Outcomes after neoadjuvant or adjuvant chemotherapy for cT2-4N0-1 non-small cell lung cancer: A propensity-matched analysis

Economic Evaluation of Neoadjuvant Versus Adjuvant Chemotherapy in Cancer Treatment: A Systematic Review and Meta-Analysis

OBJECTIVES

In the absence of evidence on whether neoadjuvant (NAC) or adjuvant chemotherapy (AC) is more beneficial for various tumor treatments, economic evaluation (EE) can assist medical decision making. There is limited evidence on their cost-effectiveness and their prospective evaluation is less likely in the future. Therefore, a systematic review and meta-analysis about EE for NAC versus AC in solid tumor help compare these therapies from various perspectives.

METHODS

Various databases were searched for studies published from inception to 2021. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines and economic-specific guidelines. The data were pooled using a random effects model when possible.

RESULTS

The retrieval identified 15 EE studies of NAC versus AC in 8 types of cancer. NAC is the dominant strategy for pancreatic, head and neck, rectal, prostate cancers and colorectal liver metastases. For ovarian cancer, NAC is cost-effective with a lower cost and higher or similar quality-adjusted life-year. There were no significant differences in cost and outcomes for lung cancer. For stage IV or high-risk patients with ovarian or prostate cancer, NAC was cost-effective but not for patients who were not high risk.

CONCLUSIONS

The EEs results for NAC versus AC were inconsistent because of their different model structures, assumptions, cost inclusions, and a shortage of studies. There are multiple sources of heterogeneity across EEs evidence synthesis. More high-quality EE studies on NAC versus AC in initial cancer treatment are necessary.

Pathological response in resectable non-small cell lung cancer: a systematic literature review and meta-analysis

BACKGROUND

Surrogate endpoints for overall survival in patients with resectable non-small cell lung cancer receiving neoadjuvant therapy are needed to provide earlier treatment outcome indicators and accelerate drug approval. This study's main objectives were to investigate the association among pathological complete response, major pathological response, event-free survival and overall survival and to determine whether treatment effects on pathological complete response and event-free survival correlate with treatment effects on overall survival.

METHODS

A comprehensive systematic literature review was conducted to identify neoadjuvant studies in resectable non-small cell lung cancer. Analysis at the patient level using frequentist and Bayesian random effects (hazard ratio [HR] for overall survival or event-free survival by pathological complete response or major pathological response status, yes vs no) and at the trial level using weighted least squares regressions (hazard ratio for overall survival or event-free survival vs pathological complete response, by treatment arm) were performed.

RESULTS

In both meta-analyses, pathological complete response yielded favorable overall survival compared with no pathological complete response (frequentist, 20 studies and 6530 patients: HR = 0.49, 95% confidence interval = 0.42 to 0.57; Bayesian, 19 studies and 5988 patients: HR = 0.48, 95% probability interval = 0.43 to 0.55) and similarly for major pathological response (frequentist, 12 studies and 1193 patients: HR = 0.36, 95% confidence interval = 0.29 to 0.44; Bayesian, 11 studies and 1018 patients: HR = 0.33, 95% probability interval = 0.26 to 0.42). Across subgroups, estimates consistently showed better overall survival or event-free survival in pathological complete response or major pathological response compared with no pathological complete response or no major pathological response. Trial-level analyses showed a moderate to strong correlation between event-free survival and overall survival hazard ratios (R2 = 0.7159) but did not show a correlation between treatment effects on pathological complete response and overall survival or event-free survival.

CONCLUSION

There was a strong and consistent association between pathological response and survival and a moderate to strong correlation between event-free survival and overall survival following neoadjuvant therapy for patients with resectable non-small cell lung cancer.

Canadian Consensus Recommendations for the Management of Operable Stage II/III Non-Small-Cell Lung Cancer: Results of a Modified Delphi Process

The treatment paradigm for patients with stage II/III non-small-cell lung cancer (NSCLC) is rapidly evolving. We performed a modified Delphi process culminating at the Early-stage Lung cancer International eXpert Retreat (ELIXR23) meeting held in Montreal, Canada, in June 2023. Participants included medical and radiation oncologists, thoracic surgeons and pathologists from across Quebec. Statements relating to diagnosis and treatment paradigms in the preoperative, operative and postoperative time periods were generated and modified until all held a high level of consensus. These statements are aimed to help guide clinicians involved in the treatment of patients with stage II/III NSCLC.

Neoadjuvant Targeted Therapy in Resectable NSCLC: Current and Future Perspectives

The standard of care (SoC) for medically operable patients with early-stage (stages I-IIIB) NSCLC is surgery combined with (neo)adjuvant systemic therapy for patients with stages II to IIIB disease and some stage IB or, rarely, chemoradiation (stage III disease with mediastinal lymph node metastases). Despite these treatments, metastatic recurrence is common and associated with poor survival, highlighting the need for systemic therapies that are more effective than the current SoC. After the success of targeted therapy (TT) in patients with advanced NSCLC harboring oncogenic drivers, these agents are being investigated for the perioperative (neoadjuvant and adjuvant) treatment of patients with early-stage NSCLC. Adjuvant osimertinib is the only TT approved for use in the early-stage setting, and there are no approved neoadjuvant TTs. We discuss the importance of comprehensive biomarker testing at diagnosis to identify individuals who may benefit from neoadjuvant targeted treatments and review emerging data from neoadjuvant TT trials. We also address the potential challenges for establishing neoadjuvant TTs as SoC in the early-stage setting, including the identification and validation of early response markers to guide care and accelerate drug development, and discuss safety considerations in the perioperative setting. Initial data indicate that neoadjuvant TTs are effective and well tolerated in patients with EGFR- or ALK-positive early-stage NSCLC. Data from ongoing trials will determine whether neoadjuvant targeted agents will become a new SoC for individuals with oncogene-addicted resectable NSCLC.

Cost-effectiveness of neoadjuvant pembrolizumab plus chemotherapy with adjuvant pembrolizumab for early-stage non-small cell lung cancer in the United States

Introduction

Perioperative (neoadjuvant and adjuvant) pembrolizumab has shown favorable efficacy in patients with early-stage non-small cell lung cancer (NSCLC). This study aims to evaluate the cost-effectiveness of this treatment from the perspective of the United States healthcare payers.

Methods

We established a Markov model to compare the cost-effectiveness of perioperative pembrolizumab with that of neoadjuvant chemotherapy in 21-day cycles, utilizing data from the phase 3 KEYNOTE-671 trial. Additional data were extracted from other publications or online sources. Sensitivity analyses were conducted to evaluate the robustness of the findings. A willingness-to-pay threshold of $150,000 per quality-adjusted life-years (QALYs) gained was established. The main outcomes of this study were the measurement of QALYs, overall costs, incremental cost-effectiveness ratio (ICER), and net monetary benefit (NMB).

Results

During a 10-year time horizon, the total costs of perioperative pembrolizumab and the control treatment were $224,779.1 and $110,026.3, respectively. The QALYs were 4.19 and 2.97 for the two treatments, respectively, which led to an ICER of $94,222.29 per QALY gained. The NMB at the WTP threshold at $150,000 per QALY gained was $67,931.3. One-way sensitivity analysis identified the cost of pembrolizumab as the primary factor influencing cost-effectiveness. Probabilistic sensitivity analysis indicated a 97.7% probability of perioperative pembrolizumab being cost-effective at the WTP threshold.

Conclusions

From the perspective of the United States healthcare payers, perioperative pembrolizumab is a cost-effective treatment for patients with early-stage NSCLC.

Survival and quality-of-life outcomes in early-stage NSCLC patients: a literature review of real-world evidence

Aim

Assess the long-term survival and quality-of-life outcomes in early-stage NSCLC (eNSCLC) patients.

Methods

Review of long-term survival and quality-of-life after curative treatment in eNSCLC patients in observational studies.

Results

Disease-free proportion decreased in stage III vs stage I patients. Recurrence-free proportion decreased with age and disease stage. Advanced stage and vascular invasion increased risk of late recurrence. Conditional 5-year relative survival rates did not exceed 87%, indicating higher mortality in eNSCLC survivors. Lower conditional survival rates and relative survival rates were associated with older age and advanced disease. Survivors of eNSCLC had poorer physical quality-of-life.

Conclusion

Despite curative-intent therapy, survivors of eNSCLC still face significant risks of recurrence, excess mortality, and diminished quality-of-life.

Does major pathological response after neoadjuvant Immunotherapy in resectable nonsmall-cell lung cancers predict prognosis? A systematic review and meta-analysis

OBJECTIVE

Overall survival is the gold-standard outcome measure for phase 3 trials, but the need for a long follow-up period can delay the translation of potentially effective treatment to clinical practice. The validity of major pathological response (MPR) as a surrogate of survival for non small cell lung cancer (NSCLC) after neoadjuvant immunotherapy remains unclear.

METHODS

Eligibility was resectable stage I-III NSCLC and delivery of PD-1/PD-L1/CTLA-4 inhibitors prior to resection; other forms/modalities of neoadjuvant and/or adjuvant therapies were allowed. Statistics utilized the Mantel-Haenszel fixed-effect or random-effect model depending on the heterogeneity ( I2 ).

RESULTS

Fifty-three trials (seven randomized, 29 prospective nonrandomized, 17 retrospective) were identified. The pooled rate of MPR was 53.8%. Compared to neoadjuvant chemotherapy, neoadjuvant chemo-immunotherapy achieved higher MPR (OR 6.19, 4.39-8.74, P <0.00001). MPR was associated with improved disease-free survival/progression-free survival/event-free survival (HR 0.28, 0.10-0.79, P =0.02) and overall survival (HR 0.80, 0.72-0.88, P <0.0001). Patients with stage III (vs I/II) and PD-L1 ≥1% (vs <1%) more likely achieved MPR (OR 1.66,1.02-2.70, P =0.04; OR 2.21,1.28-3.82, P =0.004).

CONCLUSIONS

The findings of this meta-analysis suggest that neoadjuvant chemo-immunotherapy achieved higher MPR in NSCLC patients, and increased MPR might be associated with survival benefits treated with neoadjuvant immunotherapy. It appears that the MPR may serve as a surrogate endpoint of survival to evaluate neoadjuvant immunotherapy.

Association between event-free survival and overall survival after neoadjuvant treatment for non-small cell lung cancer: a systematic review and meta-analysis

BACKGROUND

We wanted to evaluate if event-free survival (EFS) is a reliable surrogate for overall survival (OS) in patients with resectable non-small cell lung cancer (r-NSCLC) receiving neoadjuvant therapy. We conducted a systematic literature review and meta-analysis to investigate the statistical association between EFS and OS.

RESEARCH DESIGN AND METHODS

Electronic databases were searched on 30 July 2021 to identify sources reporting both EFS and OS data in patients with stage I-IIIB r-NSCLC receiving neoadjuvant therapy. Correlation and regression analyses evaluated the association between the effect of treatment on EFS and OS using log-hazard ratios (HRs). Sources in which the entire population had epidermal growth factor receptor mutations were excluded from the analyses.

RESULTS

We identified 74 sources, of which 8 reported EFS and OS HRs from randomized controlled trials. Based on these, we found a positive linear correlation and a strong association between EFS and OS log-HRs (weighted Pearson's correlation coefficient r = 0.864; 95% confidence interval 0.809-0.992; P = 0.006; random-effects meta-regression, R2 = 0.777).

CONCLUSIONS

We found a strong association between treatment effects for EFS and OS, indicating that improvements in EFS are likely to be predictive of improvements in OS. EFS may therefore be a reliable surrogate for OS after neoadjuvant therapy in r-NSCLC.

Genomic mapping of metastatic organotropism in lung adenocarcinoma

We analyzed 2,532 lung adenocarcinomas (LUAD) to identify the clinicopathological and genomic features associated with metastasis, metastatic burden, organotropism, and metastasis-free survival. Patients who develop metastasis are younger and male, with primary tumors enriched in micropapillary or solid histological subtypes and with a higher mutational burden, chromosomal instability, and fraction of genome doublings. Inactivation of TP53, SMARCA4, and CDKN2A are correlated with a site-specific shorter time to metastasis. The APOBEC mutational signature is more prevalent among metastases, particularly liver lesions. Analyses of matched specimens show that oncogenic and actionable alterations are frequently shared between primary tumors and metastases, whereas copy number alterations of unknown significance are more often private to metastases. Only 4% of metastases harbor therapeutically actionable alterations undetected in their matched primaries. Key clinicopathological and genomic alterations in our cohort were externally validated. In summary, our analysis highlights the complexity of clinicopathological features and tumor genomics in LUAD organotropism.

Clinicopathologic outcomes of preoperative targeted therapy in patients with clinical stage I to III non-small cell lung cancer

OBJECTIVE

Targeted therapy improves outcomes in patients with advanced-stage non-small cell lung cancer (NSCLC) and in the adjuvant setting, but data on its use before surgery are limited. We sought to investigate the safety and feasibility of preoperative targeted therapy in patients with operable NSCLC.

METHODS

We retrospectively reviewed 51 patients with clinical stage I to III NSCLC who received targeted therapy, alone or in combination with chemotherapy, before surgical resection with curative intent, treated from 2004 to 2021. The primary outcome was the safety and feasibility of preoperative targeted therapy; secondary outcomes included objective response rate, major pathologic response (defined as ≤10% viable tumor) rate, recurrence-free survival (RFS), and overall survival.

RESULTS

Of the 51 patients included, 46 had an activating epidermal growth factor receptor gene alteration and 5 had an anaplastic lymphoma kinase fusion. Overall, 37 of 46 evaluable patients experienced at least 1 adverse event before surgery; however, only 3 patients experienced a grade 3 or 4 event. The objective response rate was 38% (17/45) for all evaluable patients and 44% (14/32) for patients with clinical stage II or III disease. The major pathologic response rate was 20% (9/44); 2 patients had a complete pathologic response. Median RFS was 3.8 years (95% CI, 2.8 to not reached). Targeted therapy alone was associated with better RFS than combination therapy (P = .009) in patients with clinical stage II or III disease.

CONCLUSIONS

Preoperative targeted therapy was well tolerated and associated with good outcomes, with or without induction chemotherapy. In addition, radiographic response and pathologic response were strongly correlated.

The Evolving Role for Systemic Therapy in Resectable Non-small Cell Lung Cancer

During the last 2 decades, the understanding of non-small cell lung cancer (NSCLC) has evolved from a purely histologic classification system to a more complex model synthesizing clinical, histologic, and molecular data. Biomarker-driven targeted therapies have been approved by the United States Food and Drug Administration for patients with metastatic NSCLC harboring specific driver alterations in EGFR, HER2, KRAS, BRAF, MET, ALK, ROS1, RET, and NTRK. Novel immuno-oncology agents have contributed to improvements in NSCLC-related survival at the population-level. However, only in recent years has this nuanced understanding of NSCLC permeated into the systemic management of patients with resectable tumors.

Effectiveness of neoadjuvant immunochemotherapy compared to neoadjuvant chemotherapy in non-small cell lung cancer patients: Real-world data of a retrospective, dual-center study

Background

Studying the application of neoadjuvant immunochemotherapy (NICT) in the real world and evaluating its effectiveness and safety in comparison with neoadjuvant chemotherapy (NCT) are critically important.

Methods

This study included the II-IIIB stage non-small cell lung cancer (NSCLC) patients receiving NCT with or without PD-1 inhibitors and undergoing surgery after neoadjuvant treatments between January 2019 to August 2022. The clinical characteristics and treatment outcomes were retrospectively reviewed and analyzed.

Results

A total of 66 patients receiving NICT and 101 patients receiving NCT were included in this study. As compared to NCT, NICT showed similar safety while not increasing the surgical difficulty. The ORR in the NICT and NCT groups was 74.2% and 53.5%, respectively, P = 0.009. A total of 44 patients (66.7%) in the NICT group and 21 patients (20.8%) in the NCT group showed major pathology response (MPR) (P <0.001). The pathology complete response (pCR) rate was also significantly higher in NICT group than that in NCT group (45.5% vs. 10.9%, P <0.001). After Propensity Score Matching (PSM), 42 pairs of patients were included in the analysis. The results showed no significant difference in the ORR between the two groups (52.3% vs. 43.2%, P = 0.118), and the proportions of MPR (76.2%) and pCR (50.0%) in NICT group were significantly higher than those of MPR (11.9%) and pCR (4.7%) in the NCT group (P <0.001). The patients with driver mutations might also benefit from NICT.

Conclusions

As compared to NCT, the NICT could significantly increase the proportions of patients with pCR and MPR without increasing the operation-related bleeding and operation time.

Association of Pathologic Complete Response and Long-Term Survival Outcomes Among Patients Treated With Neoadjuvant Chemotherapy or Chemoradiotherapy for NSCLC: A Meta-Analysis

Introduction

Increased efforts to optimize outcomes for early stage NSCLC through the investigation of novel perioperative treatment strategies are ongoing. An emerging question is the role of pathologic response and its association with long-term clinical outcomes after neoadjuvant therapy.

Methods

To investigate the association of pathologic complete response (pCR) and event-free survival (EFS) and overall survival (OS), we performed a systematic review and meta-analysis identifying studies reporting on the prognostic impact of pCR after neoadjuvant chemotherapy or chemoradiotherapy. To evaluate this prognostic value, an aggregated data (AD) meta-analyses was conducted to estimate the pooled hazard ratios (HRs) of EFS and OS for pCR. Using reconstructed individual patient data (IPD), pooled Kaplan-Meier curves were obtained to estimate this association in a more granular fashion. Subgroup analyses were conducted to further explore the impacts of study-level characteristics.

Results

A total of 28 studies comprising 7011 patients were included in the AD meta-analysis, of which, IPD was available for 6274 patients from 24 studies. Results from our AD meta-analysis revealed a pooled pCR rate of 18% (95% confidence interval [CI]: 15%–21%), including significant improvements in OS (HR = 0.50, 95% CI: 0.45–0.56) and EFS (HR = 0.46, 95% CI: 0.37–0.57) on the basis of pCR status. Our IPD analysis revealed a 5-year OS rate of 63% (95% CI: 59.6–67.4) for patients with a pCR compared with 39% (95% CI: 34.5–44.5) for those without a pCR.

Conclusions

pCR after neoadjuvant chemotherapy plus or minus radiotherapy is associated with significant improvements in EFS and survival for patients with resectable NSCLC.

Neoadjuvant approaches in hepatocellular carcinoma: There's no time like the present

Hepatocellular carcinoma remains a lethal malignancy and is an increasingly common cause of cancer death worldwide. Curative-intent surgical resection remains the standard of care for eligible patients, yet outcomes remain poor for many patients, with most patients experiencing recurrence in the five years after resection. There is currently significant interest in utilizing locoregional and systemic therapies - in both the neoadjuvant and adjuvant settings - to increase the chance of cure. This review article appraises the existing literature and current clinical trial landscape of neoadjuvant therapies in hepatocellular carcinoma.

The Emerging Importance of Tumor Genomics in Operable Non-Small Cell Lung Cancer

During the last two decades, next-generation sequencing (NGS) has played a key role in enhancing non-small cell lung cancer treatment paradigms through the application of "targeted therapy" in advanced and metastatic disease. The use of specific tyrosine kinase inhibitors in patients with oncogenic driver alterations, such as EGFR, ALK, ROS1, BRAF V600E, MET, and NTRK mutations, among others, has changed treatment approaches and improved outcomes in patients with late-stage disease. Although NGS technology has mostly been used in the setting of systemic therapy to identify targets, response to therapy, and mechanisms of resistance, it has multiple potential applications for patients with earlier-stage disease, as well. In this review, we discuss the emerging role of NGS technologies to better understand tumor biology in patients with non-small cell lung cancer who are undergoing surgery with curative intent. In this patient cohort, we examine tumor heterogeneity, the underlying tumor genomics associated with lung adenocarcinoma subtypes, the prediction of recurrence after complete surgical resection, the use of plasma circulating tumor DNA for detection of early cancers and monitoring for minimal residual disease, the differentiation of separate primaries from intrapulmonary metastases, and the use of NGS to guide induction and adjuvant therapies.

Cost-effectiveness analysis of neoadjuvant versus adjuvant chemotherapy for cT2-4N0-1 non-small cell lung cancer patients during initial treatment phase

Objective

The choice between neoadjuvant chemotherapy (NAC) and adjuvant chemotherapy (AC) remains controversial in the treatment of non-small cell lung cancer (NSCLC). There is no significant difference in NAC and AC’s effectiveness. We investigate the cost-effectiveness of NAC versus AC for NSCLC.

Method

A decision tree model was designed from a payer perspective to compare NAC and AC treatments for NSCLC patients. Parameters included overall survival (OS), surgical complications, chemotherapy adverse events (AEs), treatment initiation probability, treatment time frame, treatment cost, and quality of life (QOL). Sensitivity analyses were performed to characterize model uncertainty in the base cases.

Result

AC treatment strategy produced a cost saving of ¥3064.90 and incremental quality-adjusted life-years (QALY) of 0.10 years per patient with the same OS. NAC would be cost-effective at a ¥35,446/QALY threshold if the median OS of NAC were 2.3 months more than AC. The model was robust enough to handle variations to all input parameters except OS. In the probability sensitivity analysis, AC remained dominant in 54.4% of simulations.

Conclusion

The model cost-effectiveness analysis indicates that with operable NSCLC, AC treatment is more cost-effective to NAC. If NAC provides a longer survival advantage, this treatment strategy may be cost-effective. The OS is the main factor that influences cost-effectiveness and should be considered in therapeutic regimes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-021-00280-w.

Morbidity and mortality of lobectomy or pneumonectomy after neoadjuvant treatment: an analysis from the ESTS database

OBJECTIVES

To evaluate the postoperative complications and 30-day mortality rates associated with neoadjuvant chemotherapy before major anatomic lung resections registered in the European Society of Thoracic Surgeons (ESTS) database.

METHODS

Retrospective analysis on 52 982 anatomic lung resections registered in the ESTS database (July 2007-31 December 2017) (6587 pneumonectomies and 46 395 lobectomies); 5143 patients received neoadjuvant treatment (9.7%) (3993 chemotherapy alone and 1150 chemoradiotherapy). To adjust for possible confounders, a propensity case-matched analysis was performed. The postoperative outcomes (morbidity and 30-day mortality) of matched patients with and without induction treatment were compared.

RESULTS

8.2% of all patients undergoing lobectomies and 20% of all patients undergoing pneumonectomies received induction treatment. Lobectomy analysis: propensity score analysis yielded 3824 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the neoadjuvant group (626 patients, 16% vs 446 patients, 12%, P < 0.001), but 30-day mortality rates were similar (71 patients, 1.9% vs 75 patients, 2.0%, P = 0.73). The incidence of bronchopleural fistula and prolonged air leak >5 days were similar between the 2 groups (neoadjuvant: 0.5% vs 0.4%, P = 0.87; 9.2% vs 9.9%, P = 0.27). Pneumonectomy analysis: propensity score analysis yielded 1312 pairs of patients with and without induction treatment. The incidence of cardiopulmonary complications was higher in the treated patients compared to those without neoadjuvant treatment (neoadjuvant 275 cases, 21% vs 18%, P = 0.030). However, the 30-day mortality was similar between the matched groups (neoadjuvant 68 cases, 5.2% vs 5.3%, P = 0.86). Finally, the incidence of bronchopleural fistula was also similar between the 2 groups (neoadjuvant 1.8% vs 1.4%, P = 0.44).

CONCLUSIONS

Neoadjuvant chemotherapy is not associated with an increased perioperative risk after either lobectomy or pneumonectomy, warranting a more liberal use of this approach for patients with locally advanced operable lung cancer.

Systematic Review of Neoadjuvant Immunotherapy for Patients With Non-Small Cell Lung Cancer

There is a paucity of robust clinical evidence for the role of neoadjuvant immunotherapy in patients with resectable non-small cell lung cancer. The primary aim of the study was to identify the available data on the feasibility, safety and efficacy of neoadjuvant immunotherapy. A systematic review was conducted using electronic databases. Relevant studies were identified according to predefined selection criteria. Five relevant publications on 4 completed trials were identified. In most studies, >90% of patients were able to undergo surgery within the planned timeframe after neoadjuvant immunotherapy. There was a high incidence of open thoracotomy procedures, either planned or converted from a planned minimally invasive approach. Mortality ranged from 0 to 5%, but none of the reported deaths were considered directly treatment-related. Morbidities were reported according to adverse events related to neoadjuvant systemic therapy, and postoperative surgical complications. Survival outcomes were limited due to short follow-up periods. Major pathologic response ranged from 40.5 to 56.7%, whilst complete pathologic response of the primary tumor ranged from 15 to 33%. Radiological responses were reported according to RECIST criteria and fluorodeoxyglucose-avidity. This systematic review reported safe perioperative outcomes of patients who underwent resection following neoadjuvant immunotherapy. However, there was a relatively high incidence of open thoracotomy procedures, partly due to the technical challenges associated with increased fibrosis and inflammation of tissue, as well as the more advanced stages of disease in patients enrolled in the studies. Future studies should focus on identifying predictors of pathological response.

Surgery after neoadjuvant immunotherapy in patients with resectable non-small cell lung cancer

Surgery is the standard of care for patients with operable non-small cell lung cancer (NSCLC). However, as a single modality, surgery for early stage or locally advanced NSCLC remains associated with high rates of local and distant recurrence. The addition of neoadjuvant or adjuvant chemotherapy has modestly improved outcomes. While systemic therapy paired with surgery for other malignancies such as breast cancer have resulted in far better outcomes for equivalent stage designations, outcome improvements for operable NSCLC have lagged in part as a result of trials where adjuvant chemotherapy seemed to incur harm for stage IA patients and only modest survival benefit for stage IB-IIIA patients (AJCC 7th ed.). In recent years, immunotherapy for NSCLC has emerged as a systemic therapy with significant benefit over traditional chemotherapy regimens. These advances with immune checkpoint inhibitors (ICIs) have opened the door to administering peri-operative immunotherapy for operable NSCLC. As a result, a great multitude of studies investigating the use of immunotherapy in combination with surgery for NSCLC as well as several other malignancies have emerged. In this review, we outline the rationale for neoadjuvant immunotherapy in the treatment of operable NSCLC and summarize the available evidence that include preoperative ICI as a single modality or in combination with systemic agents and/or radiotherapy. Further, we summarize how such treatment trajectories open multiple unique windows of opportunity for scientific discovery and potential therapeutic gains for these vulnerable patients.

Neoadjuvant chemotherapy combined with intraoperative radiotherapy is effective to prevent recurrence in high-risk non-small cell lung cancer (NSCLC) patients

Background

Basal cell hyperplasia (BCH) and squamous metaplasia (SM) in the small bronchi distant from the tumor is associated with a high risk of non-small cell lung cancer (NSCLC) recurrence. Here, we assessed whether neoadjuvant chemotherapy (NAC), intraoperative radiotherapy (IORT), or adjuvant chemotherapy (AC) is effective to prevent recurrence in NSCLC patients (n=171) with different premalignant lesions in the small bronchi

Methods

BCH, SM, and dysplasia (D) were identified in the samples of lung tissue distant from the tumor. NSCLC patients were treated by surgery, different combinations of NAC and IORT, and AC.

Results

Based on the type of bronchial lesions, NSCLC patients were classified into four groups: BCH⁺SM⁻D⁻ (55.6%, 95/171), BCH⁺SM⁺D⁻ (26.3%; 45/171), BCH⁻SM⁺D⁺ (6.4%, 11/171), and BCH⁻SM⁻D⁻ (11.7%, 20/171). During 5 years, recurrent carcinoma was found in 13.4% (23/171) of patients and represented by metachronous metastases in the thoracic lymph nodes (82.6%, 19/23) and by a relapse in the bronchial stump (17.4%, 4/23). Recurrence was frequent in BCH⁺SM⁺D⁻ patients (87.0%, 20/23), rare in BCH⁺SM⁻D⁻ and BCH⁻SM⁻D⁻ patients (13.0%, 3/23), and absent in BCH⁻SM⁺D⁺ patients (0/23). The 5-year recurrence-free survival was also shorter in BCH⁺SM⁺D⁻ patients (HR 27.35; 95% CI: 6.31−118.48; P<0.0001). In the high-risk (BCH⁺SM⁺D⁻) group, recurrence occurred mainly in cases without NAC and IORT (88.2%, 15/17) and was absent (0/15) when these therapies were combined. NAC- and IORT-negative patients also showed poor overall survival (HR 4.35; 95% CI: 1.96−9.66; P<0.0001) and tended to have decreased recurrence-free survival (P=0.075). Importantly, the recurrence rate was not different between AC-treated and AC-naïve BCH⁺SM⁺D⁻ patients.

Conclusions

The combination of NAC and IORT is an effective strategy to prevent recurrence in high-risk NSCLC patients.

Long-term outcomes following neoadjuvant or adjuvant chemoradiotherapy for stage I-IIIA non-small cell lung cancer: a propensity-matched analysis

Background

This study aimed to evaluate the long-term survival outcomes of patients undergoing neoadjuvant chemoradiotherapy or adjuvant chemoradiotherapy for T1-4N0-1M0 disease.

Methods

Patients with pT1-4N0-1M0 between 2010 and 2015 who received pre- or postoperative (R0 resection) chemoradiotherapy were identified. The exclusion criteria included N2 or M1 disease, immunotherapy, and targeted therapy. The staging was recalculated according to the new 8th edition TNM classification. Survival and predictors were assessed using Kaplan-Meier and multivariate Cox proportional-hazards model. Propensity-score matching with a ratio of 2:1 was performed to reduce bias in various clinicopathological factors.

Results

Of the 1,769 patients who met the inclusion criteria, 407 and 814 were included in the neoadjuvant and adjuvant chemoradiotherapy group, respectively, after propensity-score matching. The 5-year overall survival (OS) and cancer-specific survival (CSS) were 38.1% and 40.0% for neoadjuvant chemoradiotherapy and 26.3% and 26.5% for adjuvant chemoradiotherapy, respectively [P<0.0001, hazard ratio (HR): 0.7418, 95% confidence interval (CI): 0.6434-0.8553; P<0.0001, HR: 0.7444, 95% CI: 0.6454-0.8587)]. When stratified by stage, stage IIA (P=0.4166, HR: 0.8575, 95% CI: 0.5917-1.243) and IIIA (P=0.0740, HR: 0.7687, 95% CI: 0.5748-1.028) did not show improved 5-year OS in patients receiving neoadjuvant chemoradiotherapy. When stratified by age, similar trends were observed for patients aged more than 75 years. The multivariable analysis showed a significant association of neoadjuvant chemoradiotherapy with better survival.

Conclusions

Neoadjuvant chemoradiotherapy might improve the long-term survival of patients with stage I-IIIA non-small cell lung cancer (NSCLC). For patients aged more than 75 years, neoadjuvant chemoradiotherapy was not associated with an improvement in survival.

Neoadjuvant apatinib plus S-1 in locally advanced pulmonary adenocarcinoma: A case report and review of the literature

RATIONALE

About one-third of the lung tumors are staged as locally advanced at the time of initial diagnosis; however, the optimal induction treatment before curative resection has not been elucidated. To date, the evidence regarding the preoperative apatinib plus S-1 for locally advanced pulmonary adenocarcinoma is scarce.

PATIENT CONCERNS

A 29-year-old female was admitted because of persistent cough, sputum, and chest distress for 2 months.

DIAGNOSES

Primary pulmonary adenocarcinoma (cT3N2M0, IIIB) with unknown driver gene mutation status.

INTERVENTIONS

The patient had received 4 months of neoadjuvant therapy using oral apatinib (425 mg daily) plus S-1 (60 mg, twice daily for 4 weeks with a 2-week drug-free interval), followed by anatomical lobectomy with curative intent. Adjuvant apatinib (425 mg daily for a month, and 250 mg daily for another month) plus S-1 at the same dosage were administered for 2 months. Thereafter, maintenance of low-dose S-1 monotherapy (40 mg, twice daily for 4 weeks with a 2-week drug-free interval) was continued for 6 months.

OUTCOMES

The adverse events were tolerable and well-controlled. A postoperative recurrence-free survival for 2 years and a half up to now was indicated.

LESSONS

Preoperative apatinib plus S-1 showed efficacy in locally advanced pulmonary adenocarcinoma. However, high-quality trials are warranted before the recommendation of this therapeutic regimen.

Review and perspective on adjuvant and neoadjuvant immunotherapies in NSCLC

Postoperative patients have risk recurring, even for completed resected early stage non-small-cell lung cancer (NSCLC). To control the recurrence rate, neoadjuvant and adjuvant therapies have been applied widely in clinical practice; however, neoadjuvant and adjuvant immunotherapy clinical trials on NSCLC are still being explored. In this review, we summarized the research progress and outline the issues need to be solved on adjuvant and neoadjuvant immunotherapies in NSCLC.

Treatment rationale and design of the induction chemotherapy and adjuvant thoracic radiation in resectable N2-3A/3B non-small cell lung cancer (ICAT) study

BACKGROUND

The optimal treatment strategy for stage N2-3A/3B non-small cell lung cancer (NSCLC) remains controversial owing to its heterogeneity. Although multimodal therapy is considered the standard therapeutic approach for stage N2-3A/3B resectable NSCLC patients, the optimal combination strategy still needs to be clarified.

PATIENTS AND METHODS

In total, 25 male and female patients aged between 20 and 75 years with stage N2-3A/3B resectable NSCLC will be included. Eligible patients will undergo tri-modality therapy comprising induction chemotherapy (3 cycles of combination therapy with carboplatin and nab-paclitaxel), followed by surgery and postoperative radiotherapy. Recruitment was commenced in April 2017, with a planned last follow-up in March 2024. As of May 2019, 1 subject has been enrolled. The primary endpoint is the treatment completion rate. The secondary endpoints are objective response rate (ORR) of induction chemotherapy, treatment-related adverse event, recurrence-free survival (RFS) time, and overall survival (OS) time. RFS and OS time will be calculated as the time from this study registration to first recurrence and all-cause death, respectively.

ETHICS AND DISSEMINATION

The protocol was approved by the institutional review boards of Kyoto Prefectural University of Medicine and all the participating hospitals. Written informed consent was obtained from all patients before registration, in accordance with the Declaration of Helsinki. The study results will be disseminated via publication in peer-reviewed journals.

TRIAL REGISTRATION

Trial registration number UMIN000025010 and jRCT1051180028.