The Role of Multimodality Therapy in Locoregional Non-small Cell Lung Cancer

Pretreatment clinical mediastinal nodal bulk and extent do not influence survival in N2-positive stage IIIA non-small cell lung cancer patients treated with trimodality therapy

BACKGROUND

Treatment for patients with N2-positive stage IIIA non-small cell lung cancer has been a controversial issue. The current study evaluated the outcomes in patients treated with trimodality therapy, which consisted of neoadjuvant radiation therapy concurrent with chemotherapy followed by surgical resection, with emphasis on clinical and pathologic nodal status.

METHODS

We reviewed the records of 355 patients who were treated with trimodality therapy between 1997 and 2011.

RESULTS

After completion of neoadjuvant chemoradiation, overall down-staging and complete response rates were 50.4 % (179 patients), and 13.2 % (47 patients), respectively. With median follow-up of 35.3 months, median times of progression-free survival (PFS) and overall survival (OS) were 16.3 months and 45.5 months, respectively. Seventeen patients (4.8 %) died of postoperative complications, and the remaining 338 patients were analyzed on prognostic factors. Old age (p = 0.032), pneumonectomy (p < 0.001), and ypN+ (p < 0.001) were found to be the significant prognosticators for worse PFS, and old age (p = 0.013), pneumonectomy (p < 0.001), and ypN+ (p < 0.001) were related to worse OS. Clinical N2 status did not influence either OS or PFS: the number of involved stations (single station vs. multi-station; p = 0.187 for PFS; p = 0.492 for OS), and bulk (clinically evident vs. microscopic; p = 0.902 for PFS; p = 0.915 for OS).

CONCLUSION

ypN stage was the most important prognosticator for both PFS and OS; however, neither initial bulk nor extent of cN2 disease influenced prognosis. Surgery following neoadjuvant chemoradiation should have contributed to improved clinical outcomes regardless of clinical nodal bulk and extent.

Systematic review of dose-volume parameters in the prediction of esophagitis in thoracic radiotherapy

PURPOSE

With dose escalation and increasing use of concurrent chemoradiotherapy, radiation esophagitis (RE) remains a common treatment-limiting acute side effect in the treatment of thoracic malignancies. The advent of 3DCT planning has enabled investigators to study esophageal dose-volume histogram (DVH) parameters as predictors of RE. The purpose of this study was to assess published dosimetric parameters and toxicity data systematically in order to define reproducible predictors of RE, both for potential clinical use, and to provide recommendations for future research in the field.

MATERIALS AND METHODS

We performed a systematic literature review of published studies addressing RE in the treatment of lung cancer and thymoma. Our search strategy included a variety of electronic medical databases, textbooks and bibliographies. Both prospective and retrospective clinical studies were included. Information relating to the relationship among measured dosimetric parameters, patient demographics, tumor characteristics, chemotherapy and RE was extracted and analyzed.

RESULTS

Eighteen published studies were suitable for analysis. Eleven of these assessed acute RE, while the remainder assessed both acute and chronic RE together. Heterogeneity of esophageal contouring practices, individual differences in information reporting and variability of RE outcome definitions were assessed. Well-described clinical and logistic modeling directly related V(35Gy), V(60Gy) and SA(55Gy) to clinically significant RE.

CONCLUSIONS

Several reproducible dosimetric parameters exist in the literature, and these may be potentially relevant in the prediction of RE in the radiotherapy of thoracic malignancies. Further clarification of the predictive relationship between such standardized dosimetric parameters and observed RE outcomes is essential to develop efficient radiation treatment planning in locally advanced NSCLC in the modern concurrent chemotherapy and image-guided IMRT era.

Staging of Lung Cancer

Imaging techniques play a vital role in the diagnosis, staging, and follow-up of patients who have lung cancer. For this purpose, PET has become an important adjunct to conventional imaging techniques such as chest radiography, CT, ultrasonography, and MR imaging. The ability of PET to differentiate the metabolic properties of tissues allows more accurate assessment of undetermined lung lesions, mediastinal lymph nodes, or extrathoracic abnormalities, tumor response after induction treatment, and detection of disease recurrence.

The Role of PET Scan in Diagnosis, Staging, and Management of Non‐Small Cell Lung Cancer

Positron emission tomography (PET) is now an important cancer imaging tool, both for diagnosis and staging, as well as offering prognostic information based on response. This report attempts to comprehensively review the value of PET in the locoregional and distant staging of non-small cell lung cancer (NSCLC), illustrate the potential effects on patient management, and give a short overview of newer applications. PET sets the gold standard in the evaluation of an indeterminate solitary pulmonary nodule or mass, where PET has proven to be significantly more accurate than computed tomography (CT) in the distinction between benign and malignant lesions. In the evaluation of metastatic spread to locoregional lymph nodes, PET is significantly more accurate than CT, so that invasive surgical staging may be omitted in many patients with negative mediastinal PET images. In patients with positive mediastinal PET images, invasive surgical staging remains mandatory because of the possibility of false-positive findings due to inflammatory nodes or granulomatous disorders. In the search for metastatic spread, PET is a useful adjunct to conventional imaging. This may be due to the finding of unexpected metastatic lesions or due to exclusion of malignancy in lesions that are equivocal on standard imaging. However, at this time, PET does not replace conventional imaging. Large-scale randomized studies are currently examining whether PET staging will actually improve the appearance of lung cancer outcome.

Value of FDG-PET in the management of non-small cell lung cancer

In the past 5 years, metabolic imaging with positron emission tomography (PET) using 18F-fluoro-2-deoxy-glucose (FDG) has become an important imaging modality in lung cancer patients. FDG-PET consistently proved to be superior to structure-based imaging modalities in both the diagnosis and staging of lung cancer. At this moment the use of FDG-PET in these indications needs further validation in multi-centre large-scale randomised studies, focusing mainly on treatment outcome parameters, survival and cost-efficacy. More recently, interesting findings have also been reported in the response assessment to cytotoxic treatments providing information of greater prognostic significance than can be obtained using conventional approaches. This review focuses on the potential role of FDG-PET in the diagnosis of lung nodules and masses, and in locoregional and extrathoracic staging of non-small cell lung cancer. Emphasis is put on the potential clinical implementation of the numerous data of the last decade.

Older people with non small cell lung cancer in clinical stage IIIA and co-morbid conditions. Is curative irradiation feasible? Final results of a prospective study

Radiotherapy (RT) is widely used in the management of lung cancer but age-oriented randomized trials are lacking in older-unfit patients. We started a prospective study to evaluate the toxicity and efficacy of definitive RT in very old-unfit patients with non-small cell lung cancer (NSCLC) in clinical stage IIIA, according to AJCC 1988. Forty patients, age > or = 75 years, Karnofsky Performance status (KPS) > or = 60, unfit to receive an aggressive combined treatment, were entered in the study. Each patient had one or more comorbidities, and the Charlson score was greater than two in 7/40. All patients were treated with radiation fields encompassing the primary tumor and grossly involved lymph nodes. A median radiation dose of 60 Gy/2 Gy day/5 days a week, was delivered. The 40 patients have been followed up, including those who died, for a potential median time of 4.6 years. As results, no treatment-related mortality, and clinically insignificant acute morbidity was recorded: in 28/40 cases a mild esophagitis occurred. Two patients showed a clinical radiation pneumonitis (RP). Late normal tissue damage was represented by lung fibrosis (40/40 patients). The treatment was efficacy since each patient obtained some clinical benefit from it. Median survival (MS) was 19 months (range 5-68); the 3 and 5-year actuarial survival was 18 and 12%, respectively. In conclusion, we think that older patients with concomitant illness can be submitted to curative 'involved field' irradiation and the results observed in this trial encourage to use curative RT in older subjects with local-regionally advanced NSCLC and co-morbid condition.

Preoperative chemotherapy followed by surgery compared with primary surgery in resectable stage I (except T1N0), II, and IIIa non-small-cell lung cancer

PURPOSE

To evaluate whether preoperative chemotherapy (PCT) could improve survival in resectable stage I (except T1N0), II, and IIIA non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

A randomized trial compared PCT to primary surgery (PRS). PCT consisted of two cycles of mitomycin (6 mg/m(2), day 1), ifosfamide (1.5 g/m(2), days 1 to 3) and cisplatin (30 mg/m(2), days 1 to 3), and two additional postoperative cycles for responding patients. In both arms, patients with pT3 or pN2 disease received thoracic radiotherapy.

RESULTS

Three hundred fifty-five eligible patients were randomized. Overall response to PCT was 64%. There were two preoperative toxic deaths. Postoperative mortality was 6.7% in the PCT arm and 4.5% in the PRS arm (P =.38). Median survival was 37 months (95% confidence interval [CI], 26.7 to 48.3) for PCT and 26.0 months (95% CI, 19.8 to 33.6) for PRS (P =.15). Survival differences between both arms increased from 3.8% (95% CI, 1.3% to 25.1%) at 1 year to 8.6% (95% CI, 2.64% to 24.4%) at 4 years. A quantitative interaction between N status and treatment was observed, with benefit confined to N0 to N1 disease (relative risk [RR], 0.68; 95% CI, 0.49 to 0.96; P =.027). After a nonsignificant excess of deaths during treatment, the effect of PCT was significantly favorable on survival (RR, 0.74; 95% CI, 0.56 to 0.99; P =.044). Disease-free survival time was significantly longer in the PCT arm (P =.033).

CONCLUSION

Although impressive differences in median, 3-year, and 4-year survival were observed, they were not statistically significant, except for stage I and II disease.

Photodynamic Therapy for Patients with Advanced Non–Small-Cell Carcinoma of the Lung

Patients with advanced non-small-cell lung carcinoma (NSCLC) have poor prognoses and experience negative sequelae of disease. Patients often suffer from dyspnea and/or hemoptysis, with overall pulmonary compromise. Patients with advanced, inoperable disease have limited options for treatment. This study summarizes our early experience and findings using photodynamic therapy (PDT) as an effective modality in the palliation of hemoptysis, dyspnea, and physical airway obstruction in cases of inoperable lung cancer. A retrospective review was conducted for the first 10 patients diagnosed with stage III/IV obstructive NSCLC who underwent PDT at our institution. Endobronchial lesions were identified by bronchoscopy. Treatments were initiated 48 hours after intravenous injection of 2 mg/kg of the photosensitizing agent porfimer sodium (Photofrin, QLT PhotoTherapeutics, Vancouver, BC). The porfimer sodium was then activated by illumination with a 630 nm wavelength light using a Coherent argon ion laser through a flexible bronchoscope. Repeated bronchoscopies were performed 1-3 days following initial PDT for evaluation and airway debridement. In 8 cases, a second treatment of PDT was administered within 72 hours of the first injection. One patient received a third treatment several months later. Three patients also received endobronchial stents after PDT. Overall, all 10 patients responded to PDT. Physical airway obstruction was reduced in all patients, with a noted improvement in bronchoscopic luminal diameter. Acute hemoptysis resolved in all 7 symptomatic patients. Median survival was 5.5 months post-PDT, while median survival postdiagnosis was 10.5 months. Three patients are alive at the time of this review at 5-21 months following therapy. Patients with unresectable late-stage NSCLC have few options for treatment. Our early experience with PDT indicates effective relief of hemoptysis, dyspnea, and airway obstruction and improves their quality of life.

Prognostic factors in clinical stage I non-small cell lung cancer

BACKGROUND

Management of patients with early-stage lung cancer but a poor prognosis is controversial.

METHODS

Between January 1987 and December 1994, 365 patients with clinical stage I disease underwent surgical resection at our hospital. Eight preoperative clinical variables were entered into univariate and multivariate analyses to determine their impacts on 5-year survival.

RESULTS

The 3-year and 5-year survival rates were 78.1% and 66.5%, respectively. In the multivariate analysis, clinical T2 status and preoperative high serum carcinoembryonic antigen levels were independent significant factors indicative of a poor prognosis (hazard ratio, 2.20 and 1.88, respectively). Patients with both of these factors had 3-year and 5-year survival rates of 65% and 38% (p<0.001), and the risk of death for this subgroup was 4.14 times greater than that of the overall clinical stage I population.

CONCLUSIONS

A subgroup with clinical T2 disease and preoperative high serum carcinoembryonic antigen levels had a significantly poorer prognosis among patients with clinical stage I lung cancer. For this subgroup, a complete preoperative staging workup and multimodal therapy, especially induction chemotherapy, instead of surgical intervention alone could be beneficial.