Combined chemoradiotherapy in limited-disease, inoperable non-small cell lung cancer

How to improve loco-regional control in stages IIIa-b NSCLC? Results of a three-armed randomized trial from the Swedish Lung Cancer Study Group

BACKGROUND

A combination of chemotherapy and radiotherapy is the treatment base for locally advanced non-small cell lung cancer (NSCLC). However, both loco-regional and distant failure is frequent. Attempts to improve the loco-regional control were made in three separate phase II studies in Swedish University Hospitals, where accelerated radiotherapy or concurrent daily or weekly chemotherapy with conventional radiotherapy were tested. Comparatively good results from these studies lead to this national randomized phase II study, the RAKET-study, where the different concepts were investigated on a wider basis for further phase III studies.

METHODS

Inoperable stage III non-small cell lung cancer patients in good performance status (PS<2) were equally randomized to either of three arms in eight institutions. All arms started with two cycles of induction chemotherapy: paclitaxel 200 mg/m2 and carboplatin AUC6. Arm A: a third identical cycle was given concomitant with start of accelerated radiotherapy, 1.7 Gy BID to 64.6 Gy in 4.5 weeks. Arm B consisted of daily concomitant paclitaxel 12 mg/m2 with conventionally fractionated radiotherapy: 2 Gy to 60 Gy in 6 weeks. Arm C: weekly concomitant paclitaxel 60 mg/m2 and identical radiotherapy to 60 Gy. Primary endpoint: TTP. Secondary: OS, toxicity, QL and relapse pattern.

RESULTS

Between June 2002 and May 2005 152 patients were randomized and of them 151 were evaluable: 78 men and 73 women, median age 62 years (43-78), 55% had performance status 0 and 45% PS 1. Thirty-four percent had stage IIIa and 66% IIIb.

HISTOLOGY

adenocarcinoma 48%, squamous cell carcinoma 32% and 20% non-small cell carcinoma. The three arms were well balanced. Toxicity was manageable with 12% grades 3-4 esophagitis, 1% grades 3-4 pneumonitis and there was no clear difference between the arms. The QL data did not differ either. Median time to progression was 9.8 (8.3-12.7) months (8.8, 10.3 and 9.3 months for arms A, B and C, respectively). Median survival was 17.8 (14.4-23.7) months (17.7, 17.7 and 20.6 months for A, B and C, respectively). The 1-, 3- and 5-year overall survival was 63, 31 and 24%. Sixty-nine percent of the patients relapsed with distant metastases initially and 31% had loco-regional tumor progression, without significant differences between treatment arms. Thirty-four percent developed brain metastases.

CONCLUSIONS

Treatment results are quite equal by intensifying the loco-regional treatment either by accelerated fractionated radiotherapy or daily or weekly concomitant chemo-radiotherapy both in terms of survival, toxicity and quality of life. The optimal treatment schedule for patients with locally advanced NSCLC is still to be decided and investigated in future clinical studies. Relapse pattern with distant metastases and especially brain metastases is a great problem and need further research for better therapy options and higher cure rate for this patient group.

The Role of Radiation Therapy in Thoracic Tumors

Radiation plays an important role in the treatment of thoracic tumors. During the last 10 years there have been several major advances in thoracic RT including the incorporation of concurrent chemotherapy and the application of con-formal radiation-delivery techniques (eg, stereotactic RT, three-dimensional conformal RT, and intensity-modulated RT) that allow radiation dose escalation. Radiation as a local measure remains the definitive treatment of medically inoperable or surgically unresectable disease in NSCLC and part of a multimodality regimen for locally advanced NSCLC, limited stage SCLC, esophageal cancer, thymoma, and mesothelioma.

Prophylactic cranial irradiation for preventing brain metastases in patients undergoing radical treatment for non–small-cell lung cancer: A Cochrane Review

PURPOSE

To investigate whether prophylactic cranial irradiation (PCI) has a role in the management of patients with non-small-cell lung cancer (NSCLC) treated with curative intent.

METHODS AND MATERIALS

A search strategy was designed to identify randomized controlled trials (RCTs) comparing PCI with no PCI in NSCLC patients treated with curative intent. The electronic databases MEDLINE, EMBASE, LILACS, and Cancerlit were searched, along with relevant journals, books, and review articles to identify potentially eligible trials. Four RCTs were identified and reviewed. A total of 951 patients were randomized in these RCTs, of whom 833 were evaluable and reported. Forty-two patients with small-cell lung cancer were excluded, leaving 791 patients in total. Because of the small patient numbers and trial heterogeneity, no meta-analysis was attempted.

RESULTS

Prophylactic cranial irradiation did significantly reduce the incidence of brain metastases in three trials. No trial reported a survival advantage with PCI over observation. Toxicity data were poorly collected and no quality of life assessments were carried out in any trial.

CONCLUSION

Prophylactic cranial irradiation may reduce the incidence of brain metastases, but there is no evidence of a survival benefit. It was not possible to evaluate whether any radiotherapy regimen is superior, and the effect of PCI on quality of life is not known. There is insufficient evidence to support the use of PCI in clinical practice. Where possible, patients should be offered entry into a clinical trial.

Prophylactic cranial irradiation for preventing brain metastases in patients undergoing radical treatment for non-small cell lung cancer

BACKGROUND

In non-small cell lung cancer (NSCLC), there is a relatively high incidence of brain metastases following radical treatment. At present, the role of prophylactic cranial irradiation (PCI) in this group of patients is not clear.

OBJECTIVES

To investigate whether PCI has a role in the management of patients with NSCLC treated with radical intent.

SEARCH STRATEGY

The electronic databases MEDLINE, EMBASE and Cancerlit, along with handsearching of journals, relevant books, and review articles used to identify potentially eligible trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing PCI with no PCI in NSCLC patients treated with radical intent.

DATA COLLECTION AND ANALYSIS

Four RCTs were reviewed. Due to the small patient numbers, and variations in radiotherapy (RT) dose, no meta-analysis was attempted.

MAIN RESULTS

PCI may reduce the incidence of brain metastases, but there is no evidence of a survival benefit. There is no evidence that any regimen is superior, and the effect of PCI on quality of life (QOL) is not known.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of PCI in clinical practice. Where possible, patients should be offered entry into a clinical trial.

Subsets more likely to benefit from surgery or prophylactic cranial irradiation after chemoradiation for localized non-small-cell lung cancer

After chemoradiation for localized non-small-cell lung cancer, surgery and prophylactic cranial irradiation (PCI) have been used as additional therapies. Less than a third of patients develop brain recurrences, or have local recurrence as their sole initial site of recurrence; these are groups that would benefit from PCI or surgery, respectively. Pretreatment identification of patients more likely to benefit from surgery or PCI would be useful. A retrospective analysis of 80 patients was performed to determine prognostic factors for such patterns of failure. Twenty-nine patients were subsequently selected for surgery in a nonrandomized manner. Seventeen patients had isolated local initial recurrence and 15 had brain recurrences. In multivariable analysis, female gender and elevated LDH were found to be risk factors for brain recurrence. In the subset with stage III disease (n = 76), squamous cell histology was a risk factor for isolated initial local recurrence in both univariable and multivariable analysis. It is possible to identify subsets that may show increased benefit from PCI or surgery.

Mitomycin, cisplatin, and vindesine followed by radiotherapy combined with cisplatin in stage III nonsmall cell lung cancer: long-term results

PURPOSE

To assess the tolerance, response rate, pattern of failure, and long-term survival of patients with unresectable nonsmall cell lung cancer treated with one cycle of induction chemotherapy followed by concurrent cisplatin and radiotherapy.

METHODS AND MATERIALS

From 1986 to 1988, 45 patients with histologically proven nonsmall cell lung cancer clinical Stage III (29 IIIA and 16 IIIB) were included in this study. Patients received one cycle of Mitomycin C 10 mg/m2 day 1, Cisplatin 120 mg/m2 day 1, and Vindesine 3 mg/m2 days 1, 8, 15, and 22, by i.v. bolus injection. Radiotherapy was started within 4-6 weeks after completion of chemotherapy, with a total tumor dose of 60 Gy, at 2 Gy/day. Cisplatin, 20 mg/m2/day by i.v. continuous infusion was administered for days 1-5 of radiation treatment.

RESULTS

The main toxic acute effects were nausea-vomiting grade 1-3 in 38 patients (85%). Ten patients (22%) developed esophagitis grade 3. Leukopenia grade 1-2 was observed in 18 patients (40%), grade 3 in 12 (27%), and grade 4 in 4 (9%). Three patients (6.6%) died by granulocytopenia and sepsis. A bronchoscopic proven complete response was achieved in 9 patients (21.5%) and partial response in 28 patients (67%). With a minimum follow-up of 65 months, overall median survival was 13 months, 2-year survival was 21%, and 5-year survival was 7%, with no statistical difference between Stage IIIA and IIIB. Median survival of patients with complete response was 23.2 months, and 5-year survival was 33%.

CONCLUSION

This treatment scheme produced a severe toxicity and in spite of a high response rate, long-term survival is poor, similar to previous studies with radiotherapy alone.

Low-versus high-energy photon beams in radiotherapy for lung cancer

This retrospective study analyzed the outcome of lung cancer patients who were treated with either 4-MV or 10-MV photons. From October 1979 through December 1982, 126 patients with locally advanced, unresectable or medically inoperable, nonmetastatic non-small cell lung cancer were treated in a prospective trial in which they were randomly assigned to one of three chemotherapy combinations and thoracic radiotherapy. The patients were stratified by cell type, extent of operation, age, sex, and status of supraclavicular lymph nodes. All patients were followed until death or for a minimum of 4.8 years. Of the 102 evaluable patients, 98 were treated with either 4-MV or 10-MV photons (49 patients in each group). Outcomes examined included best primary tumor response, time to first local (in-field) recurrence, disease-free survival, and overall survival. No significant differences were detected between the patients treated with 4-MV or 10-MV photons for several important prognostic and treatment factors or for any of the study outcomes, including first local (in-field) recurrence, disease-free survival, and overall survival. For the group of 98 patients treated with either 4-MV or 10-MV photons, the estimated 2-year freedom from first local (in-field) recurrence was 47.7%. The estimated 2-year disease-free and overall survivals were 21.6% and 28.6%, respectively.

Weekly doxorubicin versus doxorubicin every 3 weeks in cyclophosphamide, doxorubicin, and cisplatin chemotherapy for non-small cell lung cancer

A prospective randomized study was done to determine the effect of different doxorubicin (Adriamycin [ADR], Adria Laboratories, Columbus, OH) administration (schedules every week versus every 3 weeks) on the productivity of a cyclophosphamide, ADR, cisplatin (CAP) chemotherapy regimen for patients with non-small cell lung cancer (NSCLC). Electrocardiograms, multigated cardiac scans, echocardiograms, and endomyocardial biopsies were done serially for cardiac monitoring. Of 102 patients, 47 ahd inoperable limited disease (LD), 47 had extensive disease (ED), and eight had no evidence of disease. In the last group chemotherapy was given adjuvantly. Fifty-one patients were entered into each treatment arm. The groups were formed according to extent of disease and were comparable in terms of patient characteristics. In these groups, the overall response rates using both schedules in LD patients were similar: in patients without chest irradiation previously, there was a response of 35% with ADR weekly, and 31% with ADR triweekly; in LD patients with chest irradiation previously, the response was 20% with ADR weekly, and 25% with ADR triweekly; and in ED patients, 16% with ADR weekly, and 11% with ADR triweekly. There was no significant difference in survival between the two treatment groups. However, results for all responders suggested a longer duration of response with weekly than with triweekly ADR (complete plus partial response: 35.8 versus 11.4 weeks, P = 0.06; minor response: 34 versus 11.5 weeks, P = 0.003, respectively). Results also suggested that weekly ADR was less cardiotoxic than triweekly ADR: 29% of patients in the former group had no changes or only minor changes in endomyocardial biopsy results, whereas all patients in the latter group had at least grade 0.5 changes at a similar dosage. The median doses of weekly ADR were higher at the same endomyocardial biopsy-defined toxicity levels. No correlation was found between toxic effects defined by endomyocardial biopsy results and those defined by noninvasive monitoring techniques, although the number of patients assessed was small. Weekly ADR produced less granulocytopenia and a lower incidence of fever (6% versus 16%, P less than 0.001) than did triweekly ADR. Alopecia, nausea, vomiting, and diarrhea were significantly less for weekly ADR than triweekly Adr (P less than 0.0005, less than 0.0005, and less than 0.005, respectively). These data suggest that weekly ADR can achieve the same therapeutic results as the standard triweekly regimen with less cardiotoxicity, myelotoxicity, alopecia, diarrhea, nausea, and vomiting in patients with NSCLC.