Effectiveness and toxicity of preoperative therapy in stage IIIA non-small cell lung cancer including the Memorial Sloan-Kettering experience with induction MVP in patients with bulky mediastinal lymph node metastases (Clinical N2)

Stage III Non-Small-Cell Lung Cancer: An Overview of Treatment Options

Lung cancer is the second-most commonly diagnosed cancer and the leading cause of cancer death worldwide. The most common histological type is non-small-cell lung cancer, accounting for 85% of all lung cancer cases. About one out of three new cases of non-small-cell lung cancer are diagnosed at a locally advanced stage—mainly stage III—consisting of a widely heterogeneous group of patients presenting significant differences in terms of tumor volume, local diffusion, and lymph nodal involvement. Stage III NSCLC therapy is based on the pivotal role of multimodal treatment, including surgery, radiotherapy, and a wide-ranging option of systemic treatments. Radical surgery is indicated in the case of hilar lymphnodal involvement or single station mediastinal ipsilateral involvement, possibly after neoadjuvant chemotherapy; the best appropriate treatment for multistation mediastinal lymph node involvement still represents a matter of debate. Although the main scope of treatments in this setting is potentially curative, the overall survival rates are still poor, ranging from 36% to 26% and 13% in stages IIIA, IIIB, and IIIC, respectively. The aim of this article is to provide an up-to-date, comprehensive overview of the state-of-the-art treatments for stage III non-small-cell lung cancer.

Surgical results of the Lung Cancer Mutation Consortium 3 trial: A phase II multicenter single-arm study to investigate the efficacy and safety of atezolizumab as neoadjuvant therapy in patients with stages IB-select IIIB resectable non-small cell lung cancer

OBJECTIVE

Multimodality treatment for resectable non-small cell lung cancer has long remained at a therapeutic plateau. Immune checkpoint inhibitors are highly effective in advanced non-small cell lung cancer and promising preoperatively in small clinical trials for resectable non-small cell lung cancer. This large multicenter trial tested the safety and efficacy of neoadjuvant atezolizumab and surgery.

METHODS

Patients with stage IB to select IIIB resectable non-small cell lung cancer and Eastern Cooperative Oncology Group performance status 0/1 were eligible. Patients received atezolizumab 1200 mg intravenously every 3 weeks for 2 cycles or less followed by resection. The primary end point was major pathological response in patients without EGFR/ALK+ alterations. Pre- and post-treatment computed tomography, positron emission tomography, pulmonary function tests, and biospecimens were obtained. Adverse events were recorded by Common Terminology Criteria for Adverse Events v.4.0.

RESULTS

From April 2017 to February 2020, 181 patients were entered in the study. Baseline characteristics were mean age, 65.1 years; female, 93 of 181 (51%); nonsquamous histology, 112 of 181 (62%); and clinical stages IIB to IIIB, 147 of 181 (81%). In patients without EGFR/ALK alterations who underwent surgery, the major pathological response rate was 20% (29/143; 95% confidence interval, 14-28) and the pathological complete response rate was 6% (8/143; 95% confidence interval, 2-11). There were no grade 4/5 treatment-related adverse events preoperatively. Of 159 patients (87.8%) undergoing surgery, 145 (91%) had pathologic complete resection. There were 5 (3%) intraoperative complications, no intraoperative deaths, and 2 postoperative deaths within 90 days, 1 treatment related. Median disease-free and overall survival have not been reached.

CONCLUSIONS

Neoadjuvant atezolizumab in resectable stage IB to IIIB non-small cell lung cancer was well tolerated, yielded a 20% major pathological response rate, and allowed safe, complete surgical resection. These results strongly support the further development of immune checkpoint inhibitors as preoperative therapy in locally advanced non-small cell lung cancer.

2nd ESMO Consensus Conference in Lung Cancer: locally advanced stage III non-small-cell lung cancer

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.

The role of chemotherapy in the management of stage IIIA non-small cell lung cancer

Patients with confirmed stage IIIA non-small cell lung cancer (NSCLC) represent a very heterogeneous group which includes those with limited microscopic ipsilateral mediastinal lymph node involvement discovered after a surgical resection, as well as those who have radiologically evident bulky subcarinal lymph node involvement at presentation. Different therapeutic options in stage IIIA disease include neoadjuvant chemo- or chemoradiotherapy followed by surgery, primary surgery followed by adjuvant chemotherapy with or without sequential adjuvant radiation therapy or definitive chemoradiation without surgery. The roles of surgery and radiation in stage IIIA disease are controversial, and there is inadequate data from randomized trials to inform the optimal therapeutic strategy. In contrast, chemotherapy has a clear indication in the curative setting. Data from randomized trials indicates that cisplatin-based chemotherapy should be given in either adjuvant or neoadjuvant settings to patients who are undergoing curative surgical resection and who are candidates for cisplatin therapy. In definitive chemoradiotherapy, cisplatin-based therapy is recommended although a carboplatin-based regimen may be given if patients cannot receive cisplatin. Finally, all patients with stage IIIA NSCLC should be evaluated early in a multidisciplinary setting that includes medical and radiation oncologists and thoracic surgeons with experience in lung cancer therapy.

Carinal resection after induction bronchial arterial infusion for locally advanced non-small cell lung cancer

We herein describe 3 cases of a carinal resection after induction bronchial arterial infusion (BAI) for locally advanced non-small cell lung cancer (NSCLC). Case 1 was a 44-year-old man with T1N2M0 adenocarcinoma. After undergoing Nd-YAG laser treatment (5079 J) and BAI [cis-diamminedichloro platinum (CDDP) 100 mg/body], a right sleeve upper lobectomy with a carinal resection and reconstruction (Montage type) was performed. Case 2 was a 67-year-old man with T4N1M0 squamous cell carcinoma. After BAI (CDDP 120 mg/body), an operation (same as case 1) was performed. Case 3 was a 72-year-old man with T4N2M0 squamous cell carcinoma. After BAI (CDDP 120 mg/body), a right sleeve peumonectomy was performed. There was neither BAI-related intraoperative nor postoperative complications. BAI with CDDP was thus found to be a useful and effective therapeutic modality for locally advanced NSCLC invading the carina.

Lung function changes and pulmonary complications in patients with stage III non-small cell lung cancer treated with gemcitabine/cisplatin as part of combined modality treatment

INTRODUCTION

Lung cancer is the leading cause of cancer mortality. Chemotherapy, ideally a platinum-based regimen as part of combined modality treatment, is appropriate for selected patients with locally advanced stage III non-small cell lung cancer (NSCLC) who have a good performance status. However, chemotherapy can induce side effects including lung function changes.

AIM OF THE STUDY

Retrospective analysis of lung function changes in 44 patients with stage III NSCLC treated with neoadjuvant chemotherapy (NCT) followed by surgery and/or radiotherapy.

PATIENTS AND METHODS

NCT consisted of three cycles of gemcitabine/cisplatin. The following data were analysed: age, sex, the presence of chronic obstructive pulmonary disease (COPD), smoking behaviour, response, complications after surgery and/or radiotherapy, and VC, FEV(1), DL(co) and K(co) before and after chemotherapy. DL(co) values were corrected for haemoglobin concentrations.

RESULTS

We found a significant decline of K(co) (-13.5% of pred; 95% CI: -16.6 to -10.4; P<0.0001), independent of tumor response or presence and severity of COPD. FEV(1) and FEV(1)/VC showed significant increases irrespective of tumor response. Significantly more pulmonary complications were recorded in the radiotherapy group after NCT (P=0.009) compared to patients who underwent surgical therapy after NCT.

CONCLUSIONS

Patients diagnosed with NSCLC stadium III who were treated with NCT consisting of cisplatin and gemcitabine showed a significant decline of DL(co) and K(co), irrespective of tumor response, presence and severity of COPD, sex and number of cycles of chemotherapy. Significantly more pulmonary complications were seen in patients treated with NCT and radiotherapy compared with patients treated with NCT and surgery. Questions concering the pathophysiological mechanisms of lung function changes and long term follow-up of pulmonary toxicity due to NCT remain still unanswered and have to be subject of future studies.

Assessment of extensive surgery for locally advanced lung cancer. Safety and efficacy of induction therapy

OBJECTIVE

Locally advanced lung cancer has a poor prognosis, despite extensive surgery conducted in an effort to improve survival. We evaluated the safety and efficacy of induction therapy prior to extensive surgery for locally advanced lung cancer.

METHODS

Primary resection for lung cancer was done in 549 consecutive patients divided into three groups; 446 undergoing standard pulmonary resection (no extensive surgery), 87 undergoing extensive surgery without induction therapy, and 16 undergoing surgery after induction therapy.

RESULTS

Morbidity was 23.5%, 28.6%, and 43.8%, respectively. The rate was significantly higher in the induction group compared with the no extensive surgery group (P < 0.05). Surgical mortality was 0.67%, 3.4%, and 6.3%, respectively. The difference was statistically significant between the no extensive surgery and extensive surgery groups (P < 0.02), and between the no extensive surgery and induction groups (P < 0.02). Hospital mortality was 2.2%, 9.2%, and 6.3%, respectively. The rates were significantly higher in the extensive surgery (P < 0.01) and induction (P < 0.05) groups compared to the no extensive surgery group. Five-year survival was 50.3% for the patients who received induction therapy, and 14.7% for the patients who did not receive induction therapy.

CONCLUSIONS

Survival differences between the induction and non induction groups were not significant, but some patients with T3 or T4 disease may benefit from induction therapy. The high morbidity of induction treatment should be recognized, and strict candidate selection and careful postoperative care used to help prevent increased mortality.