Overview of the role of neoadjuvant chemotherapy for early stage non-small cell lung cancer

[Progress of Neoadjuvant Therapy Combined with Surgery in Non-small Cell Lung Cancer]

肺癌是世界范围内发病率和死亡率最高的恶性肿瘤。对于可手术切除的Ⅲa/N2期非小细胞肺癌患者，目前国内外指南均推荐采用手术联合化疗、放疗等多学科治疗模式。最新研究表明，与术后辅助治疗一样，新辅助治疗（化疗或放化疗）可显著改善可切除非小细胞肺癌患者的预后，且在治疗依从性及耐受性方面具有明显优势。非小细胞肺癌新辅助治疗的对象主要是局部进展期病变，特别是临床Ⅲa/N2期患者，基本治疗模式为术前2-4周期化疗，新辅助治疗后并不增加手术相关的死亡及并发症风险，但是在决定手术时机、入路及切除范围等方面仍面临着挑战。

The quality of chemotherapy and its quality assurance

AIMS

Assessment of the quality of chemotherapy care and its quality assurance in clinical trials and daily practice.

METHODS

Using Medline, literature was searched combining the following words: quality assurance or quality of care, combined with anti-neoplastic agents. The bibliography of each article was reviewed for additional literature. Those reports in English, French, German or Dutch focusing quality assurance or quality of care and chemotherapy were selected.

RESULTS

One hundred and five articles were selected by Medline and after review and adding of additional literature 53 articles remained. In clinical trials information on quality of chemotherapy is sparse. Different cooperative groups reported on suboptimal dosing, suboptimal registration of chemotherapy and several trials indicated that suboptimal dosing led to impaired outcome. Most quality assurance activities in clinical trials are concerned with audit and feedback and on-site visits. In daily practice the quality of chemotherapy is mostly impaired by the fact that it is not given although indicated and if it is given non-evidence based chemotherapy or administration schedules and reduced dose intensity decrease the quality of care. Especially, age, comorbidity and socio-economic status reduce the chance of receiving good quality of care regarding chemotherapy. Activities mostly used for quality assurance are generation of guidelines, specialisation and multidisciplinary care.

CONCLUSIONS

Most quality assurance activities in clinical trials and daily practice are directed to structure and process parameters. More evidence that quality of care is related to outcome should be sought. Quality assurance in daily practice should aim at guideline implementation, specialisation and multidisciplinary care and should pay attention especially to the older patients, patients with comorbidity and patients from lower socio-economic classes.

Correlation of different markers (p53, EGF-R, c-erbB-2, Ki-67) expression in the diagnostic biopsies and the corresponding resected tumors in non-small cell lung cancer

Substaging using molecular markers has been proposed to try to identify prognostic factors allowing to define groups of patients with lung cancer for whom specific therapy might be of benefit. The pre-operative assessment of these markers seems to be important specially in case of neoadjuvant chemotherapy. The aim of our study was to compare the expression of two potential prognostic factors (p53 and Ki-67) and two potential therapeutic targets (EGF-R and c-erbB-2) assessed on biopsy samples (B) of non-small cell lung cancer (NSCLC) with that of the corresponding resected tumor (RT). The expression of these biological markers was evaluated by immunohistochemistry on B and on the paired RT in 28 patients. The mean percentage of p53 positive cells was 28% in RT and 38% in B with 81% CR between B and RT and 19% FP on B. Considering RT results as standard, the positive (PPV) and negative predictive value (NPV) of the B were, respectively, 74 and 100%. The mean percentage of EGF-R positive cells was 11% in RT and 28% in B. With a cut-off of 1%, we found 85% concordant results (CR) between B and RT, 4% false negative (FN) and 11% false positive (FP) on B. The PPV and NPV values of the B were, respectively, 80 and 92%. The 8% B and 19% RT were considered as positive for c-erbB-2. We found 15% FN and 4% FP on B with 81% CR between B and RT for c-erbB-2. The NPV of the B was 83%. The mean percentage of Ki-67 positive cells was 32% in RT and 14% in B. We found 82% CR between B and RT, 14% FN and 4% FP on B. The PPV of the B was 96%. In conclusion, biopsies may provide reliable information about p53, EGF-R, c-erbB-2 and Ki-67 in lung carcinoma and could help to elaborate a therapeutic strategy.

Induction chemotherapy before operation for multiple endobronchial squamous cell carcinoma of the lung

BACKGROUND

Multiple endobronchial squamous cell carcinoma is sometimes difficult to resect due to poor pulmonary function. Although various therapeutic modalities are available, there is no consensus on the effectiveness of chemotherapy in such rare cases. In this study, we evaluated the efficacy of preoperative induction chemotherapy for patients with otherwise unresectable multiple endobronchial squamous cell carcinoma and poor pulmonary function.

METHODS

Six patients with multiple endobronchial squamous cell carcinoma were enrolled in the study. They had a total of 15 foci that were in clinical stage I or II. Due to severe emphysema and poor pulmonary function, all 6 patients were considered unsuitable for complete surgical excision if either bilateral thoracotomy or pneumonectomy was required. The patients received two courses (at 3- to 4-week intervals) of induction chemotherapy, beginning on day 1 with cisplatin (80 mg/m2), vindesine (3 mg/m2), and mitomycin-C (8 mg/m2). After induction chemotherapy, surgical resection was performed on all 6 patients as bilateral thoracotomy and pneumonectomy were avoided due to the effectiveness of induction chemotherapy.

RESULTS

Postoperative pathologic examination revealed a complete response in eight foci. Four nonresected foci have not recurred so far. Although three residual tumors were observed in resected specimens, they all showed moderate responses to chemotherapy. The possible complete response rate is 80%. All patients have survived for 2 to 10 years without apparent recurrence.

CONCLUSIONS

Induction chemotherapy can be added to treatment options for patients with rare multiple endobronchial squamous carcinoma that cannot be resected because of poor pulmonary function.