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Induction Therapies Plus Surgery Versus Exclusive Radiochemotherapy in Stage IIIA/N2 Non-Small Cell Lung Cancer (NSCLC). Am J Clin Oncol 2019; 41:267-273. [PMID: 29116951 DOI: 10.1097/coc.0000000000000416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In spite of the growing body of data from prospective randomized clinical trials (PRCTs) and meta-analyses, the optimal treatment approach in patients with stage IIIA non-small cell lung cancer remains unknown. This review focuses on the available data directly confronting induction chemotherapy or induction radiochemotherapy (RT-CHT) when followed by surgery with exclusive RT-CHT. Seven PRCTs and 4 meta-analyses investigated this issue. In addition, numerous retrospective studies attempted to identify potential predictors and/or prognosticators that may have influenced the decision to offer surgery in a particular patient subgroup. Several retrospective studies also evaluated exclusive RT-CHT in this setting. There is not a single piece of the highest level of evidence (PRCT or MA) showing any advantage of induction therapies followed by surgery over exclusive RT-CHT with the former treatment option leading to significantly more morbidity and mortality. Although several studies attempted to identify patient subgroups favoring induction therapies followed by surgery, they have invariably been retrospective in nature, and their results have never been reproduced even in other retrospective setting. Furthermore, no PRCT investigated potential pretreatment patient and/or tumor-related predictors of surgical multimodality success. Exclusive RT-CHT achieves similar results to induction therapies followed by surgery but with less morbidity and mortality. This is accompanied with the finding that no pretreatment predictor exists to enable identification of even a subgroup of stage IIIA/pN2 patients benefiting from any surgical approach.
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Jeremic B, Gomez-Caamano A, Dubinsky P, Cihoric N, Igrutinovic I, Videtic G. Low level evidence supporting the choice of optimal multimodality treatment approach in patients with stage IIIA NSCLC- Ain't no mountain high enough…. to keep me getting to you. Lung Cancer 2018; 123:172-173. [PMID: 29921448 DOI: 10.1016/j.lungcan.2018.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/12/2018] [Indexed: 11/17/2022]
Affiliation(s)
| | - Antonio Gomez-Caamano
- Department of Radiation Oncology, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Pavol Dubinsky
- University Hospital to East Slovakia Institute of Oncology, Kosice, Slovakia
| | - Nikola Cihoric
- Department of Radiation Oncology, Inselspital, University of Bern, Bern, Switzerland
| | - Ivan Igrutinovic
- Faculty of Science, University of Kragujevac, Kragujevac, Serbia
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Jeremić B, Casas F, Dubinsky P, Gomez-Caamano A, Čihorić N, Videtic G, Igrutinovic I. Treatment-Related Predictive and Prognostic Factors in Trimodality Approach in Stage IIIA/N2 Non-Small Cell Lung Cancer. Front Oncol 2018. [PMID: 29527511 PMCID: PMC5829546 DOI: 10.3389/fonc.2018.00030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
While there are no established pretreatment predictive and prognostic factors in patients with stage IIIA/pN2 non-small cell lung cancer (NSCLC) indicating a benefit to surgery as a part of trimodality approach, little is known about treatment-related predictive and prognostic factors in this setting. A literature search was conducted to identify possible treatment-related predictive and prognostic factors for patients for whom trimodality approach was reported on. Overall survival was the primary endpoint of this study. Of 30 identified studies, there were two phase II studies, 5 “prospective” studies, and 23 retrospective studies. No study was found which specifically looked at treatment-related predictive factors of improved outcomes in trimodality treatment. Of potential treatment-related prognostic factors, the least frequently analyzed factors among 30 available studies were overall pathologic stage after preoperative treatment and UICC downstaging. Evaluation of treatment response before surgery and by pathologic tumor stage after induction therapy were analyzed in slightly more than 40% of studies and found not to influence survival. More frequently studied factors—resection status, degree of tumor regression, and pathologic nodal stage after induction therapy as well as the most frequently studied factor, the treatment (in almost 75% studies)—showed no discernible impact on survival, due to conflicting results. Currently, it is impossible to identify any treatment-related predictive or prognostic factors for selecting surgery in the treatment of patients with stage IIIA/pN2 NSCLC.
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Affiliation(s)
| | | | - Pavol Dubinsky
- University Hospital to East Slovakia Institute of Oncology, Kosice, Slovakia
| | | | - Nikola Čihorić
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Ivan Igrutinovic
- Faculty of Science, University of Kragujevac, Kragujevac, Serbia
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A nomogram to predict the survival of stage IIIA-N2 non-small cell lung cancer after surgery. J Thorac Cardiovasc Surg 2017; 155:1784-1792.e3. [PMID: 29554790 DOI: 10.1016/j.jtcvs.2017.11.098] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 11/09/2017] [Accepted: 11/16/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Postoperative survival of patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) is highly heterogeneous. Here, we aimed to identify variables associated with postoperative survival and develop a tool for survival prediction. METHODS A retrospective review was performed in the Surveillance, Epidemiology, and End Results database from January 2004 to December 2009. Significant variables were selected by use of the backward stepwise method. The nomogram was constructed with multivariable Cox regression. The model's performance was evaluated by concordance index and calibration curve. The model was validated via an independent cohort from the Jiangsu Cancer Hospital Lung Cancer Center. RESULTS A total of 1809 patients with stage IIIA-N2 NSCLC who underwent surgery were included in the training cohort. Age, sex, grade, histology, tumor size, visceral pleural invasion, positive lymph nodes, lymph nodes examined, and surgery type (lobectomy vs pneumonectomy) were identified as significant prognostic variables using backward stepwise method. A nomogram was developed from the training cohort and validated using an independent Chinese cohort. The concordance index of the model was 0.673 (95% confidence interval, 0.654-0.692) in training cohort and 0.664 in validation cohort (95% confidence interval, 0.614-0.714). The calibration plot showed optimal consistency between nomogram predicted survival and observed survival. Survival analyses demonstrated significant differences between different subgroups stratified by prognostic scores. CONCLUSIONS This nomogram provided the individual survival prediction for patients with stage IIIA-N2 NSCLC after surgery, which might benefit survival counseling for patients and clinicians, clinical trial design and follow-up, as well as postoperative strategy-making.
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Santana-Davila R, Martins R. Treatment of Stage IIIA Non-Small-Cell Lung Cancer: A Concise Review for the Practicing Oncologist. J Oncol Pract 2017; 12:601-6. [PMID: 27407154 DOI: 10.1200/jop.2016.013052] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Stage IIIA non-small-cell lung cancer occurs in a heterogenous group of patients for whom the best treatment is multimodality therapy with chemotherapy, radiation, and surgery in a select group of individuals. This clinical review intends to answer the most common questions that clinicians face in the decision about the best management in this group.
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Savic M, Kontic M, Ercegovac M, Stojsic J, Bascarevic S, Moskovljevic D, Kostic M, Vesovic R, Popevic S, Laban M, Markovic J, Jovanovic D. Comparison of mediastinal lymph node status and relapse pattern in clinical stage IIIA non-small cell lung cancer patients treated with neoadjuvant chemotherapy versus upfront surgery: A single center experience. Thorac Cancer 2017; 8:393-401. [PMID: 28671758 PMCID: PMC5582464 DOI: 10.1111/1759-7714.12447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/20/2017] [Accepted: 03/21/2017] [Indexed: 12/25/2022] Open
Abstract
Background In spite of the progress made in neoadjuvant therapy for operable non small‐cell lung cancer (NSCLC), many issues remain unsolved, especially in locally advanced stage IIIA. Methods Retrospective data of 163 patients diagnosed with stage IIIA NSCLC after surgery was analyzed. The patients were divided into two groups: a preoperative chemotherapy group including 59 patients who received platinum‐etoposide doublet treatment before surgery, and an upfront surgery group including 104 patients for whom surgical resection was the first treatment step. Adjuvant chemotherapy or/and radiotherapy was administered to 139 patients (85.3%), while 24 patients (14.7%) were followed‐up only. Results The rate of N2 disease was significantly higher in the upfront surgery group (P < 0.001). The one‐year relapse rate was 49.5% in the preoperative chemotherapy group compared to 65.4% in the upfront surgery group. There was a significant difference in relapse rate in relation to adjuvant chemotheraphy treatment (P = 0.007). The probability of relapse was equal whether radiotherapy was applied or not (P = 0.142). There was no statistically significant difference in two‐year mortality (P = 0.577). The median survival duration after two years of follow‐up was 19.6 months in the preoperative chemotherapy group versus 18.8 months in the upfront surgery group (P = 0.608 > 0.05). Conclusion There was significant difference in preoperative chemotherapy group regarding relapse rate and treatment outcomes related to the lymph node status comparing to the upfront surgery group. Neoadjuvant/adjuvant chemo‐therapy is a part of treatment for patients with stage IIIA NSCLC, but further investigation is required to determine optimal treatment.
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Affiliation(s)
- Milan Savic
- Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Milica Kontic
- Clinic for Pulmonology, Clinical Center of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Maja Ercegovac
- Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Jelena Stojsic
- Service for Pathohistology, Clinical Center of Serbia, Belgrade, Serbia
| | - Slavisa Bascarevic
- Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Dejan Moskovljevic
- Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Marko Kostic
- Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Radomir Vesovic
- Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Spasoje Popevic
- Clinic for Pulmonology, Clinical Center of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marija Laban
- Clinic for Pulmonology, Clinical Center of Serbia, Belgrade, Serbia
| | - Jelena Markovic
- Service for Pathohistology, Clinical Center of Serbia, Belgrade, Serbia
| | - Dragana Jovanovic
- Clinic for Pulmonology, Clinical Center of Serbia, Belgrade, Serbia.,School of Medicine, University of Belgrade, Belgrade, Serbia
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Jeremic B, Casas F, Dubinsky P, Gomez-Caamano A, Čihorić N, Videtic G, Latinovic M. Combined modality therapy in Stage IIIA non-small cell lung cancer: clarity or confusion despite the highest level of evidence? JOURNAL OF RADIATION RESEARCH 2017; 58:267-272. [PMID: 28339761 PMCID: PMC5440884 DOI: 10.1093/jrr/rrx003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/15/2016] [Accepted: 01/09/2017] [Indexed: 06/06/2023]
Abstract
Recent years have witnessed a number of clinical trials in Stage IIIA non-small cell lung cancer (NSCLC) comparing (A) induction chemotherapy (CHT) with induction CHT and radiotherapy (RT), each followed by surgery; (B) either induction CHT or induction RT-CHT, each followed by surgery, with definitive RT-CHT (no surgery). Due to the heterogeneity of patient, tumor and treatment characteristics across these trials, various meta-analyses (MAs) have been performed to define the optimal treatment approach in this setting for this clinical presentation. Six such MAs exist. In spite of the differences between MAs, it appears that RT does not add extra benefit to induction CHT administered before surgery, and that a trimodality (i.e. including surgery) regimen is not superior to definitive concurrent RT-CHT. While one can consider both induction CHT followed by surgery and exclusive concurrent RT-CHT as feasible in this setting, lack of pre-treatment predictive factors identifying patients who might preferentially benefit from a surgical approach limits its use to well-planned clinical trials.
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Affiliation(s)
- Branislav Jeremic
- Institute of Lung Diseases, Institutski put 4 21204, Sremska, Kamenica, Serbia
- BioIRC Centre for Biomedical Research, Serbia
| | | | - Pavol Dubinsky
- University Hospital to East Slovakia Institute of Oncology, Kosice, Slovakia
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