotomy was 13 months and survival rates at 1, 2 and 5 years were 56%, 31% and 19%,respectively. Fourteen patients in this group died within 30 days of surgery. Nine patient developed bronchopleural fistulas. The difference in survival between the two groups was not significant.

CONCLUSIONS

Histologic or cytologic confirmation of N2 disease can be considered to indicate poor prognosis. Standard, complete surgery with induction CT in selected patients improves survival for those diagnosed N2 upon thoracotomy, with no statistically significant differences.

[Surgical treatment of non-small cell lung cancer with mediastinal node invasion. A retrospective study]

OBJECTIVE

To analyze the survival of patients classified as N2M0 (N2 by cytohistology) with non-small cell lung cancer treated by surgical resection of the primary tumor and lymphadenectomy.

PATIENTS AND METHODS

Among 1043 consecutive patients with lung cancer who were considered for surgery between 1990 and 2000, 155 were classified N2M0 by histology. Surgical exeresis of the primarily pulmonary tumor and lymphadenectomy were performed in 116 patients of the 130 patients who underwent thoracotomy. Among the 116 N2M0 patients undergoing surgical resection, 23 were diagnosed N2c(C3) by mediastinoscopy and/or mediastinotomy and were given induction chemotherapy (ChT) (mitomycin/ifosfami-de/cisplatin, 3 cycles) and 93 were diagnosed N2pM0 based on samples obtained from mediastinal lymph tissue during thoracotomy. Nineteen of the latter had previously been classified negative during surgical exploration. The patients diagnosed N2p after thoracotomy were given adjuvant ChT, radiotherapy or both. N2p patients who received induction therapy were given radiotherapy. Those found negative after lymphadenectomy and patients with severe disease were given no adjuvant treatment.

RESULTS

Mean survival was 18 months for resected patients diagnosed N2 by mediastinoscopy/mediastinotomy and with induction ChT and survival at one, two and five years was 80%, 45% and 30%, respectively. No postoperative mortality was recorded in this group. One patient suffered bronchopleural fistula. Nine patients showed no residual mediastinal node disease after lymphadenectomy. The mean survival of resected patients diagnosed N2p by thoracotomy was 13 months, and one, two and five year survival rates were 56%, 31% and 19%, respectively. Fourteen patients died within 30 days of surgery. Nine patients developed a bronchopleural fistula. The difference in survival of the two groups was not significant.

CONCLUSIONS

The prognosis after cytohistologic confirmation of N2 disease can be considered poor. Standard, complete surgery plus induction therapy in screened patients improved survival for those diagnosed N2 by thoracotomy, with no statistically significant differences.

Neoadjuvant therapy and surgical resection for locally advanced non-small cell lung cancer

During the past 15 years, treatment of stage IIIA (N2) non-small cell lung cancer has evolved considerably because of improvements in patients selection, staging, and combined modality therapy. Results of several clinical trials suggest that induction chemotherapy or chemoradiation and surgical resection is superior to surgery alone. However, the optimal induction regimen has not been defined. An intergroup trial is also underway to determine whether chemoradiation and surgical resection leads to better survival than chemotherapy and radiation alone. Future studies will assess ways to combine radiation and novel chemotherapeutic agents, and will identify molecular abnormalities that predict response to induction therapy.

Unresectable or medically inoperable non-small cell lung cancer: the use of established clinical prognostic factors in making radiation-related treatment decisions

Many physicians consider the prognosis exceptionally poor for patients with localized non-small cell lung cancer who are not eligible for surgery, either because of the extent of their disease or because a coexisting medical condition precludes surgery. Thus, these patients frequently are not offered aggressive curative therapy. However, the disease of many of these patients is potentially curable and should be considered for curative treatment. Although pathologic data from surgical specimens are useful in predicting prognosis, many prognostic factors have also been identified for medically inoperable and locally advanced, unresectable disease. Several of these prognostic factors can and should be used clinically to estimate the risk of lymph node involvement within the clinically uninvolved mediastinum, thereby aiding in the design of radiation therapy fields, and to estimate prognosis, thereby helping to determine which patients should be offered aggressive therapy with curative intent.

Point: the potential importance of elective nodal irradiation in the treatment of non-small cell lung cancer

Patients who receive radiation therapy for non-small cell lung cancer (NSCLC) will require accurate targeting of the grossly involved primary and nodal disease. However, the treatment of grossly uninvolved elective nodal sites that may harbor microscopic occult disease is controversial. In simple terms, physicians are guided by 1 of 2 paradigms when they decide about the use of elective nodal irradiation in NSCLC. First, one may consider that high doses of radiation therapy for the primary and grossly involved lymph nodes represents the most important aspect of treatment and that elective irradiation of potential occult micrometastasis is not necessary because it may limit the doses that can be given to the gross disease. Additionally, this line of thought often includes the belief that most or all patients with occult micrometastasis are not curable. Alternatively, one may consider that the evidence for a dose response, for grossly involved NSCLC, beyond 60 Gy is very limited and that the omission of elective nodal irradiation obviates the chance for cure in many patients. These small deposits of tumor in regional nodes are common, are amenable to low doses of radiation (50 Gy), and treatment of these lesions does result in cures. This review focuses on this latter paradigm and the available evidence to support it.

Surgery for non-small cell lung cancer: postoperative survival based on the revised tumor-node-metastasis classification and its time trend

OBJECTIVE

To clarify results of surgery for non-small cell lung cancer (NSCLC) based on the new tumor-node-metastasis (TNM) classification revised in 1997 and its time trend.

METHODS

A total of 921 patients operated from 1980-1994 were retrospectively reviewed. For analysis of time trend, they were grouped into three periods by the year of operation (period (1): 1980-1984, period (2): 1985-1989, and period (3): 1990-19-94).

RESULTS

Concerning patients' characteristics, recent increase in the ratio of patients whose tumor was discovered at mass screening (31% in period (1), 40% in period (2), and 50% in period (3)), and increase in the ratio of p-stage IA patient (16, 20, and 29%, respectively) were marked. Decrease in the ratio of operation-related death and the ratio of exploratory thoracotomy was significant. Concerning level of operation, decrease in the ratio of pneumonectomy, increase in the ration of sublober resection and that of tracheal or bronchoplastic procedures were significant. Postoperative survival for all patients was significantly better in period (2) or (3) than that in period (1); no significant difference was demonstrated between period (2) and (3) (5-year survival rates: 35% for period (1), 56% for period (2), and 56% for period (3)). Stratified p-stage, improvement of postoperative survival in recent years was demonstrated in p-stage IIA, IIB, IIIA, and IIIB diseases.

CONCLUSIONS

Postoperative survival for all NSCLC patients has been improved with significant increase of early-stage (p-stage IA) patients. Concerning level of resection, recent increase in patients who underwent sublobar resection and bronchoplastic procedures was marked.