Distant Failure after Treatment of Postoperative Locoregional Recurrence of Non-Small Cell Lung Cancer

Hypo-fractionated radiotherapy with concurrent chemotherapy for locoregional recurrence of non-small cell lung cancer after complete resection: A prospective, single-arm, phase II study (GASTO-1017)

OBJECTIVES

To explore the efficacy and toxicities of split-course hypo-fractionated radiotherapy with concurrent chemotherapy (HFRT-CHT) with intensity modulated radiotherapy (IMRT) technique in non-small cell lung cancer (NSCLC) patients with postoperative locoregional recurrence (LRR).

MATERIALS AND METHODS

NSCLC patients were eligible if confirmed as LRR disease without distant metastasis after complete resection. HFRT-CHT using IMRT technique was administered with 51 Gy in 17 fractions or 40 Gy in 10 fractions as the first course followed by a break. Patients with no disease progression and no persistent Grade ≥2 toxicities had the second course of 15 Gy in 5 fractions or 28 Gy in 7 fractions as a boost. The primary endpoint was progression-free survival (PFS).

RESULTS

Fifty-eight patients were enrolled and analyzed. With a median follow-up of 23.9 months for all, the 2-year and 3-year PFS rate was 59.7 % and 46.4 %, the 2-year and 3-year OS rate was 72.5 % and 52.2 %, respectively, and a favorable objective response rate of 95.9 % was obtained after the whole courses protocol. Grade 3 acute pneumonitis and esophagitis occurred in 2 (3.4 %) and 7 (12.1 %) patients, and fatal pneumonitis was reported in one case (1.7 %). Exploratory subgroup analysis showed that performance status (PS) (PS 0 vs. 1: 2-year PFS, 88.1 % vs. 46.9 %,P = 0.001; 2-year OS, 100 % vs. 59.4 %, P < 0.001), recurrence site (single vs. multiple: 2-year PFS, 93.8 % vs. 47.4 %, P = 0.008; 2-year OS, 100 % vs. 63.0 %, P = 0.001), and gross tumor volume (GTV) (<50cm³ vs. ≥ 50cm³: 2-year PFS, 70.6 % vs. 46.2 %, P = 0.024; 2-year OS, 85.6 % vs. 57.4 %, P = 0.034) were significantly associated with PFS and OS.

CONCLUSION

Split-course HFRT-CHT with IMRT technique achieved promising disease control and satisfactory survival with moderate toxicities in postoperative LRR of NSCLC. Good PS, a single recurrence site and GTV<50cm³ tended to have prolonged PFS and OS. Early detection of LRR may improve the efficacy of HFRT-CHT.

Completion pneumonectomy and chemoradiotherapy as treatment options in local recurrence of non-small-cell lung cancer

INTRODUCTION

The selection of treatment for local recurrence in patients with non-small-cell lung cancer (NSCLC) depends on the possibility of performing a radical tumor resection, the patient's performance status, and cardiopulmonary efficiency. Compared with chemoradiotherapy, surgical treatment offers a greater chance of long-term survival, but results in completion pneumonectomy and is associated with a relatively high rate of complications.

AIM OF THE STUDY

Aim of the study was to evaluate early and long-term results of surgery and conservative treatment (chemoradiotherapy) in patients with local NSCLC recurrence.

MATERIAL AND METHODS

Between 1998 and 2011, 1697 NSCLC patients underwent lobectomy or bilobectomy at the Department of Thoracic Surgery in Poznań. Among them, 137 patients (8.1%) were diagnosed with cancer recurrence; chemotherapy or chemoradiotherapy was provided to 116 patients; 21 patients (15.3%) were treated with completion pneumonectomy. The median time from primary surgery to recurrence was 13.4 months. No metastases to N2 lymph nodes were observed among the patients undergoing surgery; in 7 patients N1 lymph node metastases were confirmed.

RESULTS

The rate of complications after surgery was significantly higher in comparison with conservative therapy (80.9% vs. 48.3%). Patients treated with surgery were most likely to suffer from complications associated with the circulatory system (80.9%), while hematologic complications were dominant in the group undergoing oncological treatment (41.4%). There were no perioperative deaths after completion pneumonectomy. The age of the patients was the only factor which significantly influenced the incidence of complications in both groups of patients. Analysis of the survival curves demonstrated statistically significant differences in survival between the groups treated with surgery, chemoradiotherapy, and chemotherapy (p = 0.00001). Five-year survival probability was significantly higher among patients treated surgically as compared to patients undergoing systemic therapy.

CONCLUSIONS

Despite the significant rate of postoperative complications (mostly circulatory), the long-term results of the surgical treatment of local NSCLC recurrence are more favorable than those achieved with chemoradiotherapy. The success of surgical treatment is conditioned on the exclusion of metastasis in N2 lymph nodes.

Local recurrence following lung cancer surgery: incidence, risk factors, and outcomes

PURPOSE

To date, few large-scale original studies have focused specifically on local recurrence following curative lung cancer surgery. This review seeks to consolidate and analyze data from these studies regarding local recurrence incidence, risk factors, salvage treatments, and outcomes to increase awareness in the Oncology community and to spark new research in this area.

METHODS

PubMed literature was searched for large-scale cohort studies involving recurrence following lung cancer surgery. Studies with a primary focus on local recurrence and studies that examined overall recurrence but provided relevant numerical data on local recurrence were included. Each chosen study's methods were critically analyzed to reconcile as best as possible large differences in reported results across the studies.

RESULTS

Up to 24% of patients recur locally following lung cancer surgery. Risk of local recurrence increases with the stage of the primary cancer, but even stage I patients experience local recurrence up to 19% of the time. Overall survival time following local recurrence varies widely across studies, from 7 to 26 months, and may be related to frequency of follow-up visits. Salvage therapy appears to increase survival time. However, estimates of this increase vary widely, and measurements of benefits of the various salvage options are confounded by lack of control of subjects' condition at the time of salvage therapy administration.

CONCLUSIONS

Local recurrence following lung cancer surgery is a significant problem warranting additional research. At present, data on this topic is scarce. We recommend initiation of additional large-scale studies to clearly define the parameters of local recurrence in order to provide useful guidance to clinicians.

Clinical Stage I Non-small Cell Lung Cancer Including FDG-PET Imaging: Sites and Time to Recurrence

INTRODUCTION

Positron emission tomography (PET) has improved the accuracy of staging non-small cell lung cancer (NSCLC), although some early-stage patients will still relapse. The purpose of this study was to determine the sites and time to recurrence in patients with clinical stage I NSCLC whose initial staging evaluation included conventional imaging and fluorodeoxyglucose-PET.

METHODS

This study was approved by our institutional review board and complies with the Health Insurance Portability and Accountability Act. We retrospectively searched our PET database and identified 231 patients (125 women, 106 men; ages 36-93 years) with primary NSCLC and clinical stage I disease. The sites and time to recurrence were recorded. The average follow-up time was 33 months.

RESULTS

Of the 231 patients with clinical stage I tumors, 196 patients (85%) had pathological stage I disease. Two patients developed a second primary lung cancer, and 40 patients (20%) developed local or distant recurrence. Ninety-three percent of all patients remained disease free at 1 year, and 27% (11/40) of those who recur do so in the first year. The most common site of first recurrence was the thorax, followed by the brain, bone, and adrenal glands.

CONCLUSIONS

Twenty percent of stage I NSCLC patients staged with conventional imaging and PET will develop recurrent NSCLC. The sites of recurrence with the addition of PET are similar to those reported with staging by conventional imaging alone. Additional studies are needed to determine the optimal time for follow-up imaging if intervention for recurrent disease is shown to improve survival.

The emergence of a unique population in non-small cell lung cancer: systemic or loco-regional relapse following postoperative adjuvant platinum-based chemotherapy

Surgical resection remains the foundation of curative therapy in early stage non-small cell lung cancer (NSCLC). Recent evidence from several randomized trials has shown that adjuvant chemotherapy regimens of platinum-based agents plus third-generation cytotoxic agents improve survival rates in this population of patients. Despite the use of adjuvant chemotherapy, many patients will suffer a relapse, typically systemic, and be candidates for subsequent therapies. This represents a new population of patients with NSCLC. To date, there are no published trials that evaluate prognostic factors or therapeutic outcomes in these patients. Although therapeutic paradigms have been established in patients who present with de novo metastatic NSCLC, it is not clear whether these paradigms are successful for patients who relapse following platinum-based adjuvant chemotherapy. The influence of time from the previous adjuvant exposure is likely to be as important as it seems to be in other solid tumors. However, dedicated clinical research has not yet established this paradigm in NSCLC and the influence this should have on the choice of subsequent therapy is unknown. The nature of the prior adjuvant exposure may also play a role in the choice of subsequent therapy. This has implications for the design of future trials in advanced NSCLC as these patients may or may not have the same natural history as the de novo metastatic NSCLC patient. Future clinical trials are required to address these issues as well as the biologic heterogeneity that likely exists between patients who are seemingly cured by surgery, relapse early (<1 year), or at later times following adjuvant therapy.