Alternating radiotherapy and chemotherapy for inoperable Stage III non-small-cell lung cancer: long-term results of two Phase II GOTHA trials. Groupe d'Oncologie Thoracique Alpine

Effectiveness of radiation therapy on non-small-cell lung cancer

Radiotherapy is an effective locoregional cancer treatment aimed at achieving tumor control. For almost a century, radiation has been used as a curative and/or palliative form of treatment alone or in combination with other treatment modalities for non-small-cell lung cancer. Trials are ongoing to investigate the value of altered fractionation radiation therapy alone or in combination with novel chemotherapy agents such as taxanes and gemcitabine, while monitoring for related toxicities. Attempts at minimizing the amount of normal tissue irradiated with three-dimensional treatment planning and/or protecting normal tissues with a radioprotector may allow for therapeutic escalation of radiation dose with further success at treating our nation's number one cause of cancer-related mortality.

Phase II study of twice-daily high-dose thoracic radiotherapy alternating with cisplatin and vindesine for unresectable stage III non-small-cell lung cancer: Japan Clinical Oncology Group Study 9306

PURPOSE

To evaluate the efficacy and toxicity of high-dose thoracic radiotherapy (TRT) alternating with chemotherapy (CH) for unresectable stage III non--small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Forty-one patients received TRT with 1.5 Gy twice daily, 5 days a week, on weeks 1, 2, 5, 6, and 9, up to a total dose of 66 to 72 Gy, alternating with cisplatin 80 mg/m(2) on day 1 and vindesine 3 mg/m(2) on days 1 and 8, repeated every 4 weeks, for two or three courses beginning on week 3.

RESULTS

The median (range) total dose of TRT and number of CH courses were 72 Gy (16.5 to 72 Gy) and three (zero to three), respectively. Delay in TRT > or = 5 days was observed in 24 (75%) of 32 patients who completed the projected treatment, due to leukopenia in 12, esophagitis in seven, infection in two, and other causes in three patients. Partial responses were obtained in 36 patients (88%). The median survival time and 3- and 5-year survival rates were 18.4 months, 24%, and 10%, respectively. Grade 3 or 4 leukopenia and esophagitis developed in 32 and seven patients, respectively. Grade 3 or 4 late esophageal toxicity developed in two patients.

CONCLUSION

Alternating high-dose TRT and CH for stage III NSCLC produced a high response rate with median and long-term survival comparable to prior trials utilizing standard approaches in this population. Acute and late esophageal toxicity was observed and interruption of TRT was required in most of the patients.

Is lung cancer surgery justified in patients with direct mediastinal invasion?

OBJECTIVE

To assess the results of the surgical treatment of patients with stage IIIB non-small cell lung carcinoma (NSCLC) invading the mediastinum (T4).

METHODS

Twenty-nine patients were operated on from 1986 to 1999. Histology was squamous cell carcinoma in 17 patients, adenocarcinoma in eight, large cell carcinoma in two and neuroendocrinal carcinoma in two. Three patients received a preoperative chemotherapy (n = 2) or radiochemotherapy (n = 1). The lung resection consisted of a pneumonectomy in 25 patients and a lobectomy in four. The procedure was extended to one of the following structures: superior vena cava (SVC) (n = 17), aorta (n = 1), left atrium (n = 5) and carina (n = 6). Seventeen patients had a postoperative regimen including radiochemotherapy (n = 12), radiotherapy (n = 4), or chemotherapy (n = 1).

RESULTS

Complete R0 resection was achieved in 25 patients, whereas four patients had a microscopically (n = 1) or macroscopically (n = 3) residual disease. The operative mortality rate was 7% (n = 2). Non-fatal major complications occurred in eight patients (28%). Overall 5-year survival rate was 28% (median 11 months), including the operative mortality. The median survival of the 18 patients with an N0 or N1 disease was 16 months whereas the median survival of the 11 patients with an N2 disease was 9 months. At completion of the study, 22 patients have died, two postoperatively and 10 from pulmonary causes without evidence of cancer.

CONCLUSIONS

Surgical management of T4 NSC lung cancer invading the mediastinum should be considered, in the absence of N2 disease, when a complete resection is achievable.

Combined chemoradiotherapy with daily low-dose cisplatin in locally advanced inoperable non-small cell lung cancer

Sixty-one consecutive patients with locally advanced inoperable non-small-cell lung cancer were treated with chemoradiation with 60 Gy and concomitant daily low-dose cisplatin (6 mg/m(2)) in a single uninterrupted course. Toxicity was mild, 80% of patients were treated as outpatients. The median survival of 70 weeks compares favorably to the literature.

Hyperfractionated radiotherapy for lung cancer

In several recent clinical trials, hyperfractionated or accelerated hyperfractionated thoracic radiation therapy has improved survival over conventional radiotherapy among patients with either stage III non-small-cell lung cancer or limited-stage small-cell lung cancer. Combinations of novel chemotherapy agents such as taxanes and gemcitabine with hyperfractionated or accelerated hyperfractionated radiotherapy may further improve survival, although toxicity must be closely followed. Attempts to minimize the amount of normal tissue radiated through either three-dimensional treatment planning or use of a radioprotector (such as amifostine) may allow therapeutic escalation with chemoradiation and further success at treating the number one cause of cancer-related mortality in the United States.

Hyperfractionated accelerated radiotherapy (HART) for inoperable, nonmetastatic non-small cell lung carcinoma of the lung (NSCLC): results of a phase II study for patients ineligible for combination radiochemotherapy

PURPOSE

To evaluate a hyperfractionated and accelerated radiotherapy (HART) protocol in patients with inoperable non-small cell lung carcinoma (NSCLC) who were ineligible for combination radiochemotherapy studies.

METHODS AND MATERIALS

From February 1989 through August 1994, 23 patients ineligible for available combined modality protocols in our institution were enrolled and treated with HART, consisting of 63 Gy given in 42 fractions of 1.5 Gy each, twice daily, with a minimum time interval of 6 h between fractions, 5 days a week, over an elapsed time of 4.2 weeks, or 29 days. There was no planned interruption.

RESULTS

The 1-, 2-, and 3-year survival rates were 61%, 39%, and 19%, respectively, with a median survival of 16.8 months. At the time of analysis, 4 patients are alive and 19 have died, 16 from NSCLC and 3 from cardiac disease. Overall response rate was 48%, with 22% of patients achieving a complete response and 26% a partial response. Correlation between acute response rate and survival was poor. First site of relapse was local-regional in 8 patients (35%), distant in 6 patients (26%), and local-regional and distant in 4 (17%) patients. One patient had Grade IV and 2 had Grade III esophagitis. One patient presented with chronic Grade III lung toxicity. There were no treatment-related deaths.

CONCLUSION

In this group of 23 patients ineligible for radiochemotherapy, this HART regime was quite feasible and was followed by little toxicity. Results in this particularly poor prognosis NSCLC patient category should be compared to series with a similar patient profile; however, median survival is at least similar to that obtained in recent series of combination radiochemotherapy.

Prevention of irradiation-induced esophagitis by plasmid/liposome delivery of the human manganese superoxide dismutase transgene

Esophagitis is a major toxicity of radiation therapy for nonsmall-cell lung cancer. Intraesophageal injection of manganese superoxide dismutase (MnSOD) plasmid/liposome complexes (1 mg of the pRK5-MnSOD plasmid containing the human MnSOD transgene in a 0.15 ml volume of lipofectin) before irradiation was carried out to attempt to prevent irradiation esophagitis. In control noninjected male C3H/HeNsd mice, esophagitis was induced by single fraction 3,500 cGy irradiation. Histopathology at 4 days revealed vacuole formation in squamous lining cells, separation of the squamous layer from the underlying muscle layer, ulceration at 7 days, and dehydration and death by 30 days. MnSOD plasmid/liposome complex-injected mice showed transcription of the human MnSOD transgene message in esophageal squamous lining cells by nested reverse transcriptase-polymerase chain reaction (RT-PCR) increased MnSOD biochemical activity 24 h after injection, decreased vacuole formation at day 4 (P < 0.001) after 3,500 cGy thoracic irradiation, and improved survival (P = 0.0009). In contrast, groups of mice receiving LacZ (bacterial beta-galactosidase gene) plasmid/liposome complexes or liposomes containing no DNA before 3,500 cGy irradiation showed an unaltered irradiation histopathology and decreased survival. Mice receiving intraesophageal MnSOD plasmid/liposomes followed 8 h later by human equivalent doses of Taxol (1.4 mg/kg) and carboplatin (2.5 mg/kg), then 15 h later 3,300 cGy irradiation, showed increased survival, compared with irradiated control or LacZ plasmid/liposome groups. Thus, overexpression of the human MnSOD transgene in the esophagus can prevent irradiation-induced esophagitis in the mouse model.

A phase II study of concurrent accelerated hyperfractionated radiotherapy and carboplatin/oral etoposide for elderly patients with stage III non-small-cell lung cancer

PURPOSE

To investigate feasibility, toxicity, and efficacy of accelerated hyperfractionated radiation therapy and concurrent carboplastin/oral etoposide in elderly (> 70 years) patients with stage III non-small-cell lung cancer.

METHODS AND MATERIALS

Between January 1988 and June 1993, a total of 58 patients entered a phase II study. Carboplatin (400 mg/m(2)) was given intravenously on days 1 and 29, and etoposide (50 mg/m(2)) was given orally on days 1-21 and 29-42. Accelerated hyperfractionated radiotherapy was administered starting on day 1, with a total dose of 51 Gy in 34 fractions over 3.5 weeks.

RESULTS

In 55 evaluable patients, the complete response rate was 27% and the overall response rate was 65%. For the 55 patients, the median survival time was 10 months, and the 1-, 2-, and 5-year survival rates were 45%, 24%, and 9.1%, respectively. The median time until relapse was 8 months and the 1-, 2-, and 5-year relapse-free survival rates were 45%, 20%, and 9.1%, respectively. The median time to local recurrence was 14 months and the 5-year local control rate was 13%; the median time to distant metastasis was 18 months and the 5-year distant metastasis-free rate was 15%. Hematological, esophageal, and bronchopulmonary acute grade 3 or 4 toxicities were observed in 22%, 7%, and 4% of the patients, respectively. There was no grade 5 toxicity or late grade > or = 3 toxicity.

CONCLUSION

Concurrent accelerated hyperfractionated radiotherapy and carboplatin/oral etoposide produced relatively low and acceptable toxicity. The survival results appeared to be comparable to those obtained in nonelderly patients with stage III non-small-cell lung cancer treated by full-dose radiation.