Induction concurrent chemoradiotherapy compared with induction radiotherapy for superior sulcus non-small cell lung cancer: a retrospective study

Significant prognostic determinants in lung cancers of the superior sulcus: comparable analysis of resected and unresected cases

OBJECTIVE

In this study, we aimed to identify prognostic determinants and to comparably analyze clinical features of patients with both resected and unresected superior sulcus tumors (SSTs).

METHODS

The data of 56 patients who underwent any treatment for an SST from 2004 through 2016 in our hospital were reviewed. Overall survival (OS) rates were estimated using the Kaplan-Meier method. Univariate and multivariate analyses were performed to determine independent prognostic factors for patients with resected and unresected SST separately.

RESULTS

The number of patients with resected and unresected SSTs was 24 (43%) and 32 (57%), respectively. Of the 24 patients who underwent surgery, 20 received induction therapy, with 32% achieving pathological complete response. Complete resection (R0) was performed in 22 patients (92%). On multivariate survival analysis, preoperative serum carcinoembryonic antigen (CEA) level (median 8.3 ng/ml, p = 0.021) was identified as the independent determinant of OS in surgical patients; whereas, initial treatment response (complete response or partial response, p = 0.032) was the independent OS indicator in non-surgical patients. The 5-year OS of the patient with resected and unresected SST was 68.8% and 29.1% (p = 0.008), respectively.

CONCLUSION

Significant prognostic factors differ among patients stratified by the presence of surgical resection for SSTs. Preoperative CEA level in surgical candidates and initial treatment response in non-surgical patients were the independent factors associated with OS. Surgical candidates are expected to have more favorable survival than patients with unresectable SSTs.

Management of Lung Cancer Invading the Superior Sulcus

Superior sulcus tumors have posed a formidable therapeutic challenge since their original description by Pancoast and Tobias in the early twentieth century. Initial therapeutic efforts with radiotherapy were associated with high rates of relapse and mortality. Bimodality therapy with complete surgical resection in the 1960s paved the way for trimodality therapy as the current standard of care in the treatment of superior sulcus tumors. The evolution of treatment approaches over time has provided outcomes that come increasingly closer to rivaling those of similarly staged nonapical lung cancer.

Superior sulcus tumors (Pancoast tumors)

Superior Sulcus Tumors, frequently termed as Pancoast tumors, are a wide range of tumors invading the apical chest wall. Due to its localization in the apex of the lung, with the potential invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, the superior sulcus tumors cause characteristic symptoms, like arm or shoulder pain or Horner's syndrome. The management of superior sulcus tumors has dramatically evolved over the past 50 years. Originally deemed universally fatal, in 1956, Shaw and Paulson introduced a new treatment paradigm with combined radiotherapy and surgery ensuring 5-year survival of approximately 30%. During the 1990s, following the need to improve systemic as well as local control, a trimodality approach including induction concurrent chemoradiotherapy followed by surgical resection was introduced, reaching 5-year survival rates up to 44% and becoming the standard of care. Many efforts have been persecuted, also, to obtain higher complete resection rates using appropriate surgical approaches and involving multidisciplinary team including spine surgeon or vascular surgeon. Other potential treatment options are under consideration like prophylactic cranial irradiation or the addition of other chemotherapy agents or biologic agents to the trimodality approach.

Does induction chemoradiotherapy increase survival in patients with Pancoast tumour?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was whether induction (neoadjuvant) chemoradiotherapy (iCRT) compared with other therapeutic strategies improves survival in patients with Pancoast tumours. Altogether 248 papers were identified using the below-mentioned search. Ten of them represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group, relevant outcomes and weaknesses were tabulated. Four studies were retrospective comparative studies of induction chemoradiotherapy and surgery (trimodal therapy) versus other therapeutic strategies. Two studies were retrospective and four were prospective investigating trimodal therapy. These papers comprised a total of 550 patients. The overall survival was better with trimodal therapy compared with RT (radiotherapy) followed by surgery group in all three comparative studies. The 2-year survival varied in the trimodal therapy group from 70 to 93%, in comparison to RT group where variation was from 22 to 49%. Five-year survival for trimodal therapy varied between 36.4 and 84% in the results of two comparative studies, compared with 11 and 49% for RT and surgery, respectively. One paper looked at survival in patients who underwent surgery alone [30% at 2-year and 20% at 4-year overall survival (OS)]. The 5-year OS in the retrospective group varied between 38 and 59%. Similar results were reported for the prospective group with 5-year OS between 44 and 56%. Despite a large variation in pCR (complete pathological response) (15-93%) and R0 (77-100%) reported, both represented a positive prognostic factor for survival. Three papers looked at the impact of staging following induction chemoradiotherapy. The majority of patients had T3 disease. An advantage in survival was seen in patients with early disease compared with advanced stage. No randomized controlled trials were identified. All the 10 articles suggested there was a benefit in trimodal therapy with improvement in overall survival. We conclude that combining induction chemoradiotherapy with surgery for Pancoast tumour may offer a survival benefit compared with radiotherapy with surgery or surgery alone.

Results of surgical resection after induction chemoradiation for Pancoast tumours †

OBJECTIVES

Pancoast tumour is a rare neoplasia in which the optimal therapeutic management is still controversial. The traditional treatment of Pancoast tumour (surgery, radiotherapy or a combination of both) have led to an unsatisfactory outcome due to the high rate of incomplete resection and the lack of local and systemic control. The aim of the study was to determine the efficacy of the trimodality approach.

METHODS

Fifty-six patients (male/female ratio: 47/9, median age: 64 years) in stage IIB to IIIB were treated during a period between 1994 and 2013. Induction therapy consisted of 2-3 cycles of a platinum-based chemotherapy associated with radiotherapy (30-44 Gy). After restaging, eligible patients underwent surgery 2 to 4-week post-radiation.

RESULTS

Thirty-two (57.1%) patients were cT3 and 24 (42.9%) cT4, 47 (83.9%) were N0 and 9 (16.1%) N+. Forty-eight (85.7%) patients underwent R0 resection and 10 (17.9%) had a complete pathological response (CPR). Thirty-day mortality rate was 5.4%, major surgical complications occurred in 6 (10.7%) patients. At the end of the follow-up, 17 (30.4%) patients were alive and 39 (69.6%) died (29 for cancer-related causes), with an overall 5-year survival of 38%. At statistical analysis, stage IIB (P = 0.003), R0 resection (P = 0.03), T3 tumour (P = 0.002) and CPR (P = 0.01) were significant independent predictors of better prognosis.

CONCLUSIONS

This combined approach is feasible, and allows for a good rate of complete resection. Long-term survival rates are acceptable, especially for early stage tumours radically resected. Systemic control of disease still remains poor, with distant recurrence being the most common cause of death.

Pathologic complete response to preoperative chemotherapy predicts cure in early-stage non-small-cell lung cancer: combined analysis of two IFCT randomized trials

INTRODUCTION

Our study aimed to evaluate whether pathologic complete response (pCR) in early-stage non-small-cell lung cancer (NSCLC) after neoadjuvant chemotherapy resulted in improved outcome, and to determine predictive factors for pCR.

METHODS

Eligible patients with stage-IB or -II NSCLC were included in two consecutive Intergroupe Francophone de Cancérologie Thoracique phase-III trials evaluating platinum-based neoadjuvant chemotherapy, with pCR defined by the absence of viable cancer cells in the resected surgical specimen.

RESULTS

Among the 492 patients analyzed, 41 (8.3%) achieved pCR. In the pCR group, 5-year overall survival was 80.0% compared with 55.8% in the non-pCR group (p = 0.0007). In multivariate analyses, pCR was a favorable prognostic factor of overall survival (relative risk = 0.34; 95% confidence interval = 0.18-0.64) in addition to squamous-cell carcinoma, weight loss less than or equal to 5%, and stage-IB disease. Five-year disease-free survival was 80.1% in the pCR group compared to 44.8% in the non-pCR group (p < 0.0001). Two patients (4.9%) in the pCR group experienced disease recurrence compared to 193 patients (42.8%) in the non-pCR group. SCC subtype was the only independent predictor of pCR (odds ratio [OR] = 4.30; 95% confidence interval = 1.90-9.72).

CONCLUSION

Our results showed that pCR after preoperative chemotherapy was a favorable prognostic factor in stage-IB-II NSCLC. Our study is the largest published series evaluating pCRs after preoperative chemotherapy. The only factor predictive of pCR was squamous-cell carcinoma. Identifying molecular predictive markers for pCR may help in distinguishing patients likely to benefit from neoadjuvant chemotherapy and in choosing the most adequate preoperative chemotherapy regimen.

Evaluation of arm function and quality of life after trimodality treatment for superior sulcus tumours

OBJECTIVES

Following trimodality treatment for superior sulcus tumours (SSTs), the 5-year survival rate has significantly improved. Quality of life and potential negative effects of this strategy have become more important. The objective of this study was to investigate the quality of life and the arm and shoulder function after the resection of superior sulcus tumours following neoadjuvant chemoradiation.

METHODS

Patients were selected from a thoracic surgery database. Between January 2002 and December 2010, 72 patients received trimodality treatment of whom 39 were alive at the start of this study in 2010. The following arm function tests were used: nine-hole peg test, range of motion test and action research arm test. Quality of life was assessed using the Disability of the arm and shoulder and SF-36 questionnaires. Analyses of the arm function were conducted comparing the treated side with the untreated side. For quality of life, patients treated on their dominant side were compared with those treated on their non-dominant side.

RESULTS

In total, 19 patients participated in this study (15 men and 4 women). The median age was 59 years (range 39-73), median radiation dose 50 Gy (range 39-66) and median follow-up 40 months (range 4-101). There was no statistically significant difference in arm and shoulder function between the treated and the untreated arm. However, statistically significantly less pain was found if patients were treated on their dominant side.

CONCLUSIONS

After the resection of SSTs following chemoradiotherapy, the arm and shoulder function on the affected side is comparable with the functions at the contralateral side. Patients treated for an SST on their dominant side are less affected in their quality of life regarding pain compared with those treated on their non-dominant side.

Analysis of the risk factors for myelosuppression after concurrent chemoradiotherapy for patients with advanced non-small cell lung cancer

PURPOSE

Myelosuppression induced by concurrent chemotherapy and radiotherapy can be a significant problem in patients with non-small cell lung cancer (NSCLC), but its risk factors remain largely unknown. The objective of this study was to retrospectively evaluate clinical data obtained before chemoradiotherapy (CRT) to identify the risk factors for myelosuppression in patients with advanced NSCLC.

METHODS

Between January 2007 and January 2012, 141 patients with advanced NSCLC were treated with curative intent according to the CRT protocol (50-70 Gy at 2 Gy/day with paclitaxel 135-175 mg/m(2) and carboplatin 100 mg/m(2) on days 1, 22, and 43). The endpoint of this survey was the occurrence of grade 3 or higher myelosuppression (neutropenia, leukopenia, thrombocytopenia, or anemia). Risk factors significantly related to myelosuppression were extracted using logistic regression analysis.

RESULTS

Grade 3 or higher neutropenia, leukopenia, thrombocytopenia, or anemia occurred in 19.9, 16.3, 14.9, and 0% of the patients, respectively. According to the multivariate analysis, the risk factors included age, albumin, and body surface area (BSA) for neutropenia; performance status and bone metastases for leukopenia; and age, gender, and serum creatinine concentration for thrombocytopenia (p < 0.05).

CONCLUSIONS

It was found that age, BSA, creatinine level, and female gender were the most important factors for CRT-induced myelosuppression in advanced NSCLC. By identifying these risk factors, medical staff can improve application of appropriate medical care to reduce the myelosuppression in advanced NSCLC patients treated by CRT.

[Single French centre retrospective analysis of local control after high dose radiotherapy with or without chemotherapy and local control for Pancoast tumours]

PURPOSE

Superior sulcus non-small cell lung cancer represents less than 5% of all lung cancers and is a challenge for the physicians because of clinical presentation, treatments related toxicities and poor prognosis. The aim of this preliminary retrospective report is to present outcomes of patients affected by a superior sulcus non-small cell lung cancer, treated by high dose radiotherapy (>60 Gy) with or with our chemotherapy.

PATIENTS AND METHODS

All adult inoperable or unresectable patients (≥18 years) with a clinical and radiological diagnosis of superior sulcus non-small cell lung cancer treated in our department by radiotherapy with or without chemotherapy were retrospectively analysed. Primary endpoint was the local control. Overall survival, metastasis free survival and toxicity rates were also analysed and reported.

RESULTS

From January 1999 to June 2009, 12 patients were treated by exclusive high-dose radiochemotherapy. Median age was 53 years (range: 33-64 years); mean follow-up time was 20 months (range: 2-75 months). Mean local control, overall survival and metastasis free survival were 20.2, 22 and 20 months, respectively. At the time of this analysis, seven patients died of cancer and three of them presented only a metastatic disease progression. One patient died of acute cardiac failure 36 months after the end of radiochemotherapy and was disease free. Treatment was well tolerated and any acute and/or late G3-4 toxicity was recorded (NCI-CTC v 3.0 score).

CONCLUSION

This analysis confirms the interest of exclusive high-dose radiochemotherapy in treating inoperable superior sulcus non-small cell lung cancer patients, in achieving good local control and overall survival rates.