Enduring challenge in the treatment of nonsmall cell lung cancer with clinical stage IIIB: results of a trimodality approach

Outcomes of surgery versus chemoradiotherapy in patients with clinical or pathologic stage N3 non-small cell lung cancer

BACKGROUND

Because surgery is rarely recommended, there is minimal literature comparing the outcomes of surgery and chemoradiation in stage N3 non-small cell lung cancer (NSCLC). We examined the outcomes of definitive chemoradiation versus multimodality therapy, including surgery, for patients with clinical and pathologic stage N3 NSCLC.

METHODS

The National Cancer Database was used to identify patients with clinical stage T1 to T3 N3 M0 NSCLC and clinical stage T1 to T3 Nx M0 with pathologic stage N3 NSCLC who were treated with either definitive chemoradiation or surgery between 2004-2015. A 1:1 propensity score-matched analysis was used to compare outcomes for both treatment groups in each analysis. The primary outcome was overall survival.

RESULTS

In 935 matched patient pairs with clinical stage N3 NSCLC, surgery was associated with worse survival (hazard ratio, 1.52; 95% confidence interval, 1.12-2.05) compared with chemoradiation at 6 months, but was associated with a significant survival benefit after 6 months (hazard ratio, 0.54; confidence interval, 0.47-0.63) in multivariable analysis. In 281 pairs of patients with pN3 NSCLC, surgery had similar survival compared with chemoradiation at 6 months (hazard ratio, 1.71; 95% confidence interval, 0.92-3.19), but was associated with improved survival after 6 months (hazard ratio, 0.76; 95% confidence interval, 0.58-0.99). The complete resection rate was 80% and 73% for patients with clinical stage N3 and pathologic stage N3 disease, respectively.

CONCLUSIONS

In patients with clinical or pathologic stage N3 NSCLC, surgery is associated with similar or worse short-term but improved long-term survival compared with chemoradiation. In a selected group of patients with stage N3 NSCLC, surgery may have a role in multimodal therapy.

Radiotherapy in Italy for Non-Small Cell Lung Cancer: Patterns of Care Survey

Aims and Background

Surveys in clinical practice are useful to find how current clinical approaches follow recommendations from evidence-based medicine, to stimulate discussion in a multidisciplinary team, and to hypothesize collaborative multi-centric trials. To assess management strategies for the use of radiotherapy in the treatment of lung cancer in Italy, in 2009, the Italian Society of Radiation Oncology Lung Cancer Study Group proposed the survey to all Italian radiation oncology institutions. Results were compared with literature data and international reports.

Study Design

Questionnaires on patterns of care of non-small cell lung cancer were sent to radiation oncology centers active at June 2009 and evaluated data recorded in 2008.

Results

A total of 65 of 143 Italian centers responded to the questionnaire. The responding centers reflect the distribution of radiotherapy centers throughout the country. Of the treated patients, 55.2% were stage III, and most cases had a good performance status. FDG-PET was routinely used by 51% of centers for diagnostic and contouring phases. Postoperative radiotherapy was prescribed to pN1 and pN2 patients in 42.2% and 98.5%, respectively. The possible use of neo-adjuvant concomitant chemoradiation was declared by 70% of responders. A sequential chemoradiation approach was actually used in 43.6% of cases, induction chemotherapy followed by concomitant radiochemotherapy in 42.4%, and upfront concomitant radiochemotherapy in only 14%. In 53% of the institutions, patients have a clinical examination by a radiation oncologist only after the beginning of chemotherapy and in 82.4% of cases they have already received 2–4 cycles of chemotherapy. Most of the institutions exclude elective nodal irradiation from routine application. Total dose and fractionation in adjuvant, neoadjuvant, curative and palliative settings confirm literature data. There were significant differences in treatment planning constraints applied for lung, esophageal and cardiac tissues. Of the responding centers, 41% had stereotactic therapy for primary inoperable lung cancer and for metastatic lesions.

Conclusions

In Italy, daily practice differs in some ways from the evidence supported by the results of meta-analyses/clinical trials as regards concurrent chemoradiation approaches. It could be postulated that there is an urgent need for groups that collaborate with the other societies involved in the treatment of non-small cell lung cancer in order to offer the best therapy to our patients.

What outcome after the prescription of neoadjuvant chemotherapy in lung cancer?

Background

The treatment of patients with locally advanced non-small-cell lung cancer is controversial. Surgery remains the gold standard, even in this group. Neoadjuvant chemotherapy could allow surgical resection in patients initially judged inoperable.

Methods

From January 2009 to May 2010, neoadjuvant chemotherapy was indicated in 27 patients with NSCLC (25 men, 2 women). Their mean age was 65 years. The stages were: IIB in 5, IIIA in 17 (6 in stage IIIAN2), IIIB in 2, and IV in 3.

Results

23 patients received neoadjuvant chemotherapy, 2 refused induction treatment, and 2 had impaired status. The neoadjuvant chemotherapy regimen was gemcitabine-cisplatin in 17 patients and vinorelbine-cisplatin in 6. Only 5 patients underwent complete surgical treatment after induction: 1 in stage IIB, 1 in stage IIIAN0, 1 in IIIB, and 2 in stage IV (1 operated brain metastasis, and 1 operated adrenal metastasis). Surgical treatment was not achieved after neoadjuvant chemotherapy in 18 patients because of progressive disease.

Conclusion

Neoadjuvant chemotherapy offers several potential benefits, but it may delay surgery or eliminate eligibility as a surgical candidate. Rigorous patient selection for this type of multimodal treatment is essential.

Neoadjuvant chemoradiotherapy for stage III (N2/3) non-small-cell lung cancer: a review of prospective studies

SUMMARY Trimodality therapy, a maximal combination of chemotherapy, radiotherapy and surgical resection, for stage III non-small-cell lung cancer promises improved outcomes through optimizing local, regional and distant control. Phase II trials of neoadjuvant chemoradiotherapy have explored a number of different radiotherapy dose and fractionation schemes, and have identified an important subset of patients who achieve mediastinal nodal clearance and may achieve long-term survival. Phase III trials of various combinations of chemotherapy, radiotherapy and surgery have demonstrated mixed results with regard to each modality’s impact on progression-free or overall survival. In this review, we focus on the historical lessons learned from prospective trials of trimodality therapy completed over the last 30 years and set the stage for future studies of neoadjuvant chemoradiotherapy for stage III non-small-cell lung cancer.

Induction therapy followed by surgery for T3-T4/N0 non-small cell lung cancer: long-term results

BACKGROUND

The aim of this study was to analyze the impact of the induction chemoradiotherapy (IT) on the survival pattern in T3/T4-N0 non-small cell lung cancer (NSCLC) patients.

METHODS

The data of 71 patients treated from January 1992 to May 2007 were reviewed. Of these, 31 patients received IT prior to surgery (IT group: T3, 20 patients; and T4, 11 patients), and 40 directly underwent surgery (S group: T3, 34 patients; and T4, 6 patients). Survival rates were compared using the Kaplan-Meier analysis and the Cox proportional hazards models.

RESULTS

Mean ages were 62.5±9.9 years in the IT group and 67.7±7.1 in the S group. All patients but 1 completed the IT treatment and 27 patients (87%) were operated. A radical resection was possible in 21 patients (78%). In the IT group a complete pathologic response was obtained in 6 patients (22%), where 8 patients ended up in pI stage, 7 in pII stage, and 6 in pIII stage. The overall 5-year survival (long-term survival [LTS]) and disease-free 5-year survival (DFS) for the entire cohort were 40% and 34%, respectively. No significant differences were found when LTS in the IT group (44%) and in the S group (37%) were compared. At multivariate analysis, the completeness of resection was the only independent predictive factor (hazard ratio [HR]=5.18; 95% confidence interval [CI]=2.55 to 10.28) while Cox multivariate analysis (on the IT group only) confirmed the critical role of the pathologic downstaging (HR=4.62; 95% CI=1.54 to 13.89).

CONCLUSIONS

A multimodal strategy with IT treatment followed by surgery is a safe and reasonable treatment in T3/T4-N0 NSCLC patients, but no clear evidence of prognostic improvement may be assumed at the present time. Nevertheless, patients with radical resection and complete pathologic response have a very rewarding survival.

Role of surgery following induction therapy for stage III non-small cell lung cancer

Over the last 30 years neoadjuvant treatment of stage IIIA non-small cell lung cancer (NSCLC) followed by surgical resection for stage IIIB disease has significantly improved the overall results of treatment for patients with stage III NSCLC as well as for those with locally invasive tumors. Different chemotherapy regimens have been used, although in most studies some combination of drugs that include cisplatin is the standard. Radiation when given as part of the induction protocol appears to offer a higher rate of resection and complete resection, and higher doses of radiation are associated with better nodal downstaging. Resection in patients with persistent N2 disease and pneumonectomy following induction therapy remain controversial. Resection in patients with persistent N2 disease and pneumonectomy following induction therapy remain controversial.

Evaluation of Failure Patterns Using Trimodality in Non-Small Cell Lung Cancer

Background

The effectiveness of trimodality therapy in NSCLC has been controversial.

Methods

Ninety-two patients with stage III NSCLC were analyzed retrospectively based on treatment given. Overall survival (OS) and patterns of failure were examined in patients treated with chemoradiation alone (Group 1) versus neoadjuvant chemoradiation followed by surgical resection (Group 2).

Results

OS for 2, 3, and 5 years in Group 1 and 2 were 19.7%, 15.7%, and 4.5% versus 56.4%, 40.4%, and 32.3% (P = 0.003), respectively. Median survival for Group 1 and 2 was 11.0 and 34.0 months, respectively (P = 0.003). The recurrence rate in Group 1 was 61.8% (47 of 76) with distant non-brain involvement (48.9%). In Group 2 it was 50.0% (8 of 16) with brain (50%) involvement.

Conclusions

Patients with stage IIIA and, perhaps IIIB NSCLC with a high performance status should be considered for trimodality treatment.

Multimodality treatment of stage III non-small cell lung cancer: analysis of a phase II trial using preoperative cisplatin and gemcitabine with concurrent radiotherapy

INTRODUCTION

We report the results of a phase II trial exploring the efficacy and the feasibility of combination of gemcitabine and cisplatin concurrent with radiotherapy followed by surgery in patients with stage III non-small cell lung cancer.

METHODS

Patients with histocytologically confirmed non-small cell lung cancer were treated with cisplatin 80 mg/sqm/wk of 1 and 4 or 20 mg/sqm/d of weeks 1 and 4 and weekly gemcitabine at 300 to 350 mg/m2 plus involved field radiotherapy. A 3D-conformal radiotherapy was delivered up to 50.4 Gy, with daily fractionation of 1.8 Gy. After clinical, radiologic, and pneumological reassessment, patients who reentered criteria for resectability were operated.

RESULTS

The stage at diagnosis was IIIA-N2 in 29 patients and IIIB-T4N0-2 for vascular direct infiltration for the remaining 21. Fifteen patients (30%) experienced acute grade 3 to 4 hematological toxicity, whereas acute grade 3 esophageal toxicity was recorded in three patients (6%). One patient developed a grade 4 pulmonary toxicity (2%). Clinical response was 40 (80%) partial response, one (2%) stable disease, and nine (18%) progressive disease. Thirty-six patients (72%) underwent surgery. Final pathology showed a downstaging to stage 0 to I in 25 cases (50%). Median overall survival for all patients was 21.8 months, with a 3-year survival of 40.2%.

CONCLUSIONS

The results of this phase II trial confirm the feasibility and the efficacy of concurrent chemoradiotherapy followed by surgery.

CT, positron emission tomography, and MRI in staging lung cancer

Lung cancer is a common malignancy and remains the leading cause of cancer-related deaths in both men and women in the United States. Imaging plays an important role in the detection, diagnosis, and staging of the disease as well as in assessing response to therapy and monitoring for tumor recurrence after treatment. This article reviews the staging of the two major histologic categories of lung cancer-non-small-cell lung carcinoma (NSCLC) and small-cell lung carcinoma-and emphasizes the appropriate use of CT, MRI, and positron emission tomography imaging in patient management. Also discussed are proposed revisions of the International Association for the Study of Lung Cancer's terms used to describe the extent of NSCLC in terms of the primary tumor, lymph nodes, and metastases descriptors.

Epidemiology of Lung Cancer in Spain and Forecast for the Future

Lung cancer, a steadily growing problem, ranks as the first cause of tumor-related deaths in developed countries. The relation between lung cancer and smoking makes it a potentially avoidable disease. Found mainly in men, it has made alarming gains among women. The main prognostic factor is the possibility of receiving curative surgery; however, in real practice the diagnosis usually comes when the disease has reached an advanced stage, when only 20% can be treated surgically. Nonsurgical treatments based on chemo- and radiotherapy have not advanced appreciably in recent years, and 5-year survival is poor, estimated at only around 7% to 12% in Spain. Attempts must be made to improve preventive measures and early diagnosis in order to improve the prognosis for lung cancer patients.

Induction cisplatin-gemcitabine-paclitaxel plus concurrent radiotherapy and gemcitabine in the multimodality treatment of unresectable stage IIIB non-small cell lung cancer

BACKGROUND

To evaluate feasibility and safety of induction three-drugs combination chemotherapy and concurrent radio-chemotherapy in stage IIIB NSCLC.

PATIENTS AND METHODS

Patients with stage IIIB NSCLC were treated with three courses of induction chemotherapy, cisplatin 50 mg/m(2), paclitaxel 125 mg/m(2) and gemcitabine 1000 mg/m(2) on days 1,8 of every 21 day cycle. Patients without distant progressive disease were then treated with radiotherapy and concurrent weekly gemcitabine (250 mg/m(2)). Toxicity and response of radio-chemotherapy treatment have been assessed.

RESULTS

Between Jan 01 and Nov 02, 46 patients were enrolled. Grade 3+ hematological and non-hematological toxicity during the induction phase were 41.3% and 13.1%, respectively. In 38 patients a Clinical Response or Stable Disease was recorded and these patients underwent to concurrent radio-chemotherapy. Grade 3+ hematological and non-hematological toxicities were 8.2% in this group. Further response was observed in 66% of patients. Overall median survival time was 17.8 months, with a 3-year survival rates of 23%.

CONCLUSION

Three-drugs induction chemotherapy and concurrent radio-chemotherapy with weekly gemcitabine in locally advanced stage IIIB NSCLC is feasible and safe.

[Postoperative risk after induction treatment on surgery in non-small cell lung cancer]

Induction treatments in non-small cell lung cancer are usually discussed. Long-term survival after surgery and resecability are enhanced in locally advanced cancers. Morbidity and mortality observed after surgery limit the use of these treatments, despite they depend on many other factors: comorbidities in patient, smoking status, cancer staging, and type of surgery. Right pneumectomy enhances this risk more than left pneumectomy or other limited resections allowed by neoadjuvant treatments, especially in case of downstaging.

One hundred consecutive pneumonectomies after induction therapy for non-small cell lung cancer: An uncertain balance between risks and benefits

OBJECTIVE

We sought to assess postoperative outcome after pneumonectomy after neoadjuvant therapy in patients with non-small cell lung cancer.

METHODS

This retrospective study included 100 patients treated from January 1989 through December 2003 for a primary lung cancer in whom pneumonectomy had been performed after an induction treatment. Surgical intervention had not been considered initially for the following reasons: N2 disease (stage IIIA, n = 79), doubtful resectability (stage IIIB [T4, N0], n = 19), and M1 disease (stage IV [T2, N0, M1, solitary brain metastasis], n = 2). All patients received a 2-drug platinum-based regimen with a median of 2.5 cycles (range, 2-4 cycles), and 30 had associated radiotherapy (30-45 Gy).

RESULTS

There were 55 right and 45 left resections. Overall 30-day and 90-day mortality rates were 12% and 21%, respectively. At multivariate analysis, one independent prognostic factor entered the model to predict 30-day mortality: postoperative cardiovascular event (relative risk, 45.7; 95% confidence interval, 3.7-226.7; P = .001). Four variables predicted 90-day mortality: age of more than 60 years (relative risk, 5.06; 95% confidence interval, 1.47-17.48; P = .01), male sex (relative risk, 8.25; 95% confidence interval, 1.01-67.34; P = .049), postoperative respiratory event (relative risk, 3.64; 95% confidence interval, 1.14-9.37; P = .007), and postoperative cardiovascular event (relative risk, 7.84; 95% confidence interval, 3.12-19.71; P < .001). Estimated overall survivals in 90-day survivors were 35% (range, 29%-41%) and 25% (range, 19.3%-30.7%) at 3 and 5 years, respectively. At multivariate analysis, one independent prognostic factor entered the model: pathologic stage III-IV residual disease (relative risk, 1.89; 95% confidence interval, 1.09-3.26; P = .022).

CONCLUSIONS

Pneumonectomy after induction therapy is a high-risk procedure, the survival benefit of which appears uncertain.

Repeat FDG-PET After Neoadjuvant Therapy is a Predictor of Pathologic Response in Patients With Non-Small Cell Lung Cancer

BACKGROUND

Repeat positron emission tomography (PET) with 18F-fluorodeoxyglucose (FDG) and chest computed tomography (CT) are used to assess the effectiveness of chemoradiotherapy in patients with non-small cell lung cancer (NSCLC); however, the change in the standardized uptake values (SUV) has not been correlated with the pathologic change of the primary tumor.

METHODS

This is a retrospective cohort study of a prospective database of 56 patients who had NSCLC, FDG-PET, and chest CT scans both before and after neoadjuvant therapy, followed by complete resection of their cancer. Maximum SUVs (maxSUV) and tumor size were measured, and the percentage of change was compared with the percentage of nonviable tumor cells. The primary objective was to measure the degree of correlation between these values.

RESULTS

The change in the maxSUV has a near linear relationship to the percent of nonviable tumor cells in the resected tumors. FDG-PET's maxSUV is better correlated to pathology than the change in size on CT scan (r2 = 0.75, r2 = 0.03, p < 0.001). When the maxSUV decreased by 80% or more, a complete pathologic response could be predicted with a sensitivity of 90%, specificity of 100%, and accuracy of 96%.

CONCLUSIONS

The change in maxSUV on FDG-PET scan after neoadjuvant therapy holds a near linear relationship with pathologic response. It is a more accurate predictor than the change of size on CT scan. When the maxSUV decreases by 80% or more it is likely that the patient is a complete responder irrespective of cell type, neoadjuvant treatment, or the final absolute maxSUV. These findings may help guide treatment strategies.

A pragmatic and successful approach to treating nonsmall-cell lung carcinoma

Lung cancer is the single leading cause of cancer deaths for men and women combined. Nonsmall-cell lung carcinoma (NSCLC), which results largely from smoking tobacco, accounts for 87% of all lung cancer cases. Methods of patient selection, preoperative and intraoperative care, and postoperative outcomes for patients with NSCLC who were treated from 1991 through 2003 at Inova Fairfax Hospital are discussed. All patients were treated with surgery, some selectively and progressively with a combination of preoperative neoadjuvant therapy, to try to downstage the disease to make complete resection feasible. Outcomes from this data collection period match or exceed the best results for treatment of late-stage (ie, III and IV) disease reported anywhere to date.