Bronchogenic carcinoma: nitrogen mustard as a surgical adjuvant and factors influencing survival. University surgical adjuvant lung project

Combined Modality Treatment of Non-Small-Cell Lung Cancer

Among all nonmetastatic non-small-cell lung cancer (NSCLC) patients, the best survival rates are observed in patients who undergo surgery. Nevertheless, 5-year survival rates vary between 20% and 60% depending on the stage of the disease. Several combined modality treatments have been investigated to improve outcome in localized NSCLC. These include local treatment, systemic before local treatment, concomitant systemic and local treatments, and systemic after local treatment. Preoperative irradiation was shown to be of no benefit on local recurrence rates or overall survival. Even doses of radiation >/=40 grays (Gy) were associated with lower survival rates. Postoperative irradiation did not influence survival in stage III disease and seemed to be deleterious in stages I and II disease. Modern radiotherapy techniques might be of interest in this setting but have been insufficiently tested. The early phase III studies of preoperative chemotherapy versus primary surgery in stage III NSCLC showed a tremendous difference in favor of chemotherapy. A larger study did not confirm these results but suggested that preoperative chemotherapy might have a greater effect in stages I and II of the disease. In locally advanced disease, chemotherapy followed by radiotherapy was shown to increase survival when compared with radiotherapy alone. Studies comparing concurrent chemoradiation with radiotherapy only were in favor of the concomitant schedule, which improved local control. Promising results have been reported with chemoradiation followed by surgery in stage IIIa and even stage IIIb disease. Randomized studies of postoperative chemotherapy demonstrated a 5% improvement in 5-year survival over adjuvant-free treatment. Postoperative chemoradiation showed no advantage over postoperative radiotherapy. Several trials that are ongoing or whose accrual was recently completed should further define the role of perioperative chemotherapy in resectable NSCLC and of trimodality treatments in advanced disease. Targeted agents are being developed in the postoperative setting. New schedules of chemoradiation with higher therapeutic indexes are also being investigated in nonresectable stage III NSCLC.

The role of chemotherapy in early-stage (stage I and II) resectable non-small cell lung cancer

For patients with stage I or II non-small cell lung cancer (NSCLC), surgical resection is considered the standard of care. Although surgery achieves long-term survival in many patients, a significant proportion experience locoregional or distant recurrence. Five-year survival rates after resection for stage I and II NSCLC range from 38% (T3 N0) to 67% (T1 N0). Efforts at improving survival for early-stage NSCLC patients have focused on the use of chemotherapy administered postoperatively (adjuvant) or preoperatively (neoadjuvant or induction) to eradicate micrometastatic disease. The majority of trials examining adjuvant chemotherapy have not found a survival benefit. A meta-analysis examining the role of chemotherapy in the treatment of NSCLC found a 5% absolute improvement in 5-year survival associated with the use of adjuvant cisplatin-based chemotherapy (P =.08). Chemotherapy administered before surgery or definitive irradiation has improved survival rates in patients with stage III NSCLC. The role of induction chemotherapy in stage I and II NSCLC is currently under investigation.

Chemotherapy in non-small cell lung cancer

BACKGROUND

Non-small cell lung cancer can no longer be regarded as resistant to chemotherapy, and there have recently been considerable improvements in the use of the older agents and advances in the identification of new drugs. Recent meta-analysis has also confirmed the view that chemotherapy can have small but modest survival benefits. Although in the treatment of stage IV disease the criteria of efficacy have concentrated on tumour response rates, more recently it has become obvious that these patients can also benefit in terms of improved symptom control.

RECENT ADVANCES

For patients with locally advanced stage III disease there have been important developments indicating the benefit of combined modality treatment with chemotherapy and thoracic irradiation. Furthermore, the use of neoadjuvant chemotherapy indicates that resection is possible in about half the patients, and on pathological examination of 15%-20% of the resected specimens there is no evidence of residual tumour. These results justify an increase in the use of systemic chemotherapy in this disease.

Randomized trial comparing postoperative chemotherapy with vindesine and cisplatin plus thoracic irradiation with irradiation alone in stage III (N2) non-small cell lung cancer

This prospective randomized trial was performed to determine whether postoperative chemotherapy with vindesine and cisplatin could lengthen time to progression and overall survival in stage III (T1-3N2M0) non-small cell lung cancer (NSCLC) patients. Seventy-two patients were entered; 36 were randomized to receive chemotherapy. Patients were stratified by extent of resection (complete vs. incomplete) and histology (squamous vs. nonsquamous). All had surgery and mediastinal irradiation 6-7 weeks post-thoracotomy. Incompletely resected patients had intraoperative 125I and/or 192Ir implantation. Vindesine (3 mg/m2) weekly x 5, then every 2 weeks x 8, and cisplatin (120 mg/m2) days 1, 29, 71, 113 were planned for those randomized to chemotherapy. No difference in time to progression (median 9.2 months for radiation + chemotherapy vs. 9.0 months for radiation, P = 0.35) or overall survival (16.3 months for radiation + chemotherapy vs. 19.1 months for radiation, P = 0.42) was found. Postoperative vindesine and cisplatin did not prolong time to progression or survival in this population of stage III NSCLC.

Postoperative chemotherapy for non-small-cell lung cancer

The Lung Cancer Study Group has performed a number of postoperative adjuvant trials in patients with resectable non-small-cell lung cancer (NSCLC). Adjuvant cyclophosphamide, doxorubicin, and cisplatin (CAP) chemotherapy was compared with immunotherapy in the treatment of 130 patients with stage II or III adenocarcinoma or large cell undifferentiated carcinoma. Careful intraoperative staging was performed in all patients. Disease-free interval was significantly prolonged in the chemotherapy group (p = 0.032). After 7.5 years of follow-up, the difference in time to recurrence and cancer deaths remains statistically significant. Another study compared CAP chemotherapy plus radiotherapy with radiotherapy alone in advanced stages II and III resected NSCLC. Again, the chemotherapy arm had significantly increased disease-free survival. In a third study, patients with high-risk stage I NSCLC were randomized after surgery to CAP chemotherapy or observation. In this study there was no difference in recurrence-free survival or overall survival.

Lung cancer: a review of current therapeutic modalities

This article describes the current approach to the systematic management of both small cell and non-small cell lung cancer (NSCLC). The treatment of stages I, II, and IIIa NSCLC is surgical resection. Although adjuvant chemotherapy in stage I disease offers no survival benefit, the role of adjuvant chemotherapy in stage II and IIIa NSCLC remains controversial. Results of pilot studies using neoadjuvant chemotherapy in stage IIIa NSCLC are encouraging and data from ongoing randomized trials are awaited with interest. For locally advanced NSCLC, chest irradiation remains the standard of care. However, the addition of systemic chemotherapy holds promise. The impact of cisplatin-based regimens on overall survival in stage IV NSCLC remains disappointing. The introduction of newer agents, such as 7-ethyl-10-[4-(1-piperidino)-1-piperidino] carbonyloxycamptothecin (CPT-11), a topoisomerase-I inhibitor, has shown early favorable results. Chemotherapy is the most important therapeutic modality in the management of small cell lung cancer because of this cancer's propensity for early dissemination. In limited stage small cell lung cancer, chest radiotherapy, particularly if used early and concurrently with chemotherapy, may improve survival, but at the expense of increased toxicity. The role of prophylactic brain irradiation remains controversial in limited-stage disease. Chemotherapy is also the most important treatment modality in extensive-stage disease, but its role is only palliative. Radiotherapy is reserved primarily for disease-related complications in patients in whom chemotherapy has failed.

Role of systemic therapy in advanced non-small-cell lung cancer

Increasing evidence supports the investigation of chemotherapy in patients with non-small-cell lung cancer (NSCLC). Randomized studies in patients with stage IV disease have shown increased survival in chemotherapy-treated patients compared to best supportive care and indicate the ability of chemotherapy to alter the natural history of this disease. Randomized studies involving adjuvant and neoadjuvant chemotherapy have also shown encouraging results. These studies and results of recent pilot studies utilizing neoadjuvant chemotherapy and concomitant chemoradiotherapy indicate a potential benefit from the use of chemotherapy in patients with NSCLC and call for its continued intensive investigation in clinical trials.

Failure of the perioperative PCV neoadjuvant polychemotherapy in resectable bronchogenic non-small cell carcinoma. Results from a randomized phase II trial

In 1985, the authors began a phase II study to assess the PCV perioperative polychemotherapy (cisplatin 100 mg/m2, cyclophosphamide 600 mg/m2, vindesine 3 mg/m2) in patients with resectable bronchogenic non-small cell carcinoma. Patients were randomized to receive either two preoperative courses of PCV chemotherapy, surgery, and two postoperative courses of PCV chemotherapy (PCV group) or immediate surgery (surgery group). A staging procedure using the CT scan was performed before randomization and, additionally, before surgery in the PCV group. There were 26 randomized patients, 13 in each group. In the PCV group, 11 patients agreed to receive the two preoperative courses of chemotherapy. A response was observed in five patients (45%), and a progression was observed in four patients (36%) leading to a cancellation of surgery in two of them. Postoperative care was the same for each group. Although no death could be related to chemotherapy, it was decided to stop entering new patients into this trial because of the rate of preoperative progression in the PCV group.

Adjuvant treatment in resected lung cancer

There have been many attempts to develop effective postoperative adjuvant therapy in patients with resected lung cancer. Metastatic disease is the commonest site of first recurrence. In squamous cell carcinoma local failure is another major problem and in adenocarcinoma brain metastases are frequent. There is evidence to suggest that radiotherapy can prevent local recurrence but does not appear to impact on survival. Response rates to chemotherapy alone and chemo-radiotherapy with prolongation of disease-free survival have been encouraging in locally advanced (resected stage II, III) disease when treated postoperatively. Results of clinical trials using immunotherapy or chemotherapy in early stage disease have been disappointing. Several prospective randomized studies by the Lung Cancer Study Group were undertaken to assess the merits of various adjuvant treatments and are presented.

Surgical adjuvant therapy of non-small-cell lung cancer

Results of several studies by the Lung Cancer Study Group have shown that postoperative adjuvant chemotherapy enhances survival following surgery for lung cancer. The 18-month disease-free survival almost doubled in one study using cyclophosphamide, doxorubicin, cisplatin (CAP) chemotherapy postoperatively. The recurrence rate remained significant, however. Patients with more advanced resectable disease seem to benefit most from postoperative chemotherapy. Results also suggest that CAP delays recurrences more effectively in patients with nonsquamous vs. squamous lung carcinoma. There has been considerable interest in the use of preoperative adjuvant therapy as well. Findings from studies of preoperative or induction therapy--either chemotherapy alone or in combination with radiation therapy--have shown high response rates and that patients with unresectable disease can be converted to technically resectable. Although preoperative therapy can cause difficulties with surgical dissection, surgical morbidity is acceptable. Preoperative chemotherapy and radiotherapy followed by surgical resection clearly eliminates local recurrence. Systemic recurrences remain a significant problem. The evidence, as yet, does not indicate that preoperative adjuvant therapy prolongs survival.

Non-small cell lung cancer

Lung cancer stands as the most important malignant neoplasm in the United States because of its high prevalence, increasing incidence, high rate of mortality, and great potential for prevention through the control of cigarette smoking. The World Health Organization (WHO) classification of lung cancer identifies four major types: squamous cell carcinoma, adenocarcinoma, large cell carcinoma, and small cell carcinoma. These tumors are commonly divided into two groups based on differences in their biology and treatment: small cell (SCLC) and non-small cell carcinomas (NSCLC). This review analyzes NSCLC with a strong emphasis on the practical aspects of treatment. We give recommendations about smoking cessation and early diagnosis through screening of high-risk individuals. We review contemporary diagnostic and staging techniques in the context of the new international TNM system of staging. Subsequent discussions of treatment are based on this new staging system. We stress the pivotal role of surgery for the management of local disease, and in addition present the potential contributions of newer radiation therapy techniques. We examine chemotherapy in detail, including a review of the comparative activity of the available cytotoxic agents against NSCLC, the relative contribution of combination chemotherapy, and the role of surgical adjuvant treatment with either chemotherapy or immunotherapy. We advise that patients with NSCLC be treated under the aegis of modern clinical trials of new therapy whenever possible. When this is not possible, we recommend an individualized approach based on such factors as the patient's age, general state of health, cardiopulmonary status, psychosocial status, and personal system of values.

Non-small cell lung cancer

Lung cancer stands as the most important malignant neoplasm in the United States because of its high prevalence, increasing incidence, high rate of mortality, and great potential for prevention through the control of cigarette smoking. The World Health Organization (WHO) classification of lung cancer identifies four major types: squamous cell carcinoma, adenocarcinoma, large cell carcinoma, and small cell carcinoma. These tumors are commonly divided into two groups based on differences in their biology and treatment: small cell (SCLC) and non-small cell carcinomas (NSCLC). This review analyzes NSCLC with a strong emphasis on the practical aspects of treatment. We give recommendations about smoking cessation and early diagnosis through screening of high-risk individuals. We review contemporary diagnostic and staging techniques in the context of the new international TNM system of staging. Subsequent discussions of treatment are based on this new staging system. We stress the pivotal role of surgery for the management of local disease, and in addition present the potential contributions of newer radiation therapy techniques. We examine chemotherapy in detail, including a review of the comparative activity of the available cytotoxic agents against NSCLC, the relative contribution of combination chemotherapy, and the role of surgical adjuvant treatment with either chemotherapy or immunotherapy. We advise that patients with NSCLC be treated under the aegis of modern clinical trials of new therapy whenever possible. When this is not possible, we recommend an individualized approach based on such factors as the patient's age, general state of health, cardiopulmonary status, psychosocial status, and personal system of values.

New frontiers in the treatment of lung cancer

Surgical resection still is the only significant curative approach in nonsmall cell lung cancer. Recent surgical experience indicates that a modest decrease in the death rate from bronchogenic carcinoma may occur in three general areas: (1) the detection and treatment of radiographically occult squamous cell carcinoma; (2) the combination of adjuvant chemotherapy and surgical excision in selected patients with small cell carcinoma; and (3) surgical resection and postop irradiation of patients with hilar and mediastinal lymph node metastases. At the time of diagnosis, 80 to 85% of the patients present with unresectable lung cancer. These patients may benefit from other modalities of therapy, i.e., radiotherapy, chemotherapy, or immunotherapy. Failures following radiotherapy in unresectable nonsmall cell lung cancer are due to (1) distant metastasis, (2) local region failure, and (3) local and distant failure. To increase the local control, new methods of treatment have been tried, such as hyperfractionation of radiotherapy and the use of 131I antiferritin immunoglobulin. The development of effective systemic chemotherapy is necessary to treat metastatic bronchogenic carcinoma. The response rate to chemotherapeutic agents is substantially lower in nonsmall cell carcinoma than in small cell carcinoma. Investigation is ongoing to assess the effectiveness of new antitumor drugs used alone, in combination with other drugs, or combined with other modalities for the treatment of bronchogenic carcinoma.

Thirty years of surgery for carcinoma of the bronchus

A study has been made of 8781 patients with bronchial carcinoma who were operated on by seven surgeons in England during the years 1949-80. There were 3865 pneumonectomies, 3790 lobectomies, and 1126 thoracotomies. During this period the operative mortality has fallen. Neither the resection rate nor the proportion of lobectomies bears any relation to the survival rate in any series. There has been remarkable similarity between the various survival rates in that the difference at five years was only 1.3% (25.5-26.8%) and at 10 years 4.2% (13.6-17.8%). These figures are reflected in reports published worldwide, where there is also great similarity between the results. If the improvement in operative mortality is excluded, there has been no improvement in the survival rates in the last thirty years.

Prolonged intermittent adjuvant chemotherapy with CCNU and hydroxyurea after resection of carcinoma of the lung

Eight hundred sixty-five patients with a microscopically curative resection for carcinoma of the lung were accepted for study, none of whom were excluded from analysis. Adjuvant therapy was randomly assigned about the tenth to 14th postoperative day; 432 patients (treated) were to receive CCNU and hydroxyurea for one year, while 433 patients (controls) were to receive no adjuvant therapy. Toxic reactions to therapy were reported, but only 1% were severe enough to require stopping therapy. No evidence of improved survival or delayed recurrence of disease was seen in treated patients as a whole or when examined by cell type and by postsurgical TNM category. On the contrary, survival beyond the second year of follow-up may have been impaired by the drugs when administered to patients without evidence of tumor spread to the lymph nodes.

Adjuvant therapy with levamisole in resectable lung cancer

In view of the discouraging results that have been obtained so far with the use of cytotoxic chemotherapy as an adjunct to surgery, a double-blind placebo-controlled evaluation of the adjuvant use of levamisole was conducted in 211 resectable lung cancer patients, following these patients for 2 years after their operation. Levamisole (or the placebo) was given for 3 days every 2 weeks and the dose level ranged 1.1--3.8 mg/kg per day (a fixed dose of 3 x 50 mg was given to all patients). It appeared that recurrences and carcinomatous deaths had occurred significantly less often in patients who had received a high dose (i.e., 2.1--3,8 mg/kg: patients weighing 70 kg or less) but not in the patients who received a lower dose. Patients who had more advanced cancers at the time of surgery seemed to have profited more from the treatment, but the results did not seem to depend upon the histologic type of the tumor or on the immune status of the patients as estimated from the skin test reactivity at the start. There was also suggestive evidence that levamisole may be more effective in preventing hematogenous dissemination than in inhibiting recurrences in the lung or the mediastinal tissues. Levamisole, if dosed adequately, appears to be a very suitable adjuvant treatment in resectable lung cancer patients as judged from its efficacy and its lack of troublesome side-effects.

Adjuvant cancer chemotherapy after resection of carcinoma of the lung

A prospective randomized trial was conducted by the Veterans Administration Surgical Adjuvant Group in an attempt to discern the value of prolonged intermittent courses of adjuvant cancer chemotherapy after a successful curative resection of a carcinoma of the lung in men. Four hundred and seventeen patients were randomized into three groups; 132 patients received cyclophosphamide (Cytoxan), regimen A; 142 patients received cyclophosphamide alternating with methotrexate, regimen b; and 143 patients received no additional therapy, the controls. The patients in the two treatment groups received an average of 7.1 drug courses. No drug mortality was noted, but toxic symptoms of varying severity were seen after 43.6% of the drug courses. Five-year survival in the two treatment groups was 24.9% (regiment A) and 25.7% (regimen B), respectively, and 23.5% in the control group. No treatment benefit was associated with adjuvant chemotherapy in this trial.

Adjuvant chemotherapy in lung cancer: review and prospects

The results of trials testing combined surgery and chemotherapy in lung cancer are reviewed. Fifteen adjuvant trials using various chemotherapeutic agents were analyzed to determine reasons for their lack of success. Current trials with adjuvant therapy in lung cancer are briefly outlined. In addition, analysis of the activity of chemotherapeutic agents in advanced lung cancer and its implications in the design of future adjuvant studies are detailed.

Tumour size as a prognostic factor after resection of lung carcinoma

Two hundred and ninety-five patients who underwent resection for carcinoma of the lung are reviewed, with a particular view to size of tumour and survival rate. The carcinomas were divided into four groups by size. It was found that the larger the tumour the worse was the prognosis. The prognosis in large carcinomas could not be directly attributed to a preponderance of an unfavourable cell type, lymph node metastasis or mediastinal extension. Vascular dissemination at the time of operation is believed to be a major factor for the poor prognosis in this group of carcinomas. Radiotherapy before operation and early ligation of the pulmonary veins might improve the results of resection of large carcinomas.

Immunopotentiation with levamisole in resectable bronchogenic carcinoma: a double-blind controlled trial; Study Group for Bronchogenic Carcinoma

A long-term multicentre double-blind study was designed to test the immunotropic effects of levamisole in patients undergoing operation for primary bronchial carcinoma. They received levamisole 50 mg three times a day by mouth or placebo for three days every fortnight, starting three days before surgery. Unless there was clinical evidence of recurrence, cytostatic drugs, corticosteroids, and radiotherapy were prohibited. In the 111 patients who have been followed up for one year the incidence of side effects was similar in both groups. Recurrences occurred in 10 out of 51 patients (seven deaths) receiving levamisole and in 20 out of 60 (12 deaths) receiving placebo. Further analysis showed that there were fewer recurrences on levamisole in patients with squamous cell carcinomas and medium and large primary tumours and fewer suspected and proved recurrences and deaths from metastases on levamisole in patients with extended tumours. Distant recurrences tended to be less common with levamisole, whereas the disease-free interval in relapsing patients was almost identical in the two groups. These interim results show that levamisole seems to exert its beneficial effect by preventing immunosuppression due to surgery.

Factors affecting long-term survival of patients with bronchogenic carcinoma

From January 1963 to December 1968, 148 patients underwent thoracotomy for bronchogenic carcinoma. In 123 patients either lobectomy or pneumonectomy was performed (resectability rate of 84 per cent). The over-all operative mortality was 3.4 per cent. Forty of the patients undergoing resection (34 per cent) are alive and free of cancer five years after surgery. Tumor size, nodal involvement, cell type, location, symptoms, and extent of surgery were studied in relation to the long-term results. Five year survival was directly related to the size of the tumor and the extent of nodal involvement. No patients with mediastinal nodal involvement or with lesions larger than 7 cm in diameter were among the long-term survivors.

Pathological factors in survival of lung tumours: local extent, size, and nodal involvement

The pathological features, particularly local extent, size, and nodal involvement, of 405 surgical specimens of human lung carcinomas were studied. A direct relationship was found between local extent and size of the tumour and between local extent and the incidence of lymph node metastasis, but not between tumour size and the incidence of lymph node metastasis. The survival rates in the 405 tumours were calculated with the actuarial method in relation to the 3 pathological factors: local extent, lymph node metastasis and tumour size showed a predictive value in prognosis of lung tumours. Their prognostic value, however, was much more meaningful when the three pathological factors were considered in relation to each other. As a matter of fact, the size of the tumour showed no predictive value when lymph node metastasis was present. On the ground of the mutual influence of the 3 factors in affecting prognosis a pathological stage-grouping of lung tumours has been suggested.