Preoperative concurrent chemoradiotherapy for stage IIIA non-small cell lung cancer

Risk Factor Analysis of Morbidity and 90-Day Mortality of Curative Resection in Patients with Stage IIIA-N2 Non-Small Cell Lung Cancer after Induction Concurrent Chemoradiation Therapy

Background

Major pulmonary resection after neoadjuvant concurrent chemoradiation therapy (nCCRT) is associated with a substantial risk of postoperative complications. This study investigated postoperative complications and associated risk factors to facilitate the selection of suitable surgical candidates following nCCRT in stage IIIA-N2 non-small cell lung cancer (NSCLC).

Methods

We conducted a retrospective analysis of patients diagnosed with clinical stage IIIA-N2 NSCLC who underwent surgical resection following nCCRT between 1997 and 2013. Perioperative characteristics and clinical factors associated with morbidity and mortality were analyzed using univariable and multivariable logistic regression.

Results

A total of 574 patients underwent major lung resection after induction CCRT. Thirty-day and 90-day postoperative mortality occurred in 8 patients (1.4%) and 41 patients (7.1%), respectively. Acute respiratory distress syndrome (n=6, 4.5%) was the primary cause of in-hospital mortality. Morbidity occurred in 199 patients (34.7%). Multivariable analysis identified significant predictors of morbidity, including patient age exceeding 70 years (odds ratio [OR], 1.8; p=0.04), low body mass index (OR, 2.6; p=0.02), and pneumonectomy (OR, 1.8; p=0.03). Patient age over 70 years (OR, 1.8; p=0.02) and pneumonectomy (OR, 3.26; p<0.01) were independent predictors of mortality in the multivariable analysis.

Conclusion

In conclusion, the surgical outcomes following nCCRT are less favorable for individuals aged over 70 years or those undergoing pneumonectomy. Special attention is warranted for these patients due to their heightened risks of respiratory complications. In high-risk patients, such as elderly patients with decreased lung function, alternative treatment options like definitive CCRT should be considered instead of surgical resection.

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.

Analyses on prognostic factors following tri-modality therapy for stage IIIa non-small cell lung cancer

This study is to evaluate and report the prognostic factors of N2 positive stage IIIA non-small cell lung cancer (NSCLC) treated with concurrent radiochemotherapy (CRCT) and surgery. CRCT and surgery were planned in 66 patients with stage IIIA NSCLC, and 46 evaluable patients were analyzed. Thoracic radiation therapy (TRT) dose was 45 Gy over 5 weeks, chemotherapy consisted of two cycles of intravenous cisplatin (100mg/m(2), on days 1 and 29 of TRT) and oral etoposide (50mg/m(2)/day, on days 1-14 and 29-42 of TRT), and surgery was performed in 4 weeks following CRCT completion. With the median follow up duration of 23 (range 5-74) months, the overall survival, disease-free survival, and local control rates at 5 years in all patients were 27%, 24% and 90%, respectively. The overall survival and disease-free survival rates at 5 years in the patients who achieved ypN0 stage and ypN1/2 stages were 47% and 0% (p=0.008), and 42% and 7% (p=0.01), respectively. The corresponding figures in those with initial "bulky" N2 disease and "mediastinoscopic" N2 disease were 31% and 19% (p=0.98), and 23% and 26% (p=0.68), respectively. Following CRCT and surgery, achieving ypN0 stage turned out to be a significantly favorable indicator, while the initial mediastinal lymph node extent did not, with respect to overall survival and disease-free survival.

Is trimodality approach better then bimodality in stage IIIA, N2 positive non-small cell lung cancer?

BACKGROUND

Neoadjuvant treatment followed by surgery is currently being investigated for locally advanced non-small cell lung cancer (NSCLC). This study reports efficacy, toxicity and feasibility of neoadjuvant chemotherapy with concurrent radiotherapy (CCRT) in stage IIIA, N2 positive NSCLC.

METHODS

From March 2001 to February 2004, 52 patients with histologically confirmed stage IIIA, N2 positive NSCLC were registered. Patients received preoperative CCRT that consisted of weekly paclitaxel plus platinum chemotherapy and concurrent radiotherapy followed by surgery.

RESULTS

Overall response rate was 76.9% (95% CI, 64-88%). The major grade 3-4 toxicities were radiation esophagitis (15.4%) and neutropenia (11.5%), and treatment-related mortality rate was 1.9%. Forty-two of 52 patients (80.8%) subsequently underwent surgical resection and 35 of 52 patients (67.3%) underwent complete resection. Among them, pathological complete response was obtained in 4.8%. Pathological downstaging rate to N0-1 and stage 0-II at surgery were 69.0% and 66.7%, respectively. The perioperative major morbidity rate was 23.8% and perioperative mortality was 2.4%. At a median follow-up of 33.9 months (range: 16.4-49.9), the median progression-free survival and overall survival were 16.5 months (95% CI, 6.2-26.8) and 25.6 months (95% CI, 14.6-36.6), respectively. Multivariate analyses identified that patients achieved mediastinal nodal clearance (downstage to pathological N0 or N1) after CCRT (p=0.02) and age at diagnosis<60 years (p=0.01) showed significantly improved survival.

CONCLUSION

Neoadjuvant CCRT showed a high overall response rate with tolerable toxicity profile. Downstaging after CCRT may increase the rate of complete tumor resection and result in survival benefit in stage IIIA, N2 positive NSCLC patients.

Preoperative concurrent radiochemotherapy and surgery for stage IIIA non-small cell lung cancer

This is to examine whether aggressive multimodality therapy improves the treatment outcomes in stage IIIA non-small cell lung cancer (NSCLC). Fifty-three consecutive NSCLC patients with N2 disease, confirmed by mediastinoscopic biopsy, received preoperative thoracic radiation therapy (45 Gy/5 weeks) concurrent with two cycles of oral etoposide and intravenous cisplatin and surgery. Postoperative radiation therapy (PORT, 18 Gy/2 weeks) was optionally recommended for those with the risk factors of loco-regional recurrence based on the surgical and pathological findings. Surgical resection was performed in 38 patients (71.7%), and down-staging was achieved in 19 patients (50%). The median survival period was 27 months in 38 patients who underwent resection, and the rates at 3-yr of overall survival, loco-regional control, distant metastasis-free survival, and disease-free survival were 44.3%, 87.9%, 32.9%, and 29.3%. Significantly favorable factor regarding overall survival was achieving p0/I stage by the multivariate analysis. PORT was successful in reducing locoregional recurrences in patients with the risk factors. Current preoperative concurrent radiochemotherapy and surgery by the authors resulted in comparable survival with other reports, however, further refinement of multimodality approach may be warranted for more effective reduction of distant metastasis.