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Eberhardt WEE, De Ruysscher D, Weder W, Le Péchoux C, De Leyn P, Hoffmann H, Westeel V, Stahel R, Felip E, Peters S. 2nd ESMO Consensus Conference in Lung Cancer: locally advanced stage III non-small-cell lung cancer. Ann Oncol 2015; 26:1573-88. [PMID: 25897013 DOI: 10.1093/annonc/mdv187] [Citation(s) in RCA: 273] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 04/09/2015] [Indexed: 12/25/2022] Open
Abstract
To complement the existing treatment guidelines for all tumour types, ESMO organises consensus conferences to focus on specific issues in each type of tumour. The 2nd ESMO Consensus Conference on Lung Cancer was held on 11-12 May 2013 in Lugano. A total of 35 experts met to address several questions on non-small-cell lung cancer (NSCLC) in each of four areas: pathology and molecular biomarkers, first-line/second and further lines of treatment in advanced disease, early-stage disease and locally advanced disease. For each question, recommendations were made including reference to the grade of recommendation and level of evidence. This consensus paper focuses on locally advanced disease.
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Affiliation(s)
- W E E Eberhardt
- Department of Medical Oncology, West German Cancer Centre, University Hospital, University Duisburg-Essen, Ruhrlandklinik, Essen, Germany
| | - D De Ruysscher
- Department of Radiation Oncology, KU Leuven-University of Leuven, University Hospitals Leuven, Leuven, Belgium
| | - W Weder
- Division of Thoracic Surgery, University Hospital Zürich, Zürich, Switzerland
| | - C Le Péchoux
- Department of Radiation Oncology, Gustave Roussy Cancer Institute, Villejuif, France
| | - P De Leyn
- Department of Thoracic Surgery, University Hospitals, KU Leuven, Leuven, Belgium
| | - H Hoffmann
- Department of Thoracic Surgery, Thoraxklinik, University of Heidelberg, Heidelberg, Germany
| | - V Westeel
- Department of Chest Disease, University Hospital, Besançon, France
| | - R Stahel
- Clinic of Oncology, University Hospital Zürich, Zürich, Switzerland
| | - E Felip
- Department of Medical Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - S Peters
- Département d'Oncologie, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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152
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Kidane B, Toyooka S, Yasufuku K. MDT lung cancer care: Input from the Surgical Oncologist. Respirology 2015; 20:1023-33. [DOI: 10.1111/resp.12567] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 03/12/2015] [Accepted: 04/15/2015] [Indexed: 12/14/2022]
Affiliation(s)
- Biniam Kidane
- Division of Thoracic Surgery; University of Toronto; Toronto Ontario Canada
- Division of Thoracic Surgery; Toronto General Hospital; University Health Network; Toronto Ontario Canada
| | - Shinichi Toyooka
- Department of Thoracic Surgery; Okayama University Hospital; Okayama Japan
- Department of Clinical Genomic Medicine; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery; University of Toronto; Toronto Ontario Canada
- Division of Thoracic Surgery; Toronto General Hospital; University Health Network; Toronto Ontario Canada
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153
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Lin Z, Xiong L, Zhou J, Wang J, Li Z, Hu H, Lin Q. γ-Glutamylcyclotransferase Knockdown Inhibits Growth of Lung Cancer Cells Through G0/G1 Phase Arrest. Cancer Biother Radiopharm 2015; 30:211-6. [PMID: 25941902 DOI: 10.1089/cbr.2014.1807] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Zhifeng Lin
- Department of Thoracic Surgery, Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Liwen Xiong
- Department of Pulmonary, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Jianhua Zhou
- Department of Thoracic Surgery, Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Jin Wang
- Department of Thoracic Surgery, Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Zhao Li
- Department of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Haiyang Hu
- Department of Thoracic Surgery, Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Qiang Lin
- Department of Thoracic Surgery, Shanghai First People's Hospital, Shanghai Jiaotong University, Shanghai, China
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154
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Sher DJ, Fidler MJ, Liptay MJ, Koshy M. Comparative effectiveness of neoadjuvant chemoradiotherapy versus chemotherapy alone followed by surgery for patients with stage IIIA non-small cell lung cancer. Lung Cancer 2015; 88:267-74. [DOI: 10.1016/j.lungcan.2015.03.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/11/2015] [Accepted: 03/16/2015] [Indexed: 12/28/2022]
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155
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ACR Appropriateness Criteria(®) induction and adjuvant therapy for N2 non-small-cell lung cancer. Am J Clin Oncol 2015; 38:197-205. [PMID: 25803563 DOI: 10.1097/coc.0000000000000154] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The integration of chemotherapy, radiation therapy (RT), and surgery in the management of patients with stage IIIA (N2) non-small-cell lung carcinoma is challenging. The American College of Radiology (ACR) Appropriateness Criteria Lung Cancer Panel was charged to update management recommendations for this clinical scenario. The Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. There is limited level I evidence to guide patient selection for induction, postoperative RT (PORT), or definitive RT. Literature interpretation is complicated by inconsistent diagnostic procedures for N2 disease, disease heterogeneity, and pooled analysis with other stages. PORT is an appropriate therapy following adjuvant chemotherapy in patients with incidental pN2 disease. In patients with clinical N2 disease who are potential candidates for a lobectomy, both definitive and induction concurrent chemotherapy/RT are appropriate treatments. In N2 patients who require a pneumonectomy, definitive concurrent chemotherapy/RT is most appropriate although induction concurrent chemotherapy/RT may be considered in expert hands. Induction chemotherapy followed by surgery +/- PORT may also be an option in N2 patients. For preoperative RT and PORT, 3-dimensional conformal techniques and intensity-modulated RT are most appropriate.
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156
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Tariq A, Majeed I, Khurshid A. Types of Cancers Prevailing in Pakistan and their Management Evaluation. Asian Pac J Cancer Prev 2015; 16:3605-16. [DOI: 10.7314/apjcp.2015.16.9.3605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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157
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Zhong W, Yang X, Yan H, Zhang X, Su J, Chen Z, Liao R, Nie Q, Dong S, Zhou Q, Yang J, Tu H, Wu YL. Phase II study of biomarker-guided neoadjuvant treatment strategy for IIIA-N2 non-small cell lung cancer based on epidermal growth factor receptor mutation status. J Hematol Oncol 2015; 8:54. [PMID: 25981169 PMCID: PMC4455050 DOI: 10.1186/s13045-015-0151-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 05/07/2015] [Indexed: 12/25/2022] Open
Abstract
Background Neoadjuvant erlotinib and customized adjuvant therapy are appealing but controversial. The purpose of this study was to evaluate the role of biomarker-guided neoadjuvant treatment strategy in patients with IIIA-N2 non-small cell lung cancer (NSCLC) stratified by epidermal growth factor receptor (EGFR) mutation status. Findings Patients with resectable histologically documented stage IIIA-N2 NSCLC were assigned to a neoadjuvant erlotinib arm or a gemcitabine/carboplatin (GC) arm based on EGFR mutation status. The primary endpoint was response rate (RR). Secondary endpoints were progression-free survival (PFS) and overall survival (OS). Twenty-four patients with IIIA-N2 NSCLC were enrolled in the trial from January 2008 until May 2011. The overall response rate was 41.7 % and the PFS and OS were 7.9 and 23.2 months, respectively, in overall population. The RR was 58.3 % (7/12) for the erlotinib arm with mutant EGFR and 25.0 % (3/12) for the GC arm with wild type EGFR (P = 0.18). Median PFS was 6.9 months versus 9.0 months, respectively (P = 0.071). Median OS was 14.5 months for the erlotinib arm and 28.1 months for the GC arm (P = 0.201). No unexpected toxicities were observed. Conclusions The primary endpoint was met and biomarker-guided neoadjuvant treatment strategy in patients with IIIA-N2 NSCLC is feasible. Erlotinib alone in neoadjuvant setting of EGFR mutant population showed an improved response but without survival benefits. Trial registration ClinicalTrials.gov NCT00600587 https://www.clinicaltrials.gov/ct2/show/NCT00600587?term=NCT00600587&rank=1 Electronic supplementary material The online version of this article (doi:10.1186/s13045-015-0151-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wenzhao Zhong
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Xuening Yang
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Honghong Yan
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Xuchao Zhang
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Jian Su
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Zhihong Chen
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Riqiang Liao
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Qiang Nie
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Song Dong
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Qing Zhou
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Jinji Yang
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Haiyan Tu
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, 510080, People's Republic of China.
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158
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Abstract
Lung cancer is one of the leading causes of cancer-related deaths. Accurate assessment of disease extent is important in deciding the optimal treatment approach. To play an important role in the multidisciplinary management of lung cancer patients, it is necessary that the radiologist understands the principles of staging and the implications of radiological findings on the various staging descriptors and eventual treatment decisions.
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Affiliation(s)
- Nilendu C Purandare
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Venkatesh Rangarajan
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
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159
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Deng XF, Liu QX, Zhou D, Min JX, Dai JG. Bone marrow micrometastasis is associated with both disease recurrence and poor survival in surgical patients with node-negative non-small-cell lung cancer: a meta-analysis. Interact Cardiovasc Thorac Surg 2015; 21:21-7. [PMID: 25883247 DOI: 10.1093/icvts/ivv082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 03/12/2015] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES We performed a meta-analysis in order to determine whether the molecular tumour cell detection of either micrometastasis or isolated tumour cells in the bone marrow micrometastasis is indicative of a high risk of both disease recurrence and poor survival in the setting of node-negative non-small-cell lung cancer (NSCLC). METHODS Before beginning this study, a rigorous protocol was established in accordance with the recommendations of the Cochrane Collaboration. A systematic literature search of Medline, EMbase, the Cochrane Library and the Web of Science was conducted in order to identify studies regarding the prognostic value of molecular tumour cell detection in the bone marrow of node-negative NSCLC. Any study describing the use of both immunochemistry and flow cytometry to detect bone marrow metastasis was selected. We extracted the associated 95% confidence intervals (CIs) and hazard ratios (HRs) from the included studies and performed meta-analyses on overall survival and either disease-free survival (DFS) or disease-free recurrence. Meanwhile, we compared the occurrence of bone marrow micrometastasis among different pathological types and different stages of disease. RESULTS Eleven studies with a cumulative sample size of 2159 patients were included in our analysis. Our meta-analyses revealed that the occurrence of bone marrow micrometastasis was not related to patient pathological types and stages in cancers ranging from adenocarcinoma and squamous cell carcinoma [relative risk (RR): 0.92; 95% CI: 0.78-1.08; P = 0.29], stages I and II (RR: 0.88; 95% CI: 0.67-1.17; P = 0. 39), stages II and III (RR: 0.98; 95% CI: 0.73-1.31; P = 0.89) and stages I and III (RR: 0.84; 95% CI: 0.68-1.05; P = 0.13). However, molecular tumour cell detection within the bone marrow was associated with both poor OS (HR: 1.84; 95% CI: 1.41-2.40; P < 0.00001) and poor DFS (HR: 1.75; 95% CI: 1.18-2.60; P = 0.005). Our subgroup analyses indicated that the presence of bone marrow micrometastasis was not a significant prognostic factor with respect to DFS at stage I (HR: 2.35; 95% CI: 0.67-8.25; P = 0.18). CONCLUSIONS The molecular detection of isolated tumour cell in the bone marrow is associated with both poor survival and an increased rate of recurrence in patients with node-negative NSCLC; this approach may result in the development of a new metastatic cascade concept and the development of novel approaches to cancer therapy.
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Affiliation(s)
- Xu Feng Deng
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Quan Xing Liu
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Dong Zhou
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Jia Xin Min
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Ji Gang Dai
- Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing, China
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160
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Hajdu SI, Vadmal M, Tang P. A note from history: Landmarks in history of cancer, part 7. Cancer 2015; 121:2480-513. [PMID: 25873516 DOI: 10.1002/cncr.29365] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 02/02/2015] [Indexed: 02/06/2023]
Abstract
In the 2 and half decades reviewed (1970-1995), research established that chromosomal translocation, deletion, and DNA amplification are prerequisites to cancerogenesis and that oncogenes, tumor-suppressor genes, growth factors, and cytokines play crucial roles in the pathomechanism of cancer. Human papillomavirus, human immunodeficiency virus, herpes virus, and hepatitis B virus were identified as cancer-causing viruses. Several laboratory tests were developed for the detection of primary and recurrent cancers, and cancer prevention by screening methods was popularized. Sonography, computerized tomography, magnetic resonance imaging, positron emission tomography, excision of sentinel lymph nodes, and immunohistochemical techniques became routine procedures. Clinicopathologic staging and classification of tumors were standardized. Limited surgery, adjuvant and neoadjuvant chemoradiation, and the therapeutic use of monoclonal antibodies, tumor vaccines, and targeted chemotherapy became routine practice. The decline in cancer incidence and mortality demonstrated that cancer prevention and advancement in oncology are pivotal to success in the crusade against cancer. Above all, it was clearly established that the care of patients with cancer can be accomplished best in a multidisciplinary setting involving surgical oncologists, radiologists, radiation therapists, medical oncologists, surgical pathologists, and laboratory scientists. In conclusion, the 25 years from 1970 and 1995 are the high-water mark in clinical oncology, and this is the period when oncology turned from art to science.
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Affiliation(s)
| | - Manjunath Vadmal
- Department of Dermatology, Los Angeles County-University of Southern California Medical Center, Los Angeles, California
| | - Ping Tang
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
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161
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Norcantharidin inhibits Wnt signal pathway via promoter demethylation of WIF-1 in human non-small cell lung cancer. Med Oncol 2015; 32:145. [PMID: 25814287 DOI: 10.1007/s12032-015-0592-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 03/16/2015] [Indexed: 12/26/2022]
Abstract
Wingless-type (Wnt) family of secreted glycoproteins is a group of signal molecules implicated in oncogenesis. Abnormal activation of Wnt signal pathway is associated with a variety of human cancers, including non-small cell lung cancer (NSCLC). Wnt antagonists, such as the secreted frizzled-related protein (SFRP) family, Wnt inhibitory factor-1 (WIF-1) and cerberus, inhibit Wnt signal pathway by directly binding to Wnt molecules. Norcantharidin (NCTD) is known to possess anticancer activity but less nephrotoxicity than cantharidin. In this study, we found that NCTD inhibited cell proliferation, induced apoptosis, arrested cell cycle and suppressed cell invasion/migration in vitro. Additionally, Wnt signal pathway transcription was also suppressed. NCTD treatment blocked cytoplasmic translocation of beta-catenin into the nucleus. Alterations of apoptosis-related proteins, such as Bax, cleaved caspase-3 (pro-apoptotic) and Bcl-2 (anti-apoptotic), had been detected. Furthermore, the expression levels of WIF-1 and SFRP1 were significantly increased in NCTD-treated groups compared with negative control (NC) groups. Abnormal methylation was observed in NC groups, while NCTD treatment promoted WIF-1 demethylation. The present study revealed that NCTD activated WIF-1 via promoter demethylation, inhibiting the canonical Wnt signal pathway in NSCLC, which may present a new therapeutic target in vivo.
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162
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Salvà F, Felip E. Neoadjuvant chemotherapy in early-stage non-small cell lung cancer. Transl Lung Cancer Res 2015; 2:398-402. [PMID: 25806258 DOI: 10.3978/j.issn.2218-6751.2013.10.07] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 10/09/2013] [Indexed: 12/25/2022]
Abstract
Surgical resection followed by adjuvant chemotherapy is the standard of care for completely resected stages II and III non-small cell lung cancer (NSCLC) patients. In order to improve survival in patients with early-stage NSCLC, efforts have been focused on the use of chemotherapy and radiotherapy before surgery with the aim of reducing the risk of relapse. Neoadjuvant chemotherapy is an attractive treatment option which is employed in different tumors and may well be associated with certain advantages in NSCLC patients such as being effective in treating occult microscopic systemic disease, downstaging mediastinal lymph node and improving the success of surgery by tumor reduction. Furthermore, chemotherapy compliance prior to surgery is generally better than after surgery. The potential disadvantages are treatment-related toxicities and the delay of surgery. At present, neoadjuvant chemotherapy is still considered an experimental treatment modality in early-stage disease and its role should be more clearly defined.
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Affiliation(s)
- Francesc Salvà
- Oncology Department, Valld'Hebron University Hospital, Barcelona, Spain
| | - Enriqueta Felip
- Oncology Department, Valld'Hebron University Hospital, Barcelona, Spain
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163
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Zhai H, Zhong W, Yang X, Wu YL. Neoadjuvant and adjuvant epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) therapy for lung cancer. Transl Lung Cancer Res 2015; 4:82-93. [PMID: 25806348 DOI: 10.3978/j.issn.2218-6751.2014.11.08] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 11/10/2014] [Indexed: 01/26/2023]
Abstract
The Lung Adjuvant Cisplatin Evaluation (LACE) meta-analysis and the meta-analysis of individual participant data reported by non-small cell lung cancer (NSCLC) Meta-analysis Collaborative Group in neo-adjuvant setting validated respectively that adjuvant and neoadjuvant chemotherapy would significantly improve overall survival (OS) and recurrence-free survival for resectable NSCLC. However, chemotherapy has reached a therapeutic plateau. It has been confirmed that epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) targeting therapy provides a dramatic response to patients with advanced EGFR-mutation positive NSCLC. Researchers have paid more attention to exploring applications of TKIs to early resectable NSCLCs. Several studies on adjuvant TKI treatment concluded its safety and feasibility. But there existed certain limitations of these studies as inference factors to interpret data accurately: the BR19 study recruited patients among which almost 52% had stage IB and only 15 (3.0%, 15/503) had been confirmed with EGFR-mutant type; retrospective studies performed at Memorial Sloan Kettering Cancer Center (MSKCC) selected EGFR mutant-type NSCLC patients but couldn't avoid inherent defects inside retrospective researches; the RADIANT study revised endpoints from targeting at EGFR immunohistochemistry (IHC)+ and/or fluorescence in situ hybridization (FISH)+ mutation to only EGFR IHC+ mutation, leading to selective bias; despite that the SELECT study validated efficacy of adjuvant TKI and second round of TKI after resistance occurred, a single-arm clinical trial is not that persuasive in the absence of comparison with chemotherapy. Taking all these limitations into account, CTONG1104 in China and IMPACT in Japan have been conducted and recruiting patients to offer higher level of evidences to explore efficacy of preoperative TKI therapy for early resectable EGFR mutation positive NSCLC patients (confirmed by pathological results of tumor tissue or lymph node biopsy). On the other hand, case reports and several phase II clinical trials with small sample size tried to elbow their way on respect of preoperative TKI treatment and advised that TKI tended to improve response rate. However, no data on survival rate was present. The first phase II study of biomarker-guided neoadjuvant therapy for stage IIIA-N2 NSCLC patients stratified by EGFR mutation status, sponsored by CSLC0702, showed erlotinib tended to improve response rate, but failed to show benefits of disease-free survival (DFS) or OS. Subsequently, CTONG1103 was designed to investigate efficacy of erlotinib vs. combination of gemcitabine/cisplatin (GC) as neoadjuvant treatment in stage IIIA-N2 NSCLC with sensitizing EGFR mutation in exon 19 or 21. All these ongoing trials should be worthy of our expect to provide convincing evidences for customized therapy for patients with resectable NSCLC.
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Affiliation(s)
- Haoran Zhai
- 1 Southern Medical University, Guangzhou 510515, China ; 2 Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Wenzhao Zhong
- 1 Southern Medical University, Guangzhou 510515, China ; 2 Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Xuening Yang
- 1 Southern Medical University, Guangzhou 510515, China ; 2 Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Yi-Long Wu
- 1 Southern Medical University, Guangzhou 510515, China ; 2 Guangdong Lung Cancer Institute, Guangdong General Hospital & Guangdong Academy of Medical Sciences, Guangzhou 510080, China
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164
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Choy H, Gerber DE, Bradley JD, Iyengar P, Monberg M, Treat J, Govindan R, Koustensis A, Barker S, Obasaju C. Concurrent pemetrexed and radiation therapy in the treatment of patients with inoperable stage III non-small cell lung cancer: a systematic review of completed and ongoing studies. Lung Cancer 2015; 87:232-40. [PMID: 25650301 DOI: 10.1016/j.lungcan.2014.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 12/09/2014] [Accepted: 12/11/2014] [Indexed: 12/24/2022]
Abstract
Current standard for locally advanced non-small cell lung cancer (NSCLC) is combined concurrent therapy with a platinum-based regimen. Preclinical synergistic activity of pemetrexed with radiation therapy (RT) and favorable toxicity profile has led to clinical trials evaluating pemetrexed in chemoradiation regimens. This literature search of concurrent pemetrexed and RT treatment of patients with stage III NSCLC included MEDLINE database, meeting abstracts, and the clinical trial registry database. Nineteen unique studies were represented across all databases including 11 phase I studies and eight phase II studies. Of the six phase II trials with mature data available, median overall survival ranged from 18.7 to 34 months. Esophagitis and pneumonitis occurred in 0-16% and 0-23% of patients, respectively. Of the ongoing trials, there is one phase III and four phase II trials with pemetrexed in locally advanced NSCLC. Pemetrexed can be administered safely at full systemic doses with either cisplatin or carboplatin concomitantly with radical doses of thoracic radiation therapy. While results from the ongoing phase III PROCLAIM trial are needed to address definitively the efficacy of pemetrexed-cisplatin plus RT in stage III NSCLC, available results from phase II trials suggest that this regimen has promising activity with an acceptable toxicity profile.
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Affiliation(s)
- Hak Choy
- University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - David E Gerber
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Puneeth Iyengar
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew Monberg
- Eli Lilly and Company or one of its subsidiaries, Indianapolis, IN, USA
| | - Joseph Treat
- Eli Lilly and Company or one of its subsidiaries, Indianapolis, IN, USA
| | | | - Andrew Koustensis
- Eli Lilly and Company or one of its subsidiaries, Indianapolis, IN, USA
| | - Scott Barker
- Eli Lilly and Company or one of its subsidiaries, Indianapolis, IN, USA
| | - Coleman Obasaju
- Eli Lilly and Company or one of its subsidiaries, Indianapolis, IN, USA
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165
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Setzer M, Robinson LA, Vrionis FD. Management of locally advanced pancoast (superior sulcus) tumors with spine involvement. Cancer Control 2015; 21:158-67. [PMID: 24667403 DOI: 10.1177/107327481402100209] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The preferred treatment for locally aggressive lung cancers is triple modality therapy with concurrent and induction chemotherapy with radiation therapy followed by surgery. Patients with locally advanced T4 Pancoast tumors with spine involvement, without mediastinal N2 lymph node involvement and without distant metastases, are appropriate candidates for complete resection with subsequent spine reconstruction. This review addresses the questions of whether triple modality therapy with complete en bloc resection of locally advanced Pancoast tumors offers an advantage in terms of overall survival and complication rates compared with other therapeutic modalities or therapies with incomplete resection. METHODS A comprehensive literature search was conducted using common medical databases. Inclusion and exclusion criteria for the articles were prospectively defined. The articles were independently reviewed and a consensus decision was made about each article. Selected papers were graded by level of evidence. RESULTS A total of 1,001 abstracts and 93 articles fulfilled the criteria; from these studies, 14 were included in this systematic review. No level 1 study was found in this search. Four level 2 studies and 10 level 3 retrospective case series were found. The overall 5-year survival rate reported in these studies ranged from 37% to 59% and the mortality rate ranged from 0% to 6.9%. CONCLUSIONS Evidence suggests that triple modality therapy with complete resection of locally advanced Pancoast tumors with involvement of the spine offers an advantage over other therapeutic modalities or therapies with incomplete resections.
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Affiliation(s)
- Matthias Setzer
- Department of Neurosurgery, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany.
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Boffa DJ, Hancock JG, Yao X, Goldberg S, Rosen JE, Kim AW, Moreno A, Detterbeck FC. Now or Later: Evaluating the Importance of Chemotherapy Timing in Resectable Stage III (N2) Lung Cancer in the National Cancer Database. Ann Thorac Surg 2015; 99:200-8. [DOI: 10.1016/j.athoracsur.2014.08.040] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/18/2014] [Accepted: 08/25/2014] [Indexed: 12/25/2022]
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Karim NA, Bui H, Pathrose P, Starnes S, Patil N, Shehata M, Mostafa A, Rao M, Zarzour A, Anderson M. The use of pharmacogenomics for selection of therapy in non-small-cell lung cancer. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2014; 8:139-44. [PMID: 25520568 PMCID: PMC4259862 DOI: 10.4137/cmo.s18369] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 09/21/2014] [Accepted: 09/24/2014] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Performance status (PS) is the only known clinical predictor of outcome in patients with advanced non-small-cell lung cancer (NSCLC), although pharmacogenomic markers may also correlate with outcome. The aim of our study was to correlate clinical and pharmacogenomic measures with overall survival. METHODS This was an IRB approved, retrospective study in which the medical records of 50 patients with advanced NSCLC from 1998–2008 were reviewed, and gender, race, PS, and chemotherapy regimens were documented. Stromal expression of pharmacogenomic markers (VEGFR, ERCC1, 14-3-3σ, pAKT, and PTEN) was measured. Clinical factors and pharmacogenomics markers were compared to overall survival using a Cox proportional hazards model. RESULTS Forty patients received platinum-based therapy. Median age was 65 years. Improved PS, female gender, and gemcitabine therapy were significantly associated with longer overall survival (P = 0.004, P = 0.04, and P = 0.003, respectively). Age was not associated with survival. Caucasians had better overall survival in comparison to African Americans with median survival of 14.8 months versus 10.4 months (P = 0.1). Patients treated with platinum-based therapy had better survival of 15 months versus 8 months for non-platinum based therapy (P = 0.01). There was no significant association between any of the pharmacogenomics markers and overall survival other than in patients treated with platinum, in whom ERCC1 negativity was strongly associated with longer survival (P = 0.007). CONCLUSION ERCC1 negativity with platinum therapy, gemcitabine therapy, good PS, and female gender all correlated with improved overall survival in patients with advanced NSCLC.
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Affiliation(s)
- Nagla A Karim
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Hai Bui
- Department of Pathology, Cincinnati VA Medical Center, Cincinnati, OH, USA
| | - Peterson Pathrose
- Divison of Thoracic Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Sandra Starnes
- Divison of Thoracic Surgery, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Ninad Patil
- Department of Pathology, Mount Sinai Medical Center, New York, NY, USA
| | - Mahmoud Shehata
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Ahmed Mostafa
- Division of Pulmonary, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Mb Rao
- Division of Environmental Health, University of Cincinnati, Cincinnati, OH, USA
| | - Ahmad Zarzour
- Internal Medicine Department, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Marshall Anderson
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
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Renaud S, Falcoz PE, Olland A, Reeb J, Santelmo N, Massard G. Mediastinal downstaging after induction treatment is not a significant prognostic factor to select patients who would benefit from surgery: the clinical value of the lymph node ratio. Interact Cardiovasc Thorac Surg 2014; 20:222-7. [PMID: 25413781 DOI: 10.1093/icvts/ivu378] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Multimodal management of N2 non-small-cell lung cancer is still a matter of debate. In particular, the place of surgery for persistent N2 after induction treatment is controversial and surgery is usually reserved for patients experiencing a mediastinal downstaging (pN1 and pN0). We aimed to evaluate whether there might exist subgroups of pN2 according to the lymph node ratio (LNR). METHODS Between 1996 and 2012, we retrospectively reviewed the data from 152 potentially resectable cN2 patients who underwent an induction treatment before surgery. RESULTS The median follow-up time was 32 months (2-112). The average age at the time of diagnosis was 58.52 ± 10.47 years. In univariate analysis, overall survival (OS) was significantly influenced by extracapsular spread (32 ± 5.33 vs 24 ± 12.73 months, P = 0.01), pN after surgery (65 ± 2.45 months for pN0, 44 ± 2.14 months for pN1 and 19 ± 1.72 months for pN2, P <0.0001) and LNR ≥ 1/3 (30 ± 3.77 months vs 16 ± 1.39 months, P <0.0001). When pN0 and pN1 patients were staged according to the LNR, the OS was divided by two for pN1 patients with an LNR ≥ 1/3 (48 ± 2.64 months vs 26 ± 5.65 months, P <0.001), whereas it decreased from 26 ± 0.87 to 15 ± 1.85 months (P <0.0001) for pN2 patients. OS was significantly better with adjuvant radio-chemotherapy than with chemotherapy or radiation therapy alone (P <0.0001). In multivariate analysis, mediastinal downstaging {Hazard Ratio (HR): 0.184 (95% confidence interval (CI): 0.084-0.403), P <0.0001} and LNR [HR: 0.359 (95% CI: 0.194-0.665], P = 0.001) remained significantly independent prognostic factors. CONCLUSIONS The LNR may potentially identify subgroups of pN+ patients and allow enhancement of adjuvant treatments. Because pN2 with a low LNR had an equivalent survival to pN1 with a high LNR, mediastinal downstaging does not seem to be a sufficient prognostic factor to exclude patients after induction treatment from surgery.
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Affiliation(s)
- Stéphane Renaud
- Department of Thoracic Surgery, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France EA3430: Federation of Translational Medicine, University of Strasbourg, Strasbourg, France
| | - Pierre-Emmanuel Falcoz
- Department of Thoracic Surgery, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France
| | - Anne Olland
- Department of Thoracic Surgery, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France
| | - Jérémie Reeb
- Department of Thoracic Surgery, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France
| | - Nicola Santelmo
- Department of Thoracic Surgery, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France
| | - Gilbert Massard
- Department of Thoracic Surgery, Nouvel Hôpital Civil, Strasbourg University Hospital, Strasbourg, France
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Byron E, Pinder-Schenck M. Systemic and targeted therapies for early-stage lung cancer. Cancer Control 2014; 21:21-31. [PMID: 24357738 DOI: 10.1177/107327481402100104] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Even with aggressive surgical treatment, relapse rates remain high for patients with resectable non-small-cell lung cancer (NSCLC). In an effort to improve survival in these patients, numerous clinical trials have evaluated neoadjuvant and adjuvant chemotherapy. METHODS The authors reviewed the results of the prospective randomized clinical trials that have established adjuvant chemotherapy as the standard of care for patients with surgically resected NSCLC. In addition, the authors summarize data on predictive and prognostic markers for patients with early-stage NSCLC and discuss novel therapies and clinical trials currently underway in early-stage NSCLC. RESULTS Three large randomized clinical trials and two meta-analyses have demonstrated a survival benefit for adjuvant cisplatin-based chemotherapy compared with surgery alone in patients with early-stage NSCLC. As a result, adjuvant cisplatin-based chemotherapy is recommended as the standard of care in these patients. Numerous promising biomarkers and agents have been developed in the metastatic setting and are currently being evaluated in the adjuvant setting. CONCLUSIONS While adjuvant chemotherapy has improved survival for patients with early-stage NSCLC, the prognosis for early-stage lung cancer remains poor. Incorporation of molecular markers and targeted therapies into the management of patients with advanced NSCLC has improved outcomes. Development of these strategies in the adjuvant setting offers the potential to increase cure rates in patients with early-stage NSCLC.
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Affiliation(s)
- Elizabeth Byron
- Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL 33612, USA.
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171
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Jeremić B. Standard treatment option in stage III non-small-cell lung cancer: case against trimodal therapy and consolidation drug therapy. Clin Lung Cancer 2014; 16:80-5. [PMID: 25450877 DOI: 10.1016/j.cllc.2014.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/18/2014] [Accepted: 08/26/2014] [Indexed: 11/30/2022]
Abstract
Prospective randomized trials and meta-analyses established concurrent radiochemotherapy (RT-CHT) as standard treatment approach in patients with inoperable, locally advanced (stage IIIA and B) non-small-cell lung cancer (NSCLC). In patients with either clinically (c) or pathologically (p) staged disease (stage IIIA), including those with pN2 disease, trimodal therapy was also frequently practiced in the past and is currently still advocated by large cooperative groups and organizations. Similarly, consolidation CHT provided after concurrent RT-CHT was suggested to be feasible and effective in inoperable stage III NSCLC. Contrasting these practices and suggestions, there is no evidence that trimodal therapy in stage IIIA (clinically or pathologically staged) or consolidation CHT in inoperable stage III NSCLC plays any role in its treatment. In both cases, evidence clearly demonstrates that concurrent RT-CHT is of similar efficacy and less toxic, and it should be considered a standard treatment option for all patients with stage III NSCLC.
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Affiliation(s)
- Branislav Jeremić
- Insitute for Lung Diseases, Sremska Kamenica, Serbia; BioIRC Centre for Biomedical Research, Kragujevac, Serbia.
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172
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Toyokawa G, Takenoyama M, Ichinose Y. Multimodality treatment with surgery for locally advanced non-small-cell lung cancer with n2 disease: a review article. Clin Lung Cancer 2014; 16:6-14. [PMID: 25220209 DOI: 10.1016/j.cllc.2014.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 06/28/2014] [Accepted: 07/01/2014] [Indexed: 10/24/2022]
Abstract
Stage III non-small-cell lung cancer (NSCLC) is composed of a heterogeneous population of lesions (ie, T4N0-3, T3N1-3, and T1a-2aN2-3), which makes it difficult to establish a definitive treatment strategy. Although several retrospective and prospective studies have been conducted to investigate the significance of multimodality treatments with surgery for patients with resectable stage III NSCLC, the role of surgery still remains controversial. In this article, we review the results of retrospective and prospective studies that have investigated the significance of multimodality treatment with surgery for patients with stage III NSCLC, particularly those with mediastinal lymph node metastasis, and the implications for the treatment of this controversial subset of patients.
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Affiliation(s)
- Gouji Toyokawa
- Department of Thoracic Oncology, National Kyushu Cancer Center, Fukuoka, Japan.
| | | | - Yukito Ichinose
- Department of Thoracic Oncology, National Kyushu Cancer Center, Fukuoka, Japan
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Askoxylakis V, Tanner J, Kappes J, Hoffmann H, Nicolay NH, Rief H, Debus J, Thomas M, Bischof M. Trimodal therapy for stage III-N2 non-small-cell lung carcinoma: a single center retrospective analysis. BMC Cancer 2014; 14:572. [PMID: 25104240 PMCID: PMC4137085 DOI: 10.1186/1471-2407-14-572] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 07/24/2014] [Indexed: 12/19/2022] Open
Abstract
Background Treatment of locally advanced non-small-cell lung cancer is based on a combined approach. To study the impact of trimodal therapy for stage III-N2 NSCLC a single centre retrospective evaluation focusing on survival and therapy-related toxicity was performed. Methods 71 patients diagnosed between March 2001 and August 2008 with pathologically confirmed stage III-N2 non-small-cell lung cancer at the University Clinic of Heidelberg were retrospectively analyzed. All patients were treated within trimodal therapy strategies including surgery, induction or adjuvant chemotherapy and postoperative radiotherapy. Overall survival (OS) and disease free survival (DFS) rates were calculated using the Kaplan-Meier method. The log-rank test and Fishers Exact test were applied for univariate analysis and Cox proportional regression model for multivariate analysis. Results Median survival was 32 months. 1-, 3- and 5-year overall survival (OS) rates were 84.5%, 49.6% and 35.5% respectively. Disease free survival rates at 1, 3 and 5 years were 70.4%, 41.8% and 27.4% respectively. 9 patients (12.6%) were diagnosed with a local recurrence. Multivariate analysis did not reveal any independent prognostic factors for OS, but indicated a trend for pT stage and type of surgery. In regard to toxicity 8.4% of the patients developed a clinically relevant ≥ grade 2 pneumonitis. Evaluation of the forced expiratory volume in 1 second per unit of vital capacity (FEV1/VC) before and 1-3 years post radiotherapy revealed a median decrease of 2.1%. Conclusions Our descriptive data indicate that trimodal therapy represents an effective and safe treatment approach for patients with stage III-N2 non-small-cell lung cancer. Further prospective clinical trials are necessary in order to clearly define the impact of multimodal strategies and optimize NSCLC treatment.
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Current status of induction treatment for N2-Stage III non-small cell lung cancer. Gen Thorac Cardiovasc Surg 2014; 62:651-9. [PMID: 25355643 DOI: 10.1007/s11748-014-0447-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Indexed: 12/25/2022]
Abstract
Locally advanced non-small cell lung cancer (NSCLC), particularly clinical Stage IIIA NSCLC with mediastinal lymph node metastasis, is known to be quite heterogeneous, comprising approximately one-fourth of cases of NSCLC. In this subset, patients with a minor tumor load in the mediastinal lymph nodes, such as microscopically or pathologically proven N2 in the resected specimens, are treated with surgery followed by adjuvant chemotherapy. Meanwhile, the current standard of care for patients with bulky or infiltrative N2 disease is concurrent chemoradiotherapy. The potential role of surgery in multi-modality treatment for clinical N2-Stage IIIA remains controversial. Several prospective clinical trials of this subset have been conducted; however, the heterogeneity of the N2 status and differences in chemotherapy regimens and/or radiation modalities between clinical trials make the results difficult to compare. No optimal chemotherapy regimen has been established to control possible micrometastasis, and radiotherapy is often used to achieve maximum local disease control and minimize post-surgical complications. This review summarizes the findings of prospective clinical trials that assessed the role of surgery in treating clinical N2-Stage IIIA patients within the last two decades and discusses the present status of induction treatment followed by surgery for clinical N2-Stage IIIA NSCLC.
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175
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Peer M, Stav D, Cyjon A, Sandbank J, Vasserman M, Haitov Z, Sasson L, Schreiber L, Ezri T, Priel IE, Hayat H. Morbidity and mortality after major pulmonary resections in patients with locally advanced stage IIIA non-small cell lung carcinoma who underwent induction therapy. Heart Lung Circ 2014; 24:69-76. [PMID: 25086910 DOI: 10.1016/j.hlc.2014.07.055] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 06/25/2014] [Accepted: 07/02/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal treatment for patients with locally advanced stage IIIA non-small cell lung carcinoma (NSCLC) remains controversial, but induction therapy is increasingly used. The aim of this study was to evaluate mortality, morbidity, hospital stay and frequency of postoperative complications in stage IIIA NSCLC patients that underwent major pulmonary resections after neoadjuvant chemotherapy or chemoradiation. METHODS We conducted a retrospective analysis of all patients who underwent major pulmonary resections after induction therapy for locally advanced NSCLC from October 2009 to February 2014. Forty-one patients were included in the study. RESULTS Complete resection was achieved in 40 patients (97.5%). A complete pathologic response was seen in 10 patients (24.4%). Mean hospital stay was 17.7 days (ranged 5-129 days). Early (in-hospital) mortality occurred in 2.4% (one patient after bilobectomy), late (six months) mortality in 4.9% (two patients after right pneumonectomy and bilobectomy), and overall morbidity in 58.5% (24 patients). Postoperative complications included: bronchopleural fistula (BPF) with empyema - three patients, empyema without BPF - five patients, air leak - eight patients, atrial fibrillation - eight patients, pneumonia - eight patients, and lobar atelectasis - four patients. CONCLUSION Following neoadjuvant therapy for stage IIIA NSCLC, pneumonectomy can be performed with low early and late mortality (0% and 5.8%, respectively), bilobectomy is a high risk operation (16.7% early and 16.7% late mortality); and lobectomy a low risk operation (0% early and late mortality). The need for major pulmonary resections should not be a reason to exclude patients from a potentially curative procedure if it can be performed with acceptable morbidity and mortality rates at an experienced medical centre.
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Affiliation(s)
- Michael Peer
- Department of Thoracic Surgery, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel.
| | - David Stav
- Department of Pulmonology, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Arnold Cyjon
- Department of Oncology, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Judith Sandbank
- Department of Pathology, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Margarita Vasserman
- Institute of Diagnostic Imaging, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Zoya Haitov
- Department of Anesthesiology, Assaf Harofeh Medical Center, Zerifin, affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Lior Sasson
- Department of Cardiothoracic Surgery, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Letizia Schreiber
- Department of Pathology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tiberiu Ezri
- Department of Anesthesiology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel E Priel
- Department of Pulmonary Medicine, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Henri Hayat
- Department of Oncology, Edith Wolfson Medical Center, Holon, Israel, affiliated with the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Sahiner I, Vural GU. Positron emission tomography/computerized tomography in lung cancer. Quant Imaging Med Surg 2014; 4:195-206. [PMID: 24914421 DOI: 10.3978/j.issn.2223-4292.2014.03.05] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 03/14/2014] [Indexed: 12/25/2022]
Abstract
Positron emission tomography (PET) using 2-(18F)-flouro-2-deoxy-D-glucose (FDG) has emerged as a useful tool in the clinical work-up of lung cancer. This review article provides an overview of applications of PET in diagnosis, staging, treatment response evaluation, radiotherapy planning, recurrence assessment and prognostication of lung cancer.
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Affiliation(s)
- Ilgin Sahiner
- Ankara Oncology Research and Training Hospital, Turkey
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177
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Marulli G, Verderi E, Zuin A, Schiavon M, Battistella L, Perissinotto E, Romanello P, Favaretto AG, Pasello G, Rea F. Outcomes and prognostic factors of non-small-cell lung cancer with lymph node involvement treated with induction treatment and surgical resection. Interact Cardiovasc Thorac Surg 2014; 19:256-62; discussion 262. [PMID: 24824495 DOI: 10.1093/icvts/ivu141] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Induction therapy (IT) has gained popularity in recent years, becoming a standard of treatment in resectable lymph node-positive NSCLC. IT aims to downstage the disease (shrinkage of tumour and clearance of lymph node-metastases), clear distant micrometastases and prolong survival. Potential disadvantages are increased morbidity and/or mortality after surgery and risk of progression of disease that could have been initially resected. The purpose of this study was to evaluate the outcomes and prognostic factors in a series of patients with lymph node-positive NSCLC receiving IT followed by surgery. METHODS A total of 86 patients (75.6% males, median age 63 years) affected by NSCLC in clinical stage IIIA (n = 80) or IIIB (n = 6), with pathologically proven lymph node involvement, underwent platinum-based IT followed by surgery between 2000 and 2009. RESULTS Eighty (93%) patients received a median of 3 cycles of chemotherapy, and 6 (7%) underwent induction chemoradiotherapy. Response to IT was complete in 3.5%, partial in 59.3% and stable disease in 37.2% of patients. Postoperative morbidity and mortality were 25.6 and 2.3%, respectively. At pathological evaluation, 38.4% of patients had a downstaging of disease with a complete lymph node clearance in 31.4%. Median overall survival was 23 months (5-year survival 33%). Univariate analysis found clinical stage (P = 0.02), histology (P = 0.01), response to IT (P = 0.02) and type of intervention (P = 0.047) to have predictive roles in survival. A better but not significant survival was also found for pN0 vs pN+ (P = 0.22), downstaged tumours (P = 0.08) and left side (P = 0.06). On multivariate analysis, clinical response to neoadjuvant therapy (P = 0.01) and age (P = 0.03) were the only independent predictors of survival. CONCLUSIONS The use of IT for lymph node-positive NSCLC seems justified by low morbidity and/or mortality and good survival rates. Patients with response to IT showed greater benefit in the long term.
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Affiliation(s)
- Giuseppe Marulli
- Department of Cardiologic, Thoracic and Vascular Sciences, Division of Thoracic Surgery, University of Padova, Padova, Italy
| | - Enrico Verderi
- Department of Cardiologic, Thoracic and Vascular Sciences, Division of Thoracic Surgery, University of Padova, Padova, Italy
| | - Andrea Zuin
- Department of Cardiologic, Thoracic and Vascular Sciences, Division of Thoracic Surgery, University of Padova, Padova, Italy
| | - Marco Schiavon
- Department of Cardiologic, Thoracic and Vascular Sciences, Division of Thoracic Surgery, University of Padova, Padova, Italy
| | - Lucia Battistella
- Department of Cardiologic, Thoracic and Vascular Sciences, Division of Thoracic Surgery, University of Padova, Padova, Italy
| | - Egle Perissinotto
- Department of Cardiologic, Thoracic and Vascular Sciences, Division of Thoracic Surgery, University of Padova, Padova, Italy
| | - Paola Romanello
- Department of Cardiologic, Thoracic and Vascular Sciences, Division of Thoracic Surgery, University of Padova, Padova, Italy
| | | | - Giulia Pasello
- Department of Oncology, Istituto Oncologico Veneto, Padova, Italy
| | - Federico Rea
- Department of Cardiologic, Thoracic and Vascular Sciences, Division of Thoracic Surgery, University of Padova, Padova, Italy
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Abstract
BACKGROUND Individual participant data meta-analyses of postoperative chemotherapy have shown improved survival for patients with non-small-cell lung cancer (NSCLC). We aimed to do a systematic review and individual participant data meta-analysis to establish the effect of preoperative chemotherapy for patients with resectable NSCLC. METHODS We systematically searched for trials that started after January, 1965. Updated individual participant data were centrally collected, checked, and analysed. Results from individual randomised controlled trials (both published and unpublished) were combined using a two-stage fixed-effect model. Our primary outcome, overall survival, was defined as the time from randomisation until death (any cause), with living patients censored on the date of last follow-up. Secondary outcomes were recurrence-free survival, time to locoregional and distant recurrence, cause-specific survival, complete and overall resection rates, and postoperative mortality. Prespecified analyses explored any variation in effect by trial and patient characteristics. All analyses were by intention to treat. FINDINGS Analyses of 15 randomised controlled trials (2385 patients) showed a significant benefit of preoperative chemotherapy on survival (hazard ratio [HR] 0·87, 95% CI 0·78-0·96, p=0·007), a 13% reduction in the relative risk of death (no evidence of a difference between trials; p=0·18, I(2)=25%). This finding represents an absolute survival improvement of 5% at 5 years, from 40% to 45%. There was no clear evidence of a difference in the effect on survival by chemotherapy regimen or scheduling, number of drugs, platinum agent used, or whether postoperative radiotherapy was given. There was no clear evidence that particular types of patient defined by age, sex, performance status, histology, or clinical stage benefited more or less from preoperative chemotherapy. Recurrence-free survival (HR 0·85, 95% CI 0·76-0·94, p=0·002) and time to distant recurrence (0·69, 0·58-0·82, p<0·0001) results were both significantly in favour of preoperative chemotherapy although most patients included were stage IB-IIIA. Results for time to locoregional recurrence (0·88, 0·73-1·07, p=0·20), although in favour of preoperative chemotherapy, were not statistically significant. INTERPRETATION Findings, which are based on 92% of all patients who were randomised, and mainly stage IB-IIIA, show preoperative chemotherapy significantly improves overall survival, time to distant recurrence, and recurrence-free survival in resectable NSCLC. The findings suggest this is a valid treatment option for most of these patients. Toxic effects could not be assessed. FUNDING Medical Research Council UK.
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179
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Sher DJ, Liptay MJ, Fidler MJ. Prevalence and predictors of neoadjuvant therapy for stage IIIA non-small cell lung cancer in the National Cancer Database: importance of socioeconomic status and treating institution. Int J Radiat Oncol Biol Phys 2014; 89:303-12. [PMID: 24685443 DOI: 10.1016/j.ijrobp.2014.01.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 01/06/2014] [Accepted: 01/21/2014] [Indexed: 12/28/2022]
Abstract
PURPOSE The optimal locoregional therapy for stage IIIA non-small cell lung cancer (NSCLC) is controversial, with definitive chemoradiation therapy (CRT) and neoadjuvant therapy followed by surgery (NT-S) serving as competing strategies. In this study, we used the National Cancer Database to determine the prevalence and predictors of NT in a large, modern cohort of patients. METHODS AND MATERIALS Patients with stage IIIA NSCLC treated with CRT or NT-S between 2003 and 2010 at programs accredited by the Commission on Cancer were included. Predictors were categorized as clinical, time/geographic, socioeconomic, and institutional. In accord with the National Cancer Database, institutions were classified as academic/research program and as comprehensive and noncomprehensive community cancer centers. Logistic regression and random effects multilevel logistic regression were performed for univariable and multivariable analyses, respectively. RESULTS The cohort consisted of 18,581 patients, 3,087 (16.6%) of whom underwent NT-S (10.6% induction CRT, 6% induction chemotherapy). The prevalence of NT-S was constant over time, but there were significant relative 31% and 30% decreases in pneumonectomy and right-sided pneumonectomy, respectively, over time (P trend <.02). In addition to younger age, lower T stage, and favorable comorbidity score, indicators of higher socioeconomic status were strong independent predictors of NT-S, including white race, higher income, and private/managed insurance. The type of institution (academic/research program vs comprehensive or noncomprehensive community cancer centers, odds ratio 1.54 and 2.08, respectively) strongly predicted NT-S, but treatment volume did not. CONCLUSIONS Neoadjuvant therapy followed by surgery was an uncommon treatment approach in Commission on Cancer programs, and the prevalence of postinduction pneumonectomy decreased over time. Higher socioeconomic status and treatment at academic institutions were significant predictors of NT-S. Further research should be performed to enable a better understanding of these disparities.
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Affiliation(s)
- David J Sher
- Department of Radiation Oncology, Rush University Medical Center, Chicago, Illinois.
| | - Michael J Liptay
- Department of Cardiothoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Mary Jo Fidler
- Section of Medical Oncology, Rush University Medical Center, Chicago, Illinois
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Hellmann MD, Chaft JE, William WN, Rusch V, Pisters KMW, Kalhor N, Pataer A, Travis WD, Swisher SG, Kris MG. Pathological response after neoadjuvant chemotherapy in resectable non-small-cell lung cancers: proposal for the use of major pathological response as a surrogate endpoint. Lancet Oncol 2014; 15:e42-50. [PMID: 24384493 DOI: 10.1016/s1470-2045(13)70334-6] [Citation(s) in RCA: 405] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Improvements in outcomes for patients with resectable lung cancers have plateaued. Clinical trials of resectable non-small-cell lung cancers with overall survival as the primary endpoint require a decade or longer to complete, are expensive, and limit innovation. A surrogate for survival, such as pathological response to neoadjuvant chemotherapy, has the potential to improve the efficiency of trials and expedite advances. 10% or less residual viable tumour after neoadjuvant chemotherapy, termed here major pathological response, meets criteria for a surrogate; major pathological response strongly associates with improved survival, is reflective of treatment effect, and captures the magnitude of the treatment benefit on survival. We support the incorporation of major pathological response as a surrogate endpoint for survival in future neoadjuvant trials of resectable lung cancers. Additional prospective studies are needed to confirm the validity and reproducibility of major pathological response within individual histological and molecular subgroups and with new drugs.
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Affiliation(s)
- Matthew D Hellmann
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Jamie E Chaft
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - William N William
- Department of Thoracic/Head and Neck Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Valerie Rusch
- Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Katherine M W Pisters
- Department of Thoracic/Head and Neck Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Neda Kalhor
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Apar Pataer
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William D Travis
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark G Kris
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
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Zenke Y, Ishii G, Ohe Y, Kaseda K, Yoshida T, Matsumoto S, Umemura S, Yoh K, Niho S, Goto K, Ohmatsu H, Kuwata T, Nagai K, Ochiai A. Aldehyde dehydrogenase 1 expression in cancer cells could have prognostic value for patients with non-small cell lung cancer who are treated with neoadjuvant therapy: Identification of prognostic microenvironmental factors after chemoradiation. Pathol Int 2014; 63:599-606. [DOI: 10.1111/pin.12122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 11/22/2013] [Indexed: 01/16/2023]
Affiliation(s)
- Yoshitaka Zenke
- Division of Pathology; Research Center for Innovative Oncology; National Cancer Center; Hospital East; Kashiwa Chiba Japan
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
- Juntendo University Graduate School of Medicine; Tokyo Japan
| | - Genichiro Ishii
- Division of Pathology; Research Center for Innovative Oncology; National Cancer Center; Hospital East; Kashiwa Chiba Japan
| | - Yuichiro Ohe
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
- Juntendo University Graduate School of Medicine; Tokyo Japan
| | - Kaoru Kaseda
- Division of Pathology; Research Center for Innovative Oncology; National Cancer Center; Hospital East; Kashiwa Chiba Japan
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
| | - Tatsuya Yoshida
- Division of Pathology; Research Center for Innovative Oncology; National Cancer Center; Hospital East; Kashiwa Chiba Japan
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
| | - Shingo Matsumoto
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
| | - Shigeki Umemura
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
| | - Kiyotaka Yoh
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
| | - Seiji Niho
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
| | - Koichi Goto
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
| | - Hironobu Ohmatsu
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
| | - Takeshi Kuwata
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
| | - Kanji Nagai
- Division of Thoracic Oncology; National Cancer Center Hospital East; Kashiwa Chiba Japan
| | - Atsushi Ochiai
- Division of Pathology; Research Center for Innovative Oncology; National Cancer Center; Hospital East; Kashiwa Chiba Japan
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182
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Santos ES, Castrellon A, Blaya M, Raez LE. Controversies in the management of stage IIIA non-small-cell lung cancer. Expert Rev Anticancer Ther 2014; 8:1913-29. [DOI: 10.1586/14737140.8.12.1913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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183
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Vansteenkiste JF, Schildermans RH. The future of adjuvant chemotherapy for resected non-small cell lung cancer. Expert Rev Anticancer Ther 2014; 5:165-75. [PMID: 15757448 DOI: 10.1586/14737140.5.1.165] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Non-small cell lung cancer is a frequent type of cancer, with approximately 1.2 million cases per year expected worldwide. A total of 20-30% of patients with early stage non-small cell lung cancer are amenable to radical surgery, although only 40-50% of these patients are cured. An improvement in survival has never been demonstrated for postoperative radiotherapy. However, a major step forward is several recent large randomized studies that have demonstrated improved survival with postoperative chemotherapy. This review covers the historic data on adjuvant chemotherapy for non-small cell lung cancer, meta-analyses, modern studies with cisplatin-based or other chemotherapy, implications for current clinical practice and guidelines, some practical recommendations and, finally, the questions for future studies.
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Affiliation(s)
- Johan F Vansteenkiste
- Respiratory Oncology Unit (Pulmonology), Leuven Lung Cancer Group, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium.
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184
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Powell E, Chow LQM. BLP-25 liposomal vaccine: a promising potential therapy in nonsmall-cell lung cancer. Expert Rev Respir Med 2014; 2:37-45. [DOI: 10.1586/17476348.2.1.37] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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185
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Biswas T, Sharma N, Machtay M. Controversies in the management of stage III non-small-cell lung cancer. Expert Rev Anticancer Ther 2014; 14:333-47. [PMID: 24397773 DOI: 10.1586/14737140.2014.867809] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lung cancer remains the leading cause of death in the USA and is the most common cancer both in incidence and in mortality globally (1.35 million deaths annually). Non-small-cell lung cancer accounts for >80% of all lung cancers [1] . About 35-45% of non-small-cell lung cancer patients present with locally advanced non-metastatic stage III disease. However, confirmed stage III disease represents a very heterogeneous group ranging from borderline surgical candidate with minimal mediastinal involvement to bulky mediastinal nodes or contralateral nodal involvement with significant controversy regarding optimal management in these various situations. This article specifically addresses the role of surgery, radiotherapy and chemotherapy in multimodal approach to treat stage III patients with N2/N3 involvement and controversies surrounding these recommendations.
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Affiliation(s)
- Tithi Biswas
- University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA
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186
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Naidoo R, Windsor MN, Goldstraw P. Surgery in 2013 and beyond. J Thorac Dis 2013; 5 Suppl 5:S593-606. [PMID: 24163751 PMCID: PMC3804869 DOI: 10.3978/j.issn.2072-1439.2013.07.39] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 07/29/2013] [Indexed: 01/12/2023]
Abstract
Lung cancer is a leading cause of cancer related mortality. The role of surgery continues to evolve and in the last ten years there have been a number of significant changes in the surgical management of lung cancer. These changes extend across the entire surgical spectrum of lung cancer management including diagnosis, staging, treatment and pathology. Positron Emission Tomography (PET) scanning and ultrasound (EBUS) have redefined traditional staging paradigms, and surgical techniques, including video-assisted thoracoscopy (VATS), robotic surgery and uniportal surgery, are now accepted as standard of care in many centers. The changing pathology of lung cancer, with more peripheral tumours and an increase in adenocarcinomas has important implications for the Thoracic surgeon. Screening, using Low-Dose CT scanning, is having an impact, with not only a higher percentage of lower stage cancers detected, but also redefining the role of sublobar resection. The incidence of pneumonectomy has reduced as have the rates of "exploratory thoracotomy". In general, lung resection is considered for stage I and II patients with a selected role in more advanced stage disease as part of a multimodality approach. This paper will look at these issues and how they impact on Thoracic Surgical practice in 2013 and beyond.
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Affiliation(s)
- Rishendran Naidoo
- Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, Australia
| | - Morgan N. Windsor
- Department of Cardiothoracic Surgery, The Prince Charles Hospital, Brisbane, Australia
| | - Peter Goldstraw
- Academic Department of Thoracic Surgery, Royal Brompton Hospital, London, UK
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187
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Darwiche K, Zarogoulidis P, Baehner K, Welter S, Tetzner R, Wohlschlaeger J, Theegarten D, Nakajima T, Freitag L. Assessment of SHOX2 methylation in EBUS-TBNA specimen improves accuracy in lung cancer staging. Ann Oncol 2013; 24:2866-70. [PMID: 24026539 DOI: 10.1093/annonc/mdt365] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) is a well-established method to assess mediastinal lymph nodes for lung cancer. However, a proportion of patients require further investigation, due to the low negative predictive value (NPV). The objective of this study was to determine whether the assessment of short stature homeobox 2 (SHOX2) DNA methylation level in lymph node tissue obtained by EBUS-TBNA improves the accuracy of mediastinal staging. PATIENTS AND METHODS EBUS-TBNA was carried out for suspicious lymph nodes of 154 patients. Negative or ambiguous histological results were confirmed by surgical means and clinical follow-up over 6 months. EBUS-TBNA was assessed on 80 positive and 85 negative classified lymph nodes and compared with the result of the SHOX2 DNA methylation real-time PCR analysis. Relative methylation measured by delta-delta cycle threshold (ΔΔCt) was used to classify the samples. Clinical performance of the EBUS-TBNA procedure with and without the additional SHOX2 assessment was calculated against the final classification according to the gold standard. RESULTS Based on data from 105 patients, an average 80-fold increase in the SHOX2 methylation level was measured for positive compared with negative lymph nodes. SHOX2 results with a ΔΔCt value of <6.5 indicate positive lymph nodes. Applying this molecular analysis to EBUS-TBNA cases, not diagnosed by pathologic assessment, the sensitivity of staging was improved by 17%-99%. The NPV increased from 80% to 99%. CONCLUSIONS The combination of EBUS-TBNA and SHOX2 methylation level strongly improves the assessment of the nodal status by identifying additional malignant lesions and confirming benign nodes and therefore avoiding invasive follow-up procedures.
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Affiliation(s)
- K Darwiche
- Department of Interventional Pneumology, Ruhrlandklinik, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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188
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Horita N, Miyazawa N, Morita S, Kojima R, Kimura N, Kaneko T, Ishigatsubo Y. Preoperative Chemotherapy Is Effective for Stage III Resectable Non–Small-Cell Lung Cancer: Metaanalysis of 16 Trials. Clin Lung Cancer 2013; 14:488-94. [DOI: 10.1016/j.cllc.2013.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Revised: 02/20/2013] [Accepted: 03/26/2013] [Indexed: 11/17/2022]
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189
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Scarpaci A, Mitra P, Jarrar D, Masters GA. Multimodality approach to management of stage III non-small cell lung cancer. Surg Oncol Clin N Am 2013; 22:319-28. [PMID: 23453337 DOI: 10.1016/j.soc.2012.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Stage III non-small cell lung cancer represents a heterogeneous group of patients who are best managed with a multidisciplinary approach, including evaluation for surgical, radiation, and chemotherapeutic options.
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Affiliation(s)
- Anthony Scarpaci
- Medical Oncology, Albert Einstein Medical Center Philadelphia, Philadelphia, PA 19141, USA.
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190
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191
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Ramnath N, Dilling TJ, Harris LJ, Kim AW, Michaud GC, Balekian AA, Diekemper R, Detterbeck FC, Arenberg DA. Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143:e314S-e340S. [PMID: 23649445 DOI: 10.1378/chest.12-2360] [Citation(s) in RCA: 312] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Stage III non-small cell lung cancer (NSCLC) describes a heterogeneous population with disease presentation ranging from apparently resectable tumors with occult microscopic nodal metastases to unresectable, bulky nodal disease. This review updates the published clinical trials since the last American College of Chest Physicians guidelines to make treatment recommendations for this controversial subset of patients. METHODS Systematic searches were conducted through MEDLINE, Embase, and the Cochrane Database for Systematic Review up to December 2011, focusing primarily on randomized trials, selected meta-analyses, practice guidelines, and reviews. RESULTS For individuals with stage IIIA or IIIB disease, good performance scores, and minimal weight loss, treatment with combined chemoradiotherapy results in better survival than radiotherapy alone. Consolidation chemotherapy or targeted therapy following definitive chemoradiation for stage IIIA is not supported. Neoadjuvant therapy followed by surgery is neither clearly better nor clearly worse than definitive chemoradiation. Most of the arguments made regarding patient selection for neoadjuvant therapy and surgical resection provide evidence for better prognosis but not for a beneficial impact of this treatment strategy; however, weak comparative data suggest a possible role if only lobectomy is needed in a center with a low perioperative mortality rate. The evidence supports routine platinum-based adjuvant chemotherapy following complete resection of stage IIIA lung cancer encountered unexpectedly at surgery. Postoperative radiotherapy improves local control without improving survival. CONCLUSIONS Multimodality therapy is preferable in most subsets of patients with stage III lung cancer. Variability in the patients included in randomized trials limits the ability to combine results across studies and thus limits the strength of recommendations in many scenarios. Future trials are needed to investigate the roles of individualized chemotherapy, surgery in particular cohorts or settings, prophylactic cranial radiation, and adaptive radiation.
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Affiliation(s)
- Nithya Ramnath
- University of Michigan Comprehensive Cancer Center, Ann Arbor, MI
| | | | - Loren J Harris
- Thoracic Surgery, Maimonides Medical Center, Brooklyn, NY
| | | | | | | | | | | | - Douglas A Arenberg
- Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI.
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192
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Chen Z, Luo Q, Jian H, Zhou Z, Cheng B, Lu S, Liao M. Long-term results of a randomized controlled trial evaluating preoperative chemotherapy in resectable non-small cell lung cancer. Onco Targets Ther 2013; 6:645-50. [PMID: 23776338 PMCID: PMC3681405 DOI: 10.2147/ott.s44503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE We aimed to evaluate whether preoperative chemotherapy provides benefits in the survival and prognosis of patients with non-small cell lung cancer (NSCLC) in resectable stages I to IIIA, except T1N0. METHODS In this randomized, controlled trial, 356 patients with stage I (except for T1N0), II and IIIA NSCLC were assigned to either the preoperative chemotherapy plus surgery arm (179 patients) or the primary surgery arm (177 patients). Both treatments were followed by adjuvant chemotherapy. The end point of this study included overall survival (OS), progression-free survival (PFS), and survival rate associated with clinical remission. RESULTS Statistical survival difference was found between the preoperative chemotherapy plus surgery arm and the surgery-alone arm. However, the median survival time (MST) in the preoperative chemotherapy arm was lower than that of surgery-alone arm (MST, 45.42 months vs 57.59 months) (P = 0.016). When comparing the effect of preoperative chemotherapy at each stage of NSCLC, a statistical survival difference was found in stage II NSCLC but not in stage I and IIIA (MST 40.86 months vs 80.81 months) (P = 0.044). However, no statistically significant difference in PFS was noticed between the two arms, except for stage I NSCLC (hazard radio [HR] = 0.87; 95% CI, 0.561-1.629; P = 0.027). The survival rate was higher for patients who had clinical remission after preoperative chemotherapy, but the differences did not reach statistical significance (MST 42.10 months vs 35.33 months) (P = 0.630). CONCLUSION Preoperative chemotherapy did not show benefits in OS and PFS for stage I-IIIA NSCLC patients.
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Affiliation(s)
- Zhiwei Chen
- Shanghai Lung Tumor Clinical Medical Center, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, People's Republic of China
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193
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Westeel V, Quoix E, Puyraveau M, Lavolé A, Braun D, Laporte S, Bigay-Game L, Pujol JL, Ozenne G, Rivière A, Douillard JY, Lebeau B, Debieuvre D, Poudenx M, David P, Molinier O, Zalcman G, Lemarié E, Morin F, Depierre A, Milleron B. A randomised trial comparing preoperative to perioperative chemotherapy in early-stage non-small-cell lung cancer (IFCT 0002 trial). Eur J Cancer 2013; 49:2654-64. [PMID: 23735703 DOI: 10.1016/j.ejca.2013.04.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Revised: 04/01/2013] [Accepted: 04/05/2013] [Indexed: 11/27/2022]
Abstract
HYPOTHESIS There will be a detectable increase in overall survival (OS) using preoperative (PRE) as opposed to perioperative (PERI) chemotherapy in resectable StageI-II non-small-cell lung cancer (NSCLC). METHODS This multicenter, open-label, randomised trial with a 2×2 factorial design first compared two chemotherapy strategies (PRE versus PERI), then two chemotherapy regimens (gemcitabine-cisplatin [GP] versus paclitaxel-carboplatin [TC]). The PRE group received two preoperative cycles followed by two additional preoperative cycles, while the PERI group underwent two preoperative cycles followed by two postoperative cycles, the 3rd and 4th cycles being given only to responders in both cases. RESULTS A total of 528 patients were randomised, 267 of which were assigned to the PRE group and 261 to the PERI group. Three-year OS did not differ between the two groups (67.4% and 67.7%, respectively; hazard ratio (HR)=1.01 [0.79-1.30], p=0.92), nor did 3-year disease-free survival, response rates, toxicity, or postoperative mortality. Pathological complete response was observed in 22 (8.2%) and 16 patients (6.1%), respectively. Although quality of life did not differ significantly, chemotherapy compliance was significantly higher in the PRE group. The proportion of responders who received Cycles 3 and 4 was significantly higher in the PRE group (90.4% versus 75.2%, p=0.001). In responders, the dose intensity of Cycles 3 and 4 was higher in the PRE group than in the PERI group (mean relative dose intensity of 90.4% versus 82.6%, respectively; p=0.0007). There was no difference between GP and TC in 3-year OS (HR=0.97 [95% confidence interval (CI): 0.76-1.25], p=0.80) or response rates. However, the regimens' toxicity profiles differed. CONCLUSIONS This study failed to demonstrate any difference in survival between patients receiving preoperative and perioperative chemotherapy in early-stage NSCLC. The increase from two to four preoperative chemotherapy cycles did not increase the pathological response rate.
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Affiliation(s)
- Virginie Westeel
- Centre Hospitalier Régional Universitaire de Besançon, Université de Franche-Comté, EA 3181, France.
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"When Roscius was an actor in Rome-" care for the elderly with N2-positive non-small-cell lung cancer. J Thorac Oncol 2013; 8:670-2. [PMID: 23676556 DOI: 10.1097/jto.0b013e31828f5b51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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195
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Ripley RT, Rusch VW. Role of induction therapy: surgical resection of non-small cell lung cancer after induction therapy. Thorac Surg Clin 2013; 23:273-85. [PMID: 23931012 DOI: 10.1016/j.thorsurg.2013.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Patients with Stage III non-small cell lung cancer are best managed by multimodality therapy. Patients with N2 disease can be treated with induction therapy (usually chemotherapy) followed by surgical resection. Patients whose medical comorbidities preclude surgery should be treated with definitive chemoradiotherapy. T3 or T4 tumors involving the superior sulcus or spine are best managed with induction chemoradiotherapy and surgical resection.
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Affiliation(s)
- R Taylor Ripley
- Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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196
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Kesarwala AH, Grover S, Rengan R. Role of particle beam therapy in a trimodality approach to locally advanced non-small cell lung cancer. Thorac Cancer 2013; 4:95-101. [PMID: 28920191 DOI: 10.1111/j.1759-7714.2012.00174.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Accepted: 09/14/2012] [Indexed: 12/25/2022] Open
Abstract
Lung cancer accounts for nearly one-fifth of all cancer deaths worldwide and is the most common cause of cancer-related death in the United States. Outcomes for locally advanced non-small cell lung cancer remain extremely poor with regards to both local control and overall survival. Modest gains in local control were obtained with the incorporation of multimodality treatment, including preoperative chemotherapy followed by surgical resection; combination chemoradiotherapy also improved survival, secondary to improved local control. While the natural progression to trimodality therapy resulted in superior local control, it did not translate to improved overall survival, secondary to increased toxicity. The additional morbidity is likely from radiation toxicity, the minimization of which will be crucial to the future success of trimodality therapy. One strategy to decrease toxicity is to utilize charged particles, such as protons, which deposit a high dose at the Bragg peak with a minimal dose beyond the peak, thereby reducing the dose to distal normal tissues. Trimodality therapy incorporating preoperative proton radiation therapy and chemotherapy, followed by surgery, is currently being evaluated as a potential strategy to achieve improved local control and overall survival in locally advanced non-small cell lung cancer.
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Affiliation(s)
- Aparna H Kesarwala
- Radiation Oncology Branch, National Institutes of Health, National Cancer Institute, Bethesda, MD, USA
| | - Surbhi Grover
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ramesh Rengan
- Department of Radiation Oncology, Perelman Center for Advanced Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Ohba T, Toyokawa G, Kometani T, Nosaki K, Hirai F, Yamaguchi M, Hamatake M, Seto T, Ichinose Y, Sugio K. Mutations of the EGFR and K-ras genes in resected stage I lung adenocarcinoma and their clinical significance. Surg Today 2013; 44:478-86. [PMID: 23609009 DOI: 10.1007/s00595-013-0589-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 01/16/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE This study retrospectively assessed the mutations of the epidermal growth factor receptor (EGFR) and K-ras genes and their clinical significance in patients with resected stage I adenocarcinomas. METHODS A total of 354 patients with resected lung adenocarcinomas were included, and 256 patients with stage I disease were analyzed for the prognostic and predictive value of these mutations. RESULTS Mutations of EGFR and K-ras genes were detected in 149 (41.1 %) and 23 (6.4 %) of all tumors, and in 122 (47.6 %) and 14 (5.5 %) of stage I tumors, respectively. There were no significant differences in the disease-free survival (DFS) and overall survival (OS) between the EGFR-mutant and wild-type groups. However, the DFS and OS were significantly shorter in patients with K-ras mutations than in those without (5-year DFS: 50.8 vs. 76.9 %, 5-year OS: 70.0 vs. 86.6 %, p < 0.01). A multivariate analysis showed that K-ras mutations were an independent poor prognostic factor. Twenty-four of the 41 patients with recurrent disease after surgery were treated with an EGFR-TKI. Fifteen EGFR-mutant patients treated with an EGFR-TKI had a better prognosis than did the nine EGFR-wild-type patients. CONCLUSION The presence of an EGFR gene mutation was a predictive factor for the response to EGFR-TKI treatment in patients with resected stage I adenocarcinoma, but was not a prognostic factor. The presence of a K-ras gene mutation was a poor prognostic factor.
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Affiliation(s)
- Taro Ohba
- Department of Thoracic Oncology, National Kyushu Cancer Center, 3-1-1, Notame, Minami-ku, Fukuoka, 811-1395, Japan,
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198
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Raja FA, Ming Lee S. Chemotherapy and Biological Agents. Lung Cancer 2013. [DOI: 10.1002/9781118702857.ch3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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199
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Jeremić B, Miličić B, Milisavljević S. Radiotherapy Alone vs. Radiochemotherapy in Patients With Favorable Prognosis of Clinical Stage IIIA Non–Small-Cell Lung Cancer. Clin Lung Cancer 2013; 14:172-80. [DOI: 10.1016/j.cllc.2012.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 09/29/2012] [Accepted: 10/08/2012] [Indexed: 12/28/2022]
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Roberts PJ, Stinchcombe TE. KRAS mutation: should we test for it, and does it matter? J Clin Oncol 2013; 31:1112-21. [PMID: 23401440 DOI: 10.1200/jco.2012.43.0454] [Citation(s) in RCA: 188] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Lung cancer is the leading cause of cancer mortality in the United States and worldwide. Previously, lung cancer was simplistically divided into non-small-cell lung cancer (NSCLC) and small-cell lung cancer. However, in the last decade, we have gone from a simplistic binary system of classifying lung cancer to defining NSCLC on the basis of molecular subsets. KRAS mutations represent the most common molecular change in NSCLC. The presence of KRAS mutation has been shown to be associated with a poor prognosis in NSCLC, but this is of little clinical utility. More important is determining the clinical utility of KRAS mutational analysis for predicting benefit of chemotherapy, epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs), anti-EGFR monoclonal antibodies, or other novel therapeutics. Current data does not support the routine use of KRAS mutational analysis for predicting chemotherapy benefit. Additionally, there was significant interest in using KRAS status to select patients for EGFR TKI and anti-EGFR monoclonal antibodies. However, the EGFR mutational status has demonstrated significant predictive value in the selection of patients for EGFR TKI therapy and is now the preferred test. An association between KRAS mutational status and benefit of anti-EGFR monoclonal antibodies has not been demonstrated in NSCLC. Here we review, in the context of NSCLC, the underlying biology of KRAS mutations, the predictive value of KRAS mutations for therapeutic intervention, and the integration of KRAS mutational testing into our current clinical paradigms.
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Affiliation(s)
- Patrick J Roberts
- Lineberger Comprehensive Cancer Center, The University of North Carolina School of Medicine, Chapel Hill, NC 27599-7295, USA.
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