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Watanabe SI, Yotsukura M, Miyoshi T, Hattori A, Isaka T, Maniwa T, Isaka M, Yoshioka H, Endo M, Mimae T, Tsutani Y, Nakagawa K, Aokage K. Updated review of perioperative treatment for non-small-cell lung cancer in the new era of immune checkpoint inhibitors: past, present, and future. Jpn J Clin Oncol 2024:hyae106. [PMID: 39163130 DOI: 10.1093/jjco/hyae106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 08/14/2024] [Indexed: 08/22/2024] Open
Abstract
The perioperative treatments for non-small cell lung cancer (NSCLC) should control both local and microscopic systemic disease, because the survival of patients with NSCLC who underwent surgical resection alone has been dismal except in stage IA patients. One way to improve surgical outcome is the administration of chemotherapy before or after the surgical procedure. During the last two decades, many clinical studies have focused on developing optimal adjuvant or neoadjuvant cisplatin-based chemotherapy regimens that can be combined with surgical treatment and/or radiotherapy. Based on the results of those clinical studies, multimodality therapy has been considered to be an appropriate treatment approach for locally advanced NSCLC patients. When nodal involvement is discovered postoperatively, adjuvant cisplatin-based chemotherapy has conferred an overall survival benefit. More recently, neoadjuvant and/or adjuvant use of immunotherapy adding to the cisplatin-based chemotherapy has been revealed to improve survival of the patients with locally advanced NSCLC in many large-scale clinical trials; although, optimal treatment strategies are still evolving.
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Affiliation(s)
- Shun-Ichi Watanabe
- Department of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Masaya Yotsukura
- Department of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Tomohiro Miyoshi
- Division of Thoracic Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Aritoshi Hattori
- Division of General Thoracic Surgery, Juntendo University Hospital, Tokyo, Japan
| | - Tetsuya Isaka
- Department of Thoracic Surgery, Kanagawa Cancer Center, Kanagawa, Japan
| | - Tomohiro Maniwa
- Department of Thoracic Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Mitsuhiro Isaka
- Department of Thoracic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Hiroshige Yoshioka
- Department of Thoracic Oncology, Kansai Medical University Hospital, Osaka, Japan
| | - Makoto Endo
- Department of Thoracic Surgery, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Takahiro Mimae
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan
| | - Yasuhiro Tsutani
- Division of Thoracic Surgery, Department of Surgery, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Kazuo Nakagawa
- Department of Thoracic Surgery, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Keiju Aokage
- Division of Thoracic Surgery, National Cancer Center Hospital East, Chiba, Japan
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John AO, Ramnath N. Neoadjuvant Versus Adjuvant Systemic Therapy for Early-Stage Non-Small Cell Lung Cancer: The Changing Landscape Due to Immunotherapy. Oncologist 2023; 28:752-764. [PMID: 37338126 PMCID: PMC10485299 DOI: 10.1093/oncolo/oyad125] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/02/2023] [Indexed: 06/21/2023] Open
Abstract
Non-small cell lung cancer (NSCLC) remains a major cause of morbidity and mortality worldwide. One-third of NSCLC patients present with surgically resectable, non-metastatic disease; however, many of these patients will recur despite curative surgery and adjuvant therapy. The recent publication of randomized trials incorporating immune check-point inhibitors (ICI) to the standard neo-adjuvant and adjuvant treatment regimens has reported improved survival with manageable toxicity profiles. The IMpower 010 studied the use of adjuvant atezolizumab after standard surgery and adjuvant chemotherapy. They demonstrated an improvement in 3-year disease-free survival (DFS) prompting a change in treatment guidelines. The Checkmate 816 and NADIM II studies evaluated the addition of pembrolizumab and nivolumab, respectively, to standard neo-adjuvant chemotherapy. The results from both trials showed an improvement in 2-year event-free survival (EFS) and 2-year PFS (PFS), respectively. In this review, we summarize the prior data regarding adjuvant and neo-adjuvant chemotherapy in NSCLC and elaborate on results from the newer trials incorporating ICIs. We briefly discuss the pros and cons of each treatment approach along with areas that need further clarity to inform clinical practice and future directions for research in this disease.
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Affiliation(s)
- Ajoy Oommen John
- Department of Medical Oncology, Christian Medical College, Vellore, India
| | - Nithya Ramnath
- Division of Medical Oncology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Medicine, Section of Medical Oncology, Veterans Administration, Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Mittal A, Malik PS, Kumar S, Saikia J, Chitikela S, Khurana S, Bharti S, Jain D, Pathy S, Thulkar S, Kumar R, Madan K, Mohan A. Dose-dense Paclitaxel and Carboplatin as Neoadjuvant Chemotherapy for Stage IIB/IIIA Non-small Cell Lung Cancer - A Phase II trial. Clin Oncol (R Coll Radiol) 2021; 33:e553-e560. [PMID: 34340919 DOI: 10.1016/j.clon.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 06/02/2021] [Accepted: 07/14/2021] [Indexed: 12/25/2022]
Abstract
AIMS The approach to potentially resectable non-small cell lung cancer (NSCLC) remains controversial. There is a benefit of neoadjuvant chemotherapy (NACT), but the ideal regimen is unknown. We evaluated the efficacy and safety of dose-dense NACT in potentially resectable NSCLC in this phase II trial. MATERIALS AND METHODS Paclitaxel at 80 mg/m2 on days 1, 8 and 15 with AUC-6 carboplatin on day 1, 3 weekly for four cycles was evaluated as NACT. Patients with Eastern Cooperative Oncology Group performance status 0-2, stage IIB and IIIA (with only non-bulky N2 nodes) were included. The primary end point was the objective response rate. Secondary end points included toxicity, progression-free survival, recurrence-free survival, complete resection rate and overall survival. The relative dose intensity (RDI) was calculated to define tolerability (CTRI/2016/05/006916). RESULTS In total, 37 patients were enrolled (median age 55 years). Most (78.8%) were smokers. Most patients had adenocarcinoma (57.6%) and stage IIIA disease (81.0%) according to the seventh American Joint Committee on Cancer staging system. Seventy-eight per cent of patients completed four cycles. The objective response rate was 75.6% with a complete response in 10.8%. The mean RDI of paclitaxel was 88.61%, with 68.0% of patients able to maintain an RDI ≥85.0%. In total, 187 toxicity events were recorded (120 grade 1, 64 grade 2 and three grade 3 events). Common toxicities were peripheral neuropathy (20.3%), myalgia (19.8%), nausea (15.7%) and neutropenia (10.2%). There were no treatment-related deaths. Seventeen patients underwent surgery (lobectomy 82.4%). After a median follow-up of 47 months (95% confidence interval 27-50.7 months), the median progression-free survival was 9.6 months (7.4-17.4) and overall survival was 29.2 months (16.0-37.2). CONCLUSION Dose-dense paclitaxel-carboplatin is feasible, safe and efficacious and should be evaluated further in potentially resectable NSCLC.
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Affiliation(s)
- A Mittal
- Department of Medical Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - P S Malik
- Department of Medical Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
| | - S Kumar
- Department of Surgical Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - J Saikia
- Department of Surgical Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - S Chitikela
- Department of Medical Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - S Khurana
- Department of Medical Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - S Bharti
- Department of Oncoanaesthesia and Palliative Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - D Jain
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - S Pathy
- Department of Radiation Oncology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - S Thulkar
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - R Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - K Madan
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - A Mohan
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Watanabe SI, Nakagawa K, Suzuki K, Takamochi K, Ito H, Okami J, Aokage K, Saji H, Yoshioka H, Zenke Y, Aoki T, Tsutani Y, Okada M. Neoadjuvant and adjuvant therapy for Stage III non-small cell lung cancer. Jpn J Clin Oncol 2018; 47:1112-1118. [PMID: 29136212 DOI: 10.1093/jjco/hyx147] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/23/2017] [Indexed: 11/13/2022] Open
Abstract
The treatments for advanced non-small cell lung cancer (NSCLC) should control both local and microscopic systemic disease, because the 5-year survival of patients with Stage III NSCLC who underwent surgical resection alone has been dismal. One way to improve surgical outcome is the administration of chemotherapy before or after the surgical procedure. During the last two decades, many clinical studies have focused on developing optimal adjuvant or neoadjuvant chemotherapy regimens that can be combined with surgical treatment and/or radiotherapy. Based on the results of those clinical studies, multimodality therapy is considered to be an appropriate treatment approach for Stage IIIA NSCLC patients; although, optimal treatment strategies are still evolving. When N2 nodal involvement is discovered postoperatively, adjuvant cisplatin-based chemotherapy confers an overall survival benefit. The addition of postoperative radiotherapy might be considered for patients with nodal metastases. Although definitive chemoradiation remains a standard of care for cN2 NSCLC, alternative approaches such as induction chemotherapy or chemoradiotherapy and surgery can be considered for a selective group of patients. When surgical resection can be performed after induction therapy with low risk and a good chance of complete resection, the outcome may be optimal. The decision to proceed with resection after induction therapy must include a detailed preoperative pulmonary function evaluation as well as a critical intraoperative assessment of the feasibility of complete resection.
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Affiliation(s)
| | - Kazuo Nakagawa
- Department of Thoracic Surgery, National Cancer Center Hospital
| | - Kenji Suzuki
- Division of General Thoracic Surgery, Juntendo University Hospital, Tokyo
| | - Kazuya Takamochi
- Division of General Thoracic Surgery, Juntendo University Hospital, Tokyo
| | - Hiroyuki Ito
- Department of Thoracic Surgery, Kanagawa Cancer Center, Kanagawa
| | - Jiro Okami
- Department of Thoracic Surgery, Osaka International Cancer Institute, Osaka
| | - Keiju Aokage
- Division of Thoracic Surgery, National Cancer Center Hospital East, Chiba
| | - Hisashi Saji
- Department of Chest Surgery, St. Marianna University School of Medicine, Kanagawa
| | | | - Yoshitaka Zenke
- Department of Thoracic Oncology and Respiratory Medicine, Tokyo Metropolitan Komagome Hospital
| | - Tadashi Aoki
- Department of Thoracic Surgery, Niigata Cancer Center, Niigata
| | - Yasuhiro Tsutani
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan
| | - Morihito Okada
- Department of Surgical Oncology, Hiroshima University, Hiroshima, Japan
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Lewis J, Gillaspie EA, Osmundson EC, Horn L. Before or After: Evolving Neoadjuvant Approaches to Locally Advanced Non-Small Cell Lung Cancer. Front Oncol 2018; 8:5. [PMID: 29410947 PMCID: PMC5787144 DOI: 10.3389/fonc.2018.00005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 01/05/2018] [Indexed: 12/13/2022] Open
Abstract
The treatment of patients with stage IIIA (N2) non-small cell lung cancer (NSCLC) is one of the most challenging and controversial areas of thoracic oncology. This heterogeneous group is characterized by varying tumor size and location, the potential for involvement of surrounding structures, and ipsilateral mediastinal lymph node spread. Neoadjuvant chemotherapy, administered prior to definitive local therapy, has been found to improve survival in patients with stage IIIA (N2) NSCLC. Concurrent chemoradiation has also been evaluated in phase III studies in efforts to improve control of locoregional disease. In certain instances, a tri-modality approach involving concurrent chemoradiation followed by surgery, may offer patients the best chance for cure. In this article, we provide an overview of the trials evaluating neoadjuvant therapy in patients with stage IIIA (N2) NSCLC that have resulted in current practice strategies, and we highlight the areas of uncertainty in the management of this challenging disease. We also review the current ongoing research and future directions in the management of stage IIIA (N2) NSCLC.
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Affiliation(s)
- Jennifer Lewis
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States.,Veterans Health Administration-Tennessee Valley Healthcare System, Geriatric Research Education Clinical Center, HSR&D Center, Nashville, TN, United States
| | - Erin A Gillaspie
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Evan C Osmundson
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Leora Horn
- Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
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Surgery for Stage IIIA Non–Small-cell Lung Cancer: Lack of Predictive and Prognostic Factors Identifying Any Subgroup of Patients Benefiting From It. Clin Lung Cancer 2016; 17:107-12. [DOI: 10.1016/j.cllc.2015.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 10/28/2015] [Accepted: 11/03/2015] [Indexed: 02/03/2023]
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Spaggiari L, Casiraghi M, Guarize J, Brambilla D, Petrella F, Maisonneuve P, De Marinis F. Outcome of Patients With pN2 "Potentially Resectable" Nonsmall Cell Lung Cancer Who Underwent Surgery After Induction Chemotherapy. Semin Thorac Cardiovasc Surg 2015; 28:593-602. [PMID: 28043483 DOI: 10.1053/j.semtcvs.2015.12.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2015] [Indexed: 11/11/2022]
Abstract
Patients with stage IIIA-ipsilateral mediastinal lymph node involvement (N2) non-small cell lung cancer (NSCLC) represent a heterogeneous group with different clinical presentation. The aim of this study was to analyze a series of patients with "potentially resectable" stage IIIA-pathologically proven N2 (pN2) NSCLC undergoing induction chemotherapy followed by surgery to evaluate their long-term outcomes and to identify prognostic factors. Out of 287 patients who underwent induction chemotherapy for NSCLC with ipsilateral mediastinal lymph node involvement pathologically proven, we retrospectively evaluated 141 (49%) patients with no clinical evidence of progression after induction chemotherapy and candidates for surgery. Most of them (73%) underwent at least 3 cycles of cisplatin-based chemotherapy. We used the Kaplan-Meier method to plot survival and the log-rank test to assess the survival difference between groups. Multivariable analysis was performed using Cox proportional hazards regression. A total of 15 (10.6%) patients underwent explorative thoracotomy; 126 patients underwent surgical anatomical resection after a median 27 days (range: 21-30) from the last cycle of chemotherapy. A total of 113 (89.7%) patients had a radical resection. A total of 22 (17.5%) patients had a complete pathologic lymph node downstaging (pN0), and 8 (6.3%) patients had a complete pathological response (pT0N0). The median overall survival was 24 months, with a 5-year overall survival of 30%. At multivariable analysis, downstaging and number of cycles of chemotherapy were independent prognostic factors (P = 0.006); downstaging benefit was mostly because of complete pathological response (hazards ratio = 0.23, 95% CI: 0.07-0.76). In conclusion, more than 3 cycles of chemotherapy and pathological downstaging could significantly improve 5-year survival in selected patients with "potentially resectable" pathologically proven N2 disease.
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Affiliation(s)
- Lorenzo Spaggiari
- Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy; School of Medicine, University of Milan, Milan, Italy
| | - Monica Casiraghi
- Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy.
| | - Juliana Guarize
- Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy
| | - Daniela Brambilla
- Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy
| | - Francesco Petrella
- Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy
| | - Patrick Maisonneuve
- Division of Epidemiology and Biostatistics, European Institute of Oncology, Milan, Italy
| | - Filippo De Marinis
- Division of Thoracic Oncology, European Institute of Oncology, Milan, Italy
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Jeremić B. Standard treatment option in stage III non-small-cell lung cancer: case against trimodal therapy and consolidation drug therapy. Clin Lung Cancer 2014; 16:80-5. [PMID: 25450877 DOI: 10.1016/j.cllc.2014.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/18/2014] [Accepted: 08/26/2014] [Indexed: 11/30/2022]
Abstract
Prospective randomized trials and meta-analyses established concurrent radiochemotherapy (RT-CHT) as standard treatment approach in patients with inoperable, locally advanced (stage IIIA and B) non-small-cell lung cancer (NSCLC). In patients with either clinically (c) or pathologically (p) staged disease (stage IIIA), including those with pN2 disease, trimodal therapy was also frequently practiced in the past and is currently still advocated by large cooperative groups and organizations. Similarly, consolidation CHT provided after concurrent RT-CHT was suggested to be feasible and effective in inoperable stage III NSCLC. Contrasting these practices and suggestions, there is no evidence that trimodal therapy in stage IIIA (clinically or pathologically staged) or consolidation CHT in inoperable stage III NSCLC plays any role in its treatment. In both cases, evidence clearly demonstrates that concurrent RT-CHT is of similar efficacy and less toxic, and it should be considered a standard treatment option for all patients with stage III NSCLC.
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Affiliation(s)
- Branislav Jeremić
- Insitute for Lung Diseases, Sremska Kamenica, Serbia; BioIRC Centre for Biomedical Research, Kragujevac, Serbia.
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Jeremić B, Miličić B, Milisavljević S. Radiotherapy Alone vs. Radiochemotherapy in Patients With Favorable Prognosis of Clinical Stage IIIA Non–Small-Cell Lung Cancer. Clin Lung Cancer 2013; 14:172-80. [DOI: 10.1016/j.cllc.2012.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 09/29/2012] [Accepted: 10/08/2012] [Indexed: 12/28/2022]
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10
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Liao WY, Chen JH, Wu M, Shih JY, Chen KY, Ho CC, Yang JCH, Yu CJ. Neoadjuvant chemotherapy with docetaxel-cisplatin in patients with stage III N2 non-small-cell lung cancer. Clin Lung Cancer 2013; 14:418-24. [PMID: 23291258 DOI: 10.1016/j.cllc.2012.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 09/24/2012] [Accepted: 10/08/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION To assess the efficacy and potential prognostic factors of patients with stage III N2 non-small-cell lung cancer (NSCLC) treated with neoadjuvant docetaxel-cisplatin (DP) chemotherapy followed by surgical resection. METHODS Sixty-two patients with NSCLC treated with DP as neoadjuvant chemotherapy between November 2003 and December 2009 were identified and reviewed in this study. Tumor response, survival, and clinicopathologic data were collected retrospectively. The time to event was analyzed by fitting Cox proportional hazards models. RESULTS Fifty-eight (94%) of 62 patients eventually underwent surgical resection after DP. The overall clinical response rate to induction DP chemotherapy was 42%. Patients with squamous cell carcinoma (SCC) histology were more likely to response to the DP regimen than those with adenocarcinoma histology (68% vs. 33%, P = .006). With a median follow-up of 82.4 months among the 58 patients, there were 41 (71%) tumor relapses and 27 (47%) deaths. The median event-free survival was 27.5 months (95% CI, 22.3-32.7 months), and the median overall survival was 66.7 months (95% CI, 35.1-98.3 months). In multivariate analysis, when fitting the Cox proportional hazards model, SCC histology (hazard ratio [HR] 0.234 [95% CI, 0.098-0.560]; P = .001) and mediastinal downstaging to N0 (HR 0.451 [95% CI, 0.226-0.898]; P = .024) were independent predictors of better event-free survival. CONCLUSIONS Neoadjuvant chemotherapy with the DP regimen is both active and well tolerated in patients with stage III N2 NSCLC. SCC histology predicted a better treatment response and survival outcome than adenocarcinoma histology in this patient group. Further investigation of combined-modality treatment is warranted to improve survival in the adenocarcinoma subset of stage III N2 NSCLC.
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Affiliation(s)
- Wei-Yu Liao
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Poudenx M, Bondiau PY, Chamorey E, Venissac N, Otto J, Pourel N, Castelnau O, Tessier E, De Surmont Salasc B, Berdah JF, Pop D, Michel C, Mouroux J. Cisplatin-docetaxel induction plus concurrent 3-D conformal radiotherapy and weekly chemotherapy for locally advanced non-small cell lung cancer patients: a phase II trial. Oncology 2012; 83:321-8. [PMID: 22986621 DOI: 10.1159/000342081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 07/23/2012] [Indexed: 02/03/2023]
Abstract
Concurrent chemoradiotherapy (CHRT) is the standard of care for unresectable locally advanced stage III non-small cell lung cancer. However, the optimal combination remains unclear. The aim of this study was to evaluate the efficacy of 2 induction chemotherapy cycles (days 1 and 22) with docetaxel 75 mg/m(2) and cisplatin 75 mg/m(2) followed by concurrent chemotherapy (weekly docetaxel-cisplatin, 20 mg/m(2)) and 3-D conformal radiotherapy for 6 weeks (66 Gy/5 fractions per week/2 Gy per fraction). The primary endpoint was the response rate. Secondary objectives were toxicity, time to progression, and overall survival. Forty-four patients were included and 40 were eligible. The mean age was 60.5 years (range 40.7-72.1), and 75% had stage IIIB disease. Six patients underwent complete R0 resection including 2 pathologic complete responses after a planned intermediate evaluation. Thirty-three patients completed CHRT. The objective response rate was 65% (95% CI 50.2-79.8). Grade 3-4 hematologic and digestive toxicities were observed mainly during the induction phase. Grade 3 esophagitis (5%) was experienced during CHRT. With a median follow-up of 38.7 months, the median progression-free survival was 28.3 months (95% CI 11.0-35.0) and the median survival rate was 31.4 months. Cisplatin-docetaxel induction followed by concurrent 3-D conformal radiotherapy and weekly chemotherapy is a feasible protocol associated with a promising response rate and acceptable toxicity.
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Affiliation(s)
- M Poudenx
- Centre Antoine Lacassagne, Nice, France. michel.poudenx @ nice.unicancer.fr
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12
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Aydiner A, Sen F, Saglam EK, Oral EN, Eralp Y, Tas F, Toker A, Dilege S. Induction Chemotherapy With Triweekly Docetaxel and Cisplatin Followed by Concomitant Chemoradiotherapy With or Without Surgery in Stage III Non–Small-Cell Lung Cancer: A Phase II Study. Clin Lung Cancer 2011; 12:286-92. [DOI: 10.1016/j.cllc.2011.03.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 02/15/2011] [Accepted: 03/15/2011] [Indexed: 11/17/2022]
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Oral Vinorelbine and Cisplatin with Concurrent Radiotherapy After Induction Chemotherapy with Cisplatin and Docetaxel for Patients with Locally Advanced Non-small Cell Lung Cancer: The GFPC 05-03 Study. J Thorac Oncol 2011; 6:351-7. [DOI: 10.1097/jto.0b013e318200f47e] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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14
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Tieu BH, Sanborn RE, Thomas CR. Neoadjuvant therapy for resectable non-small cell lung cancer with mediastinal lymph node involvement. Thorac Surg Clin 2009; 18:403-15. [PMID: 19086609 DOI: 10.1016/j.thorsurg.2008.07.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The optimal treatment for stage IIIA (N2) NSCLC remains controversial. Numerous studies with induction chemotherapy or chemoradiotherapy show that both approaches in the neoadjuvant setting are feasible. Outcomes following induction therapy have been associated with mediastinal nodal response, with residual mediastinal involvement a negative predictor of survival. Appropriate selection of patients to undergo resection following induction therapy is critical. Lobectomy may be safely performed following induction therapy while pneumonectomy may carry a high and possibly unacceptable rate of perioperative mortality. Combined modality therapy has increased the overall survival of patients with stage III NSCLC. Future trials looking at different induction regimens with or without radiotherapy and with or without surgery may help identify the ideal treatment for this heterogeneous disease stage. The SAKK-16/00 study is an ongoing phase III European trial randomizing patients with stage IIIA NSCLC to receive neoadjuvant chemotherapy with three cycles of docetaxel and cisplatin followed by radiation and then surgical resection, or to chemotherapy with the same regimen followed by surgery alone. Other ongoing trials include investigations of novel chemotherapeutic combinations, such as cisplatin with pemetrexed, in the phase II setting. The RTOG 0229 phase II study is evaluating neoadjuvant paclitaxel and carboplatin concurrently with radiation therapy, followed by surgery and consolidation chemotherapy with paclitaxel and carboplatin for stage III NSCLC. The combination of neoadjuvant docetaxel, carboplatin, and radiation therapy followed by surgical resection for stage III NSCLC is also currently being investigated in a phase II trial. The future of treatment for stage III NSCLC may lie in the outcome of trials investigating molecularly targeted agents, such as EGFR inhibitors, anti-angiogenic agents, or multitargeted agents. Optimal incorporation into the multimodality approach required of locally advanced N2 NSCLC will require careful investigation. The results from these trials are eagerly awaited.
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Affiliation(s)
- Brandon H Tieu
- Department of Surgery, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, USA
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15
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Garrido P, González-Larriba JL, Insa A, Provencio M, Torres A, Isla D, Sanchez JM, Cardenal F, Domine M, Barcelo JR, Tarrazona V, Varela A, Aguilo R, Astudillo J, Muguruza I, Artal A, Hernando-Trancho F, Massuti B, Sanchez-Ronco M, Rosell R. Long-Term Survival Associated With Complete Resection After Induction Chemotherapy in Stage IIIA (N2) and IIIB (T4N0-1) Non–Small-Cell Lung Cancer Patients: The Spanish Lung Cancer Group Trial 9901. J Clin Oncol 2007; 25:4736-42. [DOI: 10.1200/jco.2007.12.0014] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeTo assess the activity of induction chemotherapy followed by surgery in stage IIIA and selected stage IIIB non–small-cell lung cancer patients.Patients and MethodsMediastinoscopy proof of either positive N2 (IIIA) or T4N0-1 (IIIB) disease was required. Induction therapy was three cycles of cisplatin/gemcitabine/docetaxel, followed by surgery.ResultsFrom December 1999 to March 2003, 136 patients were entered onto the study; the clinical response rate in 129 assessable patients was 56%. The overall complete resection rate was 68.9% of patients eligible for surgery (72% of stage IIIA patients and 66% of stage IIIB patients) and 48% of all assessable patients. Eight (12.9%) of 62 completely resected patients had a pathologic complete response. Seven patients (7.8%) died during the postoperative period. The median overall survival time was 15.9 months, 3-year survival rate was 36.8%, and 5-year survival rate was 21.1%, with no significant differences in survival between stage IIIA and stage IIIB patients. Median survival time was 48.5 months for 62 completely resected patients, 12.9 months for 13 incompletely resected patients, and 16.8 months for 15 nonresected patients (P = .005). Three- and 5-year survival rates were 60.1% and 41.4% for completely resected patients, 23.1% and 11.5% for incompletely resected patients, and 31.1% and 0% for nonresected patients, respectively. In the multivariate analysis, complete resection (hazard ratio [HR] = 0.35; P < .0001), clinical response (HR = 0.32; P < .0001), and age younger than 60 years (HR = 0.64; P = .027) were the most powerful prognostic factors.ConclusionInduction chemotherapy followed by surgery is effective in stage IIIA and in selected stage IIIB patients attaining complete resection.
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Affiliation(s)
- Pilar Garrido
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - José Luis González-Larriba
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Amelia Insa
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Mariano Provencio
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Antonio Torres
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Dolores Isla
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - José Miguel Sanchez
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Felipe Cardenal
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Manuel Domine
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Jose Ramon Barcelo
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Vicente Tarrazona
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Andres Varela
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Rafael Aguilo
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Julio Astudillo
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Ignacio Muguruza
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Angel Artal
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Florentino Hernando-Trancho
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Bartomeu Massuti
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Maria Sanchez-Ronco
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
| | - Rafael Rosell
- From the Hospital Ramon y Cajal; Hospital San Carlos; Clinica Puerta de Hierro; Fundacion Jimenez Diaz; Autonomous University of Madrid, Madrid; Hospital Clinico, Valencia; Hospital Clinico; Hospital Miguel Servet, Zaragoza; Hospital Germans Trias i Pujol, Catalan Institute of Oncology, Badalona; Hospital Duran i Reynals, Catalan Institute of Oncology, Bellvitge; Hospital Cruces, Bilbao; and Hospital General, Alicante, Spain
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Abstract
Locally advanced non-small cell lung cancer (NSCLC) is a multifaceted disease that is challenging to manage. The majority of patients can be appropriately treated with a combination of chemotherapy and radiation therapy; however, a subset of stage III patients who are considered surgical candidates may require a modification of this plan. For example, a trimodal approach using chemoradiation followed by surgery may be beneficial for fit patients with bulky mediastinal disease who are candidates for lobectomy, whereas patients with minimal mediastinal nodal involvement may receive only chemotherapy before surgical resection. No standard chemotherapy exists for this group of stage IIIA resectable patients. Phase II data from studies employing neoadjuvant cisplatin combinations suggest that these regimens are active and well tolerated. For patients with unresectable stage III NSCLC, concurrent chemoradiation is the standard of care at the present time for patients with good performance status, good pulmonary function tests, and an acceptable volume of normal lung receiving 20 Gy (V20). To manage distant micrometastasis further, induction and consolidation regimens are under investigation during which full-dose chemotherapy is administered either before (as induction) or after (as consolidation) concurrent chemoradiotherapy. To date, consolidation docetaxel after concurrent etoposide, cisplatin and thoracic radiation has shown encouraging survival results in a large Southwest Oncology Group phase II trial. This article will review the current treatment strategies for stage III NSCLC.
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van Meerbeeck JP, Kramer GWPM, Van Schil PEY, Legrand C, Smit EF, Schramel F, Tjan-Heijnen VC, Biesma B, Debruyne C, van Zandwijk N, Splinter TAW, Giaccone G. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non-small-cell lung cancer. J Natl Cancer Inst 2007; 99:442-50. [PMID: 17374834 DOI: 10.1093/jnci/djk093] [Citation(s) in RCA: 484] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Induction chemotherapy before surgical resection increases survival compared with surgical resection alone in patients with stage IIIA-N2 non-small-cell lung cancer (NSCLC). We hypothesized that, following a response to induction chemotherapy, surgical resection would be superior to thoracic radiotherapy as locoregional therapy. METHODS Selected patients with histologic or cytologic proven stage IIIA-N2 NSCLC were given three cycles of platinum-based induction chemotherapy. Responding patients were subsequently randomly assigned to surgical resection or radiotherapy. Survival curves were estimated using Kaplan-Meier analyses from time of randomization. RESULTS Induction chemotherapy resulted in a response rate of 61% (95% confidence interval [CI] = 57% to 65%) among the 579 eligible patients. A total of 167 patients were allocated to resection and 165 to radiotherapy. Of the 154 (92%) patients who underwent surgery, 14% had an exploratory thoracotomy, 50% a radical resection, 42% a pathologic downstaging, and 5% a pathologic complete response; 4% died after surgery. Postoperative radiotherapy was administered to 62 (40%) of patients in the surgery arm. Among the 154 (93%) irradiated patients, overall compliance to the radiotherapy prescription was 55%, and grade 3/4 acute and late esophageal and pulmonary toxic effects occurred in 4% and 7%; one patient died of radiation pneumonitis. Median and 5-year overall survival for patients randomly assigned to resection versus radiotherapy were 16.4 versus 17.5 months and 15.7% versus 14%, respectively (hazard ratio = 1.06, 95% CI = 0.84 to 1.35). Rates of progression-free survival were also similar in both groups. CONCLUSION In selected patients with pathologically proven stage IIIA-N2 NSCLC and a response to induction chemotherapy, surgical resection did not improve overall or progression-free survival compared with radiotherapy. In view of its low morbidity and mortality, radiotherapy should be considered the preferred locoregional treatment for these patients.
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Affiliation(s)
- Jan P van Meerbeeck
- Department of Respiratory Medicine, 7K12IE, University Hospital Ghent, De Pintelaan 185, 9000 Gent, Belgium.
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18
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Johnson DH, Rusch VW, Turrisi AT. Scalpels, Beams, Drugs, and Dreams: Challenges of Stage IIIA-N2 Non-Small-Cell Lung Cancer. J Natl Cancer Inst 2007; 99:415-8. [PMID: 17374824 DOI: 10.1093/jnci/djk107] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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