Concomitant and alternating radiation therapy (RT) and chemotherapy (CT) for inoperable, M0, non-small cell lung cancers (NSCLC): a consensus report

[Non-metastatic advanced non-small cell lung carcinoma: systemic high-dose brachytherapy following curative external radiotherapy]

PURPOSE

To analyse retrospectively the local control, overall survival and immediate and long-term tolerance after a radiotherapy delivered with a curative intent systematically including a high-dose rate brachytherapy.

PATIENTS AND METHODS

From January 1993 to January 1995, 50 patients (45 males-five females, median age: 61) with non-small cell lung cancers, inoperable for tumour reasons, non-metastatic, were included in the protocol. Following external radiotherapy (55-65 Gy conventional fractionation), all the patients received high-dose rate brachytherapy delivering 14 to 24 Gy using fractions of 7 Gy.

RESULTS

Immediate tolerance was good. Two months after the end of the treatment, five patients suffered from massive haemorrhages and three others experienced a mucosal necrosis (two tracheal sites). Tumour response was observed endoscopically in 88% of the cases (38/50) and was complete in 38%. Median survival of complete responders was 15 months. In the mean follow-up period of 24 months, five patients were still alive with no evidence of disease (median survival: 30 months). Most of the patients died from distant metastases (33/50: 66%).

CONCLUSION

Systematic use of endoluminal high-dose rate brachytherapy in addition to external radiotherapy did not improve survival. The gain in the local control rate was counteracted by an increase in haemorrhages and mucosal necroses. Improving techniques and dosimetry, and combining different methods which have proved their efficiency, should result in improvements in survival. Quality of life would be part of the analysed parameters in any future study.

Non-surgical therapy for patients with advanced non-small cell lung cancer

Advanced non-small cell lung cancer (NSCLC) denotes those of TNM stage III and IV. NSCLC has its specific characteristics in respect of oncological behaviour, molecular biology, sensitivity to chemotherapy (CT) and radiotherapy (RT), and requires different therapeutic strategies in comparison with small cell lung cancer. The therapies include: (1) surgery in combination with new effective drugs is resulted in improved RR from 15% a decade ago to 40-60% today. Cisplatin (C-DDP) is the most attractive drug in the treatment of NSCLC, in lengthening the life-span of Stage IV NSCLC patients and as an indispensable sensitizer in RT. Taxinol, Gemcitabine (GEM), Navelbine (NVB), Edatrexate (ETX), CPT-11 and high dose Epirubicin (EPI HD) are recommended as new effective drugs. Response rates recently reported for the combination CT with the drugs mentioned above for NSCLC are from 30-65%, and with 8-42 weeks of MST. Induction or neoadjuvant therapies for advanced NSCLC, with 40-69% of RR, 25-29% of complete resection rate, 8-34% of CR and 17-45% of one year SR are reviewed. Eight random studies comparing MST between CT with C-DDP and best supportive care for NSCLC are statistically significant. (2) RT for Stage III NSCLC with 2 year and 5 year survivals of 20 and 5% respectively. Although such outcome is hardly acceptable, RT sensitizer, modified RT techniques and chemoradiotherapy (CRT) are imperative to improve the effect of RT in advanced NSCLC. Clinical literature suggest that CRT is better than RT, though without marked difference. Further studies and sufficient follow-up are necessary to judge the efficacy in terms of long-term survival and toxic reaction. (3) Biological therapy: gene therapy of NSCLC is still in the experimental and developmental stage. Of biological response modifier (BRM), alpha IFN in 11 cases of NSCLC with RR of 9% and MST of 14 months, IL-2 and LAK cell treatment in 11 cases with RR of 9% and MST of 18 months are reported. Instillation of BRM such as IL-2 or alpha-IFN into the pleura after drainage of cancerous effusion has been reported as the most effective for those whose RR is of 80-90% and the clinical response time is fairly long. Hematological cytokine as a protective adjuvant therapy against CT/RT toxicity makes high dose of CT possible and raises the response and patient tolerance. In multimodality therapy, it plays an important role to reduce post CT infection and septicemia.

Accelerated induction therapy and resection for poor prognosis stage III non-small cell lung cancer

BACKGROUND

Induction therapy and resection may improve the survival of patients with poor prognosis stage III non-small cell lung cancer, at the cost of significant treatment prolongation. The purpose of this study was to assess toxicity, response, and survival of an accelerated induction regimen and resection in poor prognosis stage III non-small cell lung cancer.

METHODS

Forty-two surgically staged patients with poor prognosis stage III non-small cell lung cancer received 11 days of induction treatment consisting of 96 hours of continuous chemotherapy infusions of cisplatin (20 mg.m-2.day-2), 5 fluorouracil (1,000 mg.m-2.day-2), and etoposide (75 mg.m-2.day-2) concurrent with accelerated fractionation radiation therapy (1.5 Gy twice a day, to a dose of 27 Gy). Induction was followed in 4 weeks by resection. Postoperatively, a second course of continuous chemotherapy and concurrent accelerated fractionation radiation therapy (postoperative dose 13 to 36 Gy) was given.

RESULTS

Despite some degree of induction toxicity in all patients there was only one induction death (2.4%). A clinical partial response was seen in 24 patients (57%). Thirty-six patients (86%) underwent thoracotomy, and resection was possible in 33 (79%). Pathologic downstaging was seen in 17 patients (40%), and 2 patients (5%) had no residual carcinoma at operation. There were 11 postoperative complications (31%) and 4 postoperative deaths (11%). Thirteen patients (31%) are alive and disease-free, 24 (57%) have persistent disease or have recurred (15 distant, 5 locoregional, 4 both), and 9 patients are alive with disease. The median survival is 21 months and the 2-year Kaplan-Meier survival is 43%, with no differences identified between stages IIIA and IIIB patients (p = 0.63).

CONCLUSIONS

We conclude that accelerated induction therapy and resection in poor prognosis stage III non-small cell lung cancer (1) is toxic, with a 12% treatment mortality; (2) is effective with a 79% resection rate and 40% pathologic downstaging rate; (3) provides excellent local control; (4) may prolong survival; and (5) is of value in stage IIIB as well as stage IIIA patients.