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

Recurrence/prognosis estimation using a molecularly positive surgical margin-based model calls for alternative curative strategies in pIIIA/N2 NSCLC

Stage pIIIA/N2 non-small cell lung cancer (NSCLC) is primarily treated by complete surgical resection combined with neoadjuvant/adjuvant therapies. However, up to 40% of patients experience tumor recurrence. Here, we studied 119 stage pIIIA/N2 NSCLC patients who received complete surgery plus adjuvant chemotherapy (CT) or chemoradiotherapy (CRT). The paired tumor and resection margin samples were analyzed using next-generation sequencing (NGS). Although all patients were classified as negative resection margins by histologic methods, NGS revealed that 47.1% of them had molecularly positive surgical margins. Patients who tested positive for NGS-detected residual tumors had significantly shorter disease-free survival (DFS) (P = 0.002). Additionally, metastatic lymph node ratio, erb-b2 receptor tyrosine kinase 2 (ERBB2) mutations, and SWI/SNF-related, matrix-associated, actin-dependent regulator of chromatin, subfamily a, member 4 (SMARCA4) mutations were also independently associated with DFS. We used these four features to construct a COX model that could effectively estimate recurrence risk and prognosis. Notably, mutational profiling through broad-panel NGS could more sensitively detect residual tumors than the conventional histologic methods. Adjuvant CT and adjuvant CRT exhibited no significant difference in eliminating locoregional recurrence risk for stage pIIIA/N2 NSCLC patients with molecularly positive surgical margins.

Neoadjuvant therapy in non-small cell lung cancer: basis, promise, and challenges

Introduction

Survival rates for early-stage non-small cell lung cancer (NSCLC) remain poor despite the decade-long established standard of surgical resection and systemic adjuvant therapy. Realizing this, researchers are exploring novel therapeutic targets and deploying neoadjuvant therapies to predict and improve clinical and pathological outcomes in lung cancer patients. Neoadjuvant therapy is also increasingly being used to downstage disease to allow for resection with a curative intent. In this review, we aim to summarize the current and developing landscape of using neoadjuvant therapy in the management of NSCLC.

Methods

The PubMed.gov and the ClinicalTrials.gov databases were searched on 15 January 2023, to identify published research studies and trials relevant to this review. One hundred and seven published articles and seventeen ongoing clinical trials were selected, and relevant findings and information was reviewed.

Results & Discussion

Neoadjuvant therapy, proven through clinical trials and meta-analyses, exhibits safety and efficacy comparable to or sometimes surpassing adjuvant therapy. By attacking micro-metastases early and reducing tumor burden, it allows for effective downstaging of disease, allowing for curative surgical resection attempts. Research into neoadjuvant therapy has necessitated the development of surrogate endpoints such as major pathologic response (MPR) and pathologic complete response (pCR) allowing for shorter duration clinical trials. Novel chemotherapy, immunotherapy, and targeted therapy agents are being tested at a furious rate, paving the way for a future of personalized systemic therapy in NSCLC. However, challenges remain that prevent further mainstream adoption of preoperative (Neoadjuvant) therapy. These include the risk of delaying curative surgical resection in scenarios of adverse events or treatment resistance. Also, the predictive value of surrogate markers of disease cure still needs robust verification. Finally, the body of published data is still limited compared to adjuvant therapy. Addressing these concerns with more large scale randomized controlled trials is needed.

Lobe-specific analysis of perioperative chemotherapy for non-small cell lung cancer patients

OBJECTIVES

Perioperative cisplatin-based chemotherapy decreases the risk of death over surgery alone and is a standard of care. Here, we examined perioperative chemotherapy indications for stage IB-III non-small cell lung cancer (NSCLC) patients according to lobe-specific analysis.

METHODS

Resectable NSCLC patients with stage IB-III who received perioperative chemotherapy with and without radiotherapy after lung resection were identified from the SEER database. Propensity score matching (PSM) analysis was performed to reduce the inherent bias of retrospective studies. The Kaplan-Meier method and log-rank tests were used to assess the differences in overall survival (OS).

RESULTS

The study enrolled 23,844 patients before PSM. The perioperative chemotherapy group had better OS than the nonperioperative chemotherapy group in stage IB-III NSCLC patients before and after PSM. However, subgroup analysis according to stage demonstrated that perioperative chemotherapy did not markedly benefit patients with stage IB. Furthermore, lobar subgroup analysis did not show survival advantages in primary tumors located in either the right middle lobe in stages II and III NSCLC or the right lower lobe in stage III NSCLC.

CONCLUSIONS

Lobe-specific perioperative chemotherapy is recommended in NSCLC patients. For stage IB NSCLC, right middle lobe NSCLC from stage IB-III and right lower lobe NSCLC from stage III, perioperative chemotherapy might not confer survival benefits.

The optimal neoadjuvant regimen for nonsmall cell lung cancer: A meta-analysis

OBJECTIVE

To compare the efficacy and complications of different neoadjuvant to determine the optimal regimens for nonsmall cell lung cancer (NSCLC) patients.

METHODS

A systematic search of the Web of Science, and PubMed databases was conducted through June 3, 2021, reporting a comparison of chemotherapy, chemoradiotherapy, and immunotherapy.

RESULTS

Of 3462 studies, 25 were considered for evidence synthesis. 1035 patients who received chemotherapy or radiotherapy before surgery did not prolong the overall survival (OS) compared with 1038 patients who received surgery alone (hazard ratio [HR] 1.13, 95% CI 1·00-1·28, P = 0·05). 1192 patients received chemoradiotherapy and 864 patients received chemotherapy or radiotherapy; chemoradiotherapy prolonged the OS compared with chemotherapy (HR 0.52, 95% CI 0·29 to 0.95, P = .03). Compared with 110 patients who received other therapy, 93 patients who received immunotherapy had prolonged the OS (HR 1.56, 95% CI 1·08-2·25, P = .02). Chemoradiotherapy increased the pathological response rate (HR 1.68, 95% CI 1·33-2·12, P < .0001), and grade 3 and 4 adverse effects were not increased (HR 5.90, 95% CI 0.88 to 39.60, P = .007). Immunotherapy increased the pathological response (HR 2.79, 95% CI 1·71-4·54, P < .0001), with no significant effects on grades 3 and 4 adverse(HR 0.71, 95% CI 0·19-2·64, P = .61).

CONCLUSION

Our data showed that chemotherapy may prolong OS and PFS, but not statistically significant; however, the combination of chemotherapy and radiation did show an advantage, and immunotherapy may be also the choice for neoadjuvant therapy.

The earlier, the better? A review of neoadjuvant immunotherapy in resectable non-small-cell lung cancer

Immune checkpoint inhibitors (ICIs) have revolutionized the approach to advanced and locally advanced non-small-cell lung cancer (NSCLC). Antibodies blocking inhibitory immune checkpoints, such as programmed death 1 (PD-1) and its ligand (PD-L1), have remarkable antitumor efficacy and have been approved as a standard first- or second-line treatment in non-oncogene-addicted advanced NSCLC. The successful application of immunotherapy in advanced lung cancer has motivated researchers to further evaluate its clinical role as a neoadjuvant setting for resectable NSCLC and for improved long-term overall survival and curative rates. In this review, we discuss the efforts that incorporate ICIs into the treatment paradigm for surgically resectable lung cancer. We reviewed the early-phase results from neoadjuvant clinical trials, the landscape of the majority of ongoing phase III trials, and discuss the prospects of ICIs as a curative therapy for resectable lung cancer. We also summarized the potential biomarkers and beneficiaries involved in the current study, as well as the remaining unresolved challenges for neoadjuvant immunotherapy.

Treatment Sequencing in Resectable Lung Cancer: The Good and the Bad of Adjuvant Versus Neoadjuvant Therapy

The treatment scenario for patients with resectable non-small cell lung cancer has changed dramatically with the incorporation of immunotherapy. The introduction of immunotherapy into treatment algorithms has yielded improved clinical outcomes in several phase II and III trials in both adjuvant (Impower010 and PEARLS) and neoadjuvant settings (JHU/MSK, LCMC3, NEOSTAR, Columbia/MGH, NADIM, and CheckMate-816), leading to new U.S. Food and Drug Administration approvals in this sense. Different treatment options are now available for patients, making the optimal treatment scenario a matter of intense debate. In this review, we summarize the main results concerning treatment sequencing in resectable non-small cell lung cancer from the past 30 years in the preimmunotherapy era, focusing on recent advances after incorporation of immunotherapy. Finally, the utility of several parameters (PD-L1, tumor mutational burden, radiomics, circulating tumor DNA, T-cell receptor, and immune populations) as predictive biomarkers for therapy personalization is discussed.

Neoadjuvant PD-1 inhibitor combines with chemotherapy versus neoadjuvant chemotherapy in resectable squamous cell carcinoma of the lung

BACKGROUND

A single-agent of anti programmed cell death 1/programmed cell death ligand 1 (anti-PD-1/PD-L1) therapy has been explored for resectable lung cancer before surgery. However, the effectiveness and safety of neoadjuvant programmed cell death 1 (PD-1) blockade combined with chemotherapy have not been published.

METHODS

Twenty-one consecutive patients with potentially resectable squamous cell carcinoma of the lung who received neoadjuvant therapy followed by surgery in Beijing Cancer Hospital were included in this study. Eight patients received two cycles of neoadjuvant platinum-based doublet chemotherapy combined with anti-programmed cell death 1 (anti-PD-1) therapy, while 13 patients received two cycles of neoadjuvant platinum-based doublet chemotherapy only. Chest computed tomography was repeated before neoadjuvant treatment and surgery. Adverse events were monitored. The major pathological response (MPR) rate was determined after surgery. Selected specimens were sent for immunohistochemical and multiplex immunofluorescence analyses, and T-cell receptor DNA sequencing.

RESULTS

Compared with neoadjuvant chemotherapy alone, the combination of PD-1 blockade and chemotherapy increased the pathological complete response rate (37.5% vs. 7.69%) and MPR rate (50% vs. 38.46%). The pathological and radiological evaluations are not consistent. No unknown adverse effects were reported for all the patients. More tumor infiltrating lymphocytes were observed in patients who received PD-1 blockade. No unknown pathological features associated with PD-1 blockade were found. Immune suppression in the peritumoral spaces around the residual tumor cells was observed. The amino acid sequences of the T-cell receptors are not significantly shared among the patients.

CONCLUSIONS

The combination of neoadjuvant chemotherapy and PD-1 blockade is safe and feasible, and might indicate an increased MPR and pathological complete response rate. More investigations are needed for the best combination of the neoadjuvant therapy.

Important Surgical and Clinical End Points in Neoadjuvant Immunotherapy Trials in Resectable NSCLC

Neoadjuvant immunotherapy may improve outcomes in patients with resectable NSCLC and is being evaluated in phase 2 and 3 studies. Nevertheless, preoperative treatment postpones resection; the potential for increased surgical complexity and greater intra- and postoperative morbidity and mortality is an additional consideration. In studies primarily designed to evaluate efficacy, the impact of neoadjuvant immunotherapy on surgery is based on parameters that are poorly defined and reported differently between studies. Defining and reporting common end points among trials would improve understanding and facilitate cross-comparison of different immunotherapy regimens and may facilitate wider adoption of induction therapies by surgeons and oncologists. We propose several surgical end points and related metrics for neoadjuvant immunotherapy in resectable NSCLC. These include the periods from screening to treatment initiation and from last neoadjuvant dose to surgery; reporting of the allowable window for surgery to preclude masking delays caused by induction treatment-related toxicity; complete resection (R0) rate; preoperative downstaging; a standardized list of immune-related adverse events and associated delay to surgery; preoperative attrition; postoperative attrition before adjuvant therapy; and postoperative 30- and 90-day mortality and morbidity rates. Intraoperative end points (blood loss, duration, and type of surgery) and our proposed system of grading complexity based on lymphadenopathy and fibrosis would allow quantitation of technical difficulty and quality of oncologic resection. In conclusion, the standardization, reporting, and prospective inclusion of these end points in study protocols would provide a comparative overview of the impact of different neoadjuvant immunotherapy regimens on surgery and ultimately clinical oncologic outcomes in resectable NSCLC.

Aneuploid Circulating Tumor Cells as a Predictor of Response to Neoadjuvant Chemotherapy in Non-Small Cell Lung Cancer

Purpose

This study aimed to explore the potential application of circulating tumor cells (CTCs) in predicting the therapeutic effect of neoadjuvant chemotherapy (NAC) in non-small-cell lung cancer (NSCLC).

Methods

Using integrated subtraction enrichment and immunostaining-fluorescence in situ hybridization, the serial CTCs of patients with NSCLC were detected in 7.5 mL of blood at baseline and after two cycles of cisplatin-based NAC, and all aneuploidies of chromosome 8 were examined in the enriched CTCs. Tumor responses were evaluated radiologically with serial chest computed tomography (CT) using the response evaluation criteria in solid tumors and microscopically using the tumor cell necrosis rate (TCNR) of the resected specimen after NAC.

Results

After two cycles of cisplatin-based NAC, 89% (8/9) of the patients with radiological partial response to NAC had reduced CTC numbers, while 73% (8/11) of the patients with stable disease exhibited increased CTC numbers (P = 0.0098). On pathological examination, 90% (9/10) of patients with a TCNR lower than 30% had >1 CTC post-NAC, while 80% (4/5) of patients with a TCNR higher than 30% had ≤1 CTC post-NAC (P = 0.017). In aneuploidy analysis, the positive rate (CTC > 0) of triploid CTCs was found to have increased after NAC, in contrast with the tetraploid and multiploid CTCs. Furthermore, tetraploid and multiploid CTCs were found to be significantly downregulated in the patients with partial response to NAC.

Conclusion

The correlations of aneuploid CTCs with both radiological and pathological responses in patients with NSCLC who received NAC were summarized, and the findings indicate that enumerating and karyotyping aneuploid CTCs can serve as a surrogate marker for disease monitoring in NSCLC.

Neoadjuvant Therapy in Lung Cancer: What Is Most Important: Objective Response Rate or Major Pathological Response?

Lung cancer is the most fatal and frequently diagnosed malignant tumor. Neoadjuvant therapy is a promising approach for prolonging survival and increasing the chance of cure rates for patients with potentially resectable disease. Currently, many therapeutic alternatives, including chemotherapy, targeted therapy, and immunotherapy, are continually being explored to enrich the content of neoadjuvant therapy. However, neoadjuvant therapy remains to have no unified evaluation standards. Overall survival (OS) is the "gold standard" for evaluating the clinical benefit of cancer treatment, but it needs years for a reliable evaluation. Hence, researchers need to identify surrogate endpoints that can predict OS accurately and reliably without long follow-up periods. In this review, we describe the research progress of different neoadjuvant therapies and explore their response evaluation, aiming to identify stronger predictors of OS.

A narrative review of primary research endpoints of neoadjuvant therapy for lung cancer: past, present and future

Objective

This review summarizes the current status of neoadjuvant therapy and discusses the choice of new clinical research endpoints for non-small cell lung cancer.

Background

Neoadjuvant chemotherapy is a recognized practice in patients with resectable and locally advanced lung cancer. With the introduction of molecular targeted drugs and immune checkpoint inhibitors (ICIs), the overall survival (OS) of patients with lung cancer has been significantly improved, and the original traditional clinical research endpoints are no longer suitable for existing clinical research. In order to accelerate the process of clinical trials and the development and approval of drugs, it is necessary to find suitable alternative indicators as the main indicators of clinical research.

Methods

Therefore, this article focuses on clinical trials using disease-free survival (DFS), progression free survival, and pathological evaluation indicators, pathologic complete response and major pathologic response, as surrogate endpoints. We search related literature through PubMed database and clinical trials through clinicaltrials.gov.

Conclusions

Pathologic complete response and major pathologic response are recommended as surrogate endpoints in the era of neoadjuvant immunotherapy, and secondary endpoints are listed for the prediction of pathological results. In addition, the definitions of major pathological response (MPR) and PCR should be standardized, and a new pathological evaluation standard should be developed, which is applicable to all current treatment methods.

Keywords

Neoadjuvant therapy; resectable lung cancer; clinical research endpoint; pathological response.

Neoadjuvant Chemoimmunotherapy in Patients with Resectable Non-small Cell Lung Cancer

OPINION STATEMENT

Worldwide, lung cancer is the most common cause of cancer morbidity and mortality. Despite a trend towards an escalating diagnosis of resectable non-small cell lung cancer (NSCLC), overall survival (OS) in patients with resectable NSCLC remains poor. The incorporation of chemotherapy into the neoadjuvant setting has improved disease-free survival (DFS), time to distant recurrence, and OS. Furthermore, the incorporation of immunotherapy and the combination of chemotherapy and immunotherapy have improved pathological responses, which seems to be associated with increased survival. Therefore, immunotherapy represents a paradigm shift in treating resectable NSCLC. However, validation in large randomized trials is mandatory and a longer postoperative follow-up period is required. Additionally, neoadjuvant therapy trials offer an exceptional environment for testing predictive biomarkers. PD-L1 expression and tumor mutational burden (TMB) are the most helpful tools for predicting the likelihood of response with immunotherapy in metastatic NSCLC. However, in the neoadjuvant setting, PD-L1 expression and TMB have had opposite results until now. Recently, the immune profiling and some immune-related genes also appear to be involved in the prognosis and response to immunotherapy in NSCLC. Further prospective studies are needed to derive definitive conclusions.

Neoadjuvant and Adjuvant Immunotherapy in Early-Stage Non-Small Cell Lung Cancer

Surgery or concurrent chemoradiation are standard of care treatments for patients with localized and locally advanced non-small cell lung cancer (NSCLC). While resection and chemoradiation are potentially curative therapies for early-stage disease, relapse rates remain high. Adjuvant or neoadjuvant chemotherapy improves cure rates 5-15% compared with surgery alone for patients with resectable disease. Immune checkpoint inhibitors (ICI) have heralded a new era for the treatment of advanced NSCLC with one-third of patients experiencing long-term survival. There is increasing interest in examining the role of ICI therapy in patients with early-stage NSCLC. Consolidation durvalumab after chemoradiation has become a part of standard of care for patients with inoperable, locally advanced disease. More recently, there is emerging evidence that neoadjuvant treatment with ICIs results in substantial rates of major pathologic response and pathologic complete response, and high rates of R0 resection with no significant delay in time to surgery. Furthermore, preliminary data show that adjuvant treatment with ICIs after adjuvant chemotherapy improves disease-free survival and may play a critical role in reducing disease recurrence in patients with resectable disease. In this review, we discuss recently reported and ongoing studies that are designed to define the role of immunotherapy in patients with non-metastatic NSCLC.

Evaluation of prognostic factors in lung cancers with surgical complete response after induction treatment

Background

This study aims to evaluate long-term results of induction treatment and to investigate prognostic factors affecting survival in non-small cell lung cancer patients with a pathological complete response.

Methods

Between January 2010 and December 2017, a total of 39 patients (38 males, 1 female; mean age: 56.2±8.3 years; range, 38 to 77 years) having locally advanced (IIIA-IIIB) non-small cell lung cancer who were given induction treatment and underwent surgery after induction treatment and had a pathological complete response were retrospectively analyzed. Survival rates of the patients and prognostic factors of survival were analyzed.

Results

Clinical staging before induction treatment revealed Stage IIB, IIIA, and IIIB disease in three (7.7%), 26 (66.7%), and 10 (25.6%) patients, respectively. The five-year overall survival rate was 61.2%, and the disease-free survival rate was 55.1%. In nine (23.1%) patients, local and distant recurrences were detected in the postoperative period.

Conclusion

In patients with locally advanced non-small cell lung cancer undergoing surgery after induction treatment, the rates of pathological complete response are at considerable levels. In these patients, the five-year overall survival is quite satisfactory and the most important prognostic factor affecting overall survival is the presence of single-station N2.

Neoadjuvant EGFR-TKI Therapy for EGFR-Mutant NSCLC: A Systematic Review and Pooled Analysis of Five Prospective Clinical Trials

Purpose

The role of neoadjuvant epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) targeted therapy for patients with EGFR-mutant non-small cell lung cancer (NSCLC) has not been clarified. A pooled analysis of prospective clinical trials was conducted to evaluate the efficacy and safety of neoadjuvant EGFR-TKI therapy.

Methods

The PubMed, Embase, Web of Science, and Cochrane Library databases, as well as meeting abstracts were searched for prospective clinical trials evaluating the efficacy and safety of neoadjuvant EGFR-TKI for treatment of EGFR-mutant NSCLC. The main outcomes included the objective response rate (ORR), downstaging rate, surgical resection rate (SRR), pathologic complete response (pCR) rate, progression-free survival (PFS), and adverse events.

Results

A total of five, phase II, prospective, clinical trials involving 124 patients with resectable or potentially resectable EGFR-mutant NSCLC treated with neoadjuvant erlotinib or gefitinib treatment were included in this pooled analysis. The median neoadjuvant medication time was 42 (range, 21–56) days and the median time of response evaluation was 45 (range, 42–56) days. The pooled ORR was 58.5% [95% confidence interval (CI), 45.5%–71.8%] and the surgical resection and complete resection (R0) rates were 79.9% (95% CI, 65.3%–94.5%) and 64.3% (95% CI, 43.8%–84.8%), respectively. In the stage IIIA subgroup (n = 68), the pooled ORR, SRR, and R0 rate were 51.4%, 72.9%, and 57.0%, respectively, while the downstaging and pCR rates were 14.0% and 0.0%, respectively. The pooled median PFS and overall survival were 13.2 and 41.9 months, respectively. Of the most common grade 3/4 adverse events in the overall group, the incidences of hepatotoxicity and skin rash were 5.3% and 14.7%, respectively. The most commonly reported postoperative complications were lung infection, arrhythmia, and pneumothorax.

Conclusion

Neoadjuvant EGFR-TKI therapy provides a feasible treatment modality for patients with resectable or potentially resectable EGFR-mutant NSCLC, with satisfactory surgical outcomes and low toxicity. Although further phase III clinical trials are needed to confirm these findings, it is necessary to explore the feasibility of a more effective EGFR-TKI combination neoadjuvant therapy given the modest downgrade and pCR rates for EGFR-TKI alone.

Prognostic factors in potentially resectable stage III non-small cell lung cancer receiving neoadjuvant treatment-a narrative review

Lung cancer is the leading cause of cancer-related death in worldwide. The most important treatment for patients with stage I and II non-small cell lung cancer (NSCLC) is surgery. Resected stage II and III NSCLC patients should be offered adjuvant chemotherapy and in patients with resected stage IB disease and with a primary tumor >4 cm this treatment could be considered. The treatment of resectable locally advanced NSCLC should be evaluated within an experienced multidisciplinary team. Neoadjuvant chemotherapy can be considered in patients with resectable disease and clear candidates for complementary chemotherapy. Neoadjuvant chemotherapy has similar impact on overall survival (OS) than adjuvant chemotherapy, however postoperative chemotherapy has more evidence-based support. Immunotherapy is being studied in early and locally advanced NSCLC as a neoadjuvant or adjuvant treatment. Different prognostic factors have been described in patients with stage III who have received neoadjuvant treatment, which we intend to review in this article.

Integrating immune checkpoint inhibitors and targeted therapies in the treatment of early stage non-small cell lung cancer: a narrative review

Prognosis of early stage non-small cell lung cancer (eNSCLC) is poor even when treated radically with surgery and (neo)adjuvant chemotherapy (Cht). The discovery of tyrosine kinase inhibitors (TKIs) for oncogene addicted NSCLC and immune checkpoint inhibitors (ICIs) have revolutionised the therapeutic paradigm and improved survival of advanced NSCLC. The unprecedented impact of these drugs has shifted the focus of investigation to early stage disease aiming at improving cure. In this context, several single arm phase II studies evaluating neoadjuvant ICI alone or in combination with platinum-based Cht have shown encouraging rates of pathological response which have spurred several ongoing randomized trials with (neo)adjuvant ICI. More recently, ADAURA study evaluating adjuvant osimertinib demonstrated a profound reduction of the risk of recurrence in patients with stage I (>4 cm)-IIIA eNSCLC harbouring EGFR sensitizing mutations. ICIs and TKIs represent a true revolution in the treatment of eNSCLC call to challenge the current standard of care. However, questions regarding drug resistance, recurrence patterns, biomarker identification, optimal treatment duration and sequencing need be answered to effectively integrate new drugs in the rapidly evolving therapeutic landscape of NSCLC. In this review we critically review new developments and future perspectives of TKIs and ICI as (neo)adjuvant strategies for eNSCLC.

Bayesian network meta-analysis of efficacy and safety of neoadjuvant therapy for non-small-cell lung cancer

Objective:

Neoadjuvant chemotherapy has increased the survival benefit of non-small cell lung cancer (NSCLC) patients. The effects of different neoadjuvant therapies are still controversial. We carried out the study to evaluate the efficacy and safety of neoadjuvant therapy.

Methods:

We performed a search of electronic databases (PubMed, Embase, MEDLINE, Cochrane) for randomized controlled trials (RCTs) comparing neoadjuvant treatment. After literature screening and data extraction, efficacy, and safety were analyzed by the Bayesian network meta-analysis (NMA).

Results:

A total of 19 RCTs were included, covering 3276 patients and six kinds of neoadjuvant therapies, including immunotherapy, targeted therapy, chemotherapy drugs and radiotherapy. Erlotinib, the first-generation epidermal growth factor receptor tyrosine inhibitors (EGFR TKIs), neoadjuvant targeted therapy is best for improving overall survival (OS) and progression-free survival (PFS), which is superior to other neoadjuvant therapy, such as neoadjuvant chemotherapy with platinum drugs [hazard ratio (HR) 0.39, 95% confidence intervals (CIs) 0.16–0.96], neoadjuvant chemoradiotherapy (HR 0.37, 95% CI 0.14–0.96) and neoadjuvant chemotherapy with non-platinum drugs (HR 0.25, 95% CI 0.07–0.90). OS of all neoadjuvant therapies is superior to surgery alone, but only neoadjuvant chemotherapy with platinum drugs showed a significant advantage (HR 0.76, 95% CI 0.59–0.93). Besides, for the stage IIIA N2 NSCLC patients, no significant difference was found between neoadjuvant therapies.

Conclusions:

Targeted neoadjuvant therapy is the best treatment for prolonging PFS. The neoadjuvant chemotherapy with platinum drugs was associated with the better OS benefits for patients with NSCLC, compared with surgery alone. There is no significant difference in the efficacy of neoadjuvant therapy for the stage IIIA N2 NSCLC.

Resectable IIIA-N2 Non-Small-Cell Lung Cancer (NSCLC): In Search for the Proper Treatment

Locally advanced non-small cell lung cancer accounts for one third of non-small cell lung cancer (NSCLC) at the time of initial diagnosis and presents with a wide range of clinical and pathological heterogeneity. To date, the combined multimodality approach involving both local and systemic control is the gold standard for these patients, since occult distant micrometastatic disease should always be suspected. With the rapid increase in treatment options, the need for an interdisciplinary discussion involving oncologists, surgeons, radiation oncologists and radiologists has become essential. Surgery should be recommended to patients with non-bulky, discrete, or single-level N2 involvement and be included in the multimodality treatment. Resectable stage IIIA patients have been the subject of a number of clinical trials and retrospective analysis, discussing the efficiency and survival benefits on patients treated with the available therapeutic approaches. However, most of them have some limitations due to their retrospective nature, lack of exact pretreatment staging, and the involvement of heterogeneous populations leading to the awareness that each patient should undergo a tailored therapy in light of the nature of his tumor, its extension and his performance status.

Long-term outcomes following neoadjuvant or adjuvant chemoradiotherapy for stage I-IIIA non-small cell lung cancer: a propensity-matched analysis

Background

This study aimed to evaluate the long-term survival outcomes of patients undergoing neoadjuvant chemoradiotherapy or adjuvant chemoradiotherapy for T1-4N0-1M0 disease.

Methods

Patients with pT1-4N0-1M0 between 2010 and 2015 who received pre- or postoperative (R0 resection) chemoradiotherapy were identified. The exclusion criteria included N2 or M1 disease, immunotherapy, and targeted therapy. The staging was recalculated according to the new 8th edition TNM classification. Survival and predictors were assessed using Kaplan-Meier and multivariate Cox proportional-hazards model. Propensity-score matching with a ratio of 2:1 was performed to reduce bias in various clinicopathological factors.

Results

Of the 1,769 patients who met the inclusion criteria, 407 and 814 were included in the neoadjuvant and adjuvant chemoradiotherapy group, respectively, after propensity-score matching. The 5-year overall survival (OS) and cancer-specific survival (CSS) were 38.1% and 40.0% for neoadjuvant chemoradiotherapy and 26.3% and 26.5% for adjuvant chemoradiotherapy, respectively [P<0.0001, hazard ratio (HR): 0.7418, 95% confidence interval (CI): 0.6434-0.8553; P<0.0001, HR: 0.7444, 95% CI: 0.6454-0.8587)]. When stratified by stage, stage IIA (P=0.4166, HR: 0.8575, 95% CI: 0.5917-1.243) and IIIA (P=0.0740, HR: 0.7687, 95% CI: 0.5748-1.028) did not show improved 5-year OS in patients receiving neoadjuvant chemoradiotherapy. When stratified by age, similar trends were observed for patients aged more than 75 years. The multivariable analysis showed a significant association of neoadjuvant chemoradiotherapy with better survival.

Conclusions

Neoadjuvant chemoradiotherapy might improve the long-term survival of patients with stage I-IIIA non-small cell lung cancer (NSCLC). For patients aged more than 75 years, neoadjuvant chemoradiotherapy was not associated with an improvement in survival.

Results of video-assisted thoracic surgery versus thoracotomy in surgical resection of pN2 non-small cell lung cancer in a Chinese high-volume Center

PURPOSE

To investigate the short-term outcomes and long-term oncological efficacy of video-assisted thoracic surgery (VATS) for surgical treatment of pN2 non-small cell lung cancer (NSCLC) compared with open thoracotomy (OT).

PATIENTS AND METHODS

We retrospectively collected data from 1034 patients who underwent pulmonary resection and systemic lymph node dissection for pathological N2 NSCLC from September 2005 to December 2017 (536 patients in VATS group and 498 patients in OT group). Propensity score matching was applied to reduce the confounding effects. Factors affecting survival were assessed by Kaplan-Meier estimates and Cox regression analysis.

RESULTS

The VATS procedure was associated with shorter operative time compared with the OT procedure (147.96 ± 58.91 min vs. 165.34 ± 58.91 min, P < 0.001). No significant difference was identified between the two groups in the number of dissected mediastinal lymph nodes (MLNs) and number of dissected MLNs stations. More patients after VATS procedure received postoperative adjuvant therapy (83.4% vs. 75.5%, P = 0.002). At a median follow-up of 36 (range 4-150) months, comparing VATS procedure and OT procedure, no significant differences were noted in 5-year DFS (20.7% vs. 22.5%, P = 0.89) and 5-year OS (30.7% vs. 34.5%, P = 0.821). The VATS procedure was not found to be an independent predictor of DFS (hazard ratio, 0.986; 95% CI, 0.809 to 1.202) or OS (hazard ratio, 0.977; 95% CI 0.802 to 1.191).

CONCLUSION

In this large propensity-matched comparison, the VATS procedure offered comparable short-term outcomes and long-term oncological efficacy for patients with pN2 NSCLC when compared with OT procedure.

Agreement on Major Pathological Response in NSCLC Patients Receiving Neoadjuvant Chemotherapy

INTRODUCTION

We have suggested that major pathologic response (MPR) could serve as a surrogate endpoint for survival and provide rapid means of comparing different neoadjuvant treatment regimens. Here, we confirm that MPR is predictive of long-term overall survival (OS) in patients with non-small-cell lung cancer (NSCLC) who underwent neoadjuvant chemotherapy and surgical resection, to assess agreement on MPR between 2 observers, and to determine the minimum number of slides needed to obtain an accurate determination of MPR.

PATIENTS AND METHODS

We identified 151 patients with NSCLC who had been treated with neoadjuvant chemotherapy followed by complete surgical resection from 2008 to 2012. Tissue specimens were retrospectively evaluated by 2 pathologists who had been blinded to patients' treatment and outcome. We assessed the relationships between MPR and OS, the levels of agreement between the pathologists, and determined the number of slides needed to obtain an accurate determination of MPR.

RESULTS

Our results reveal that MPR examined by either observer 1 (experienced) or by observer 2 (trained) was significantly predictive of long-term OS after neoadjuvant chemotherapy. MPR was associated with long-term OS in patients with NSCLC undergoing neoadjuvant chemotherapy on multivariable analysis (hazard ratio 2.68; P = .01). The levels of agreement between 2 pathologists were high after direct in-person training by one pathologist or the other (R² = 0.994). Our data suggest that at least 3 slides should be read to accurately determine MPR.

CONCLUSIONS

MPR is significantly predictive of long-term OS in neoadjuvant chemotherapy-treated patients with NSCLC. MPR may serve as a surrogate endpoint for evaluating novel chemotherapies and immunotherapy response in biomarker-driven translational clinical trials.

Prognostic significance of pathological complete response in non-small cell lung cancer following neoadjuvant treatment

BACKGROUND

This study aims to investigate the factors associated with pathological complete response following neoadjuvant treatment and to examine the prognostic value of pathological complete response in patients with non-small cell lung cancer undergoing surgical resection.

METHODS

Between February 2009 and January 2016, a total of 112 patients (96 males, 16 females; mean age 60±8 years; range, 37 to 85 years) with the diagnosis of non-small cell lung cancer who underwent anatomical pulmonary resection after neoadjuvant treatment were retrospectively analyzed. Demographic, clinical, radiological, and pathological characteristics of the patients were recorded. The patients were classified as pathological complete response and nonpathological complete response according to the presence of tumors in the pathology reports. Predictive factors for pathological complete response and its prognostic significance were analyzed.

RESULTS

The mean follow-up was 35±20 (range, 0 to 110) months. Of the patients, 30 (27%) achieved a pathological complete response. Reduction rate in tumor size was significantly higher in the responsive group (32.5±21.6% vs. 19.2±18.8%, respectively) and was a predictor of pathological complete response independent from the T and N factors (p=0.004). Survival of the responsive patients was significantly longer than unresponsive patients (75±9 vs. 30±4 months, respectively; p<0.001). During follow-up, tumor recurrence was seen in 30 patients. Recurrence was observed in only one patient in the responsive group, while 29 patients in the unresponsive group had recurrence or metastasis.

CONCLUSION

Tumor shrinkage rate after neoadjuvant treatment in non-small cell lung cancer is a predictive factor for pathological complete response. Survival of patients with a pathological complete response is also significantly longer than unresponsive patients.

[Adjuvant and inductive systemic treatment in non-small cell lung cancer]

A large number of randomized trials have demonstrated an undoubted advantage of adjuvant chemotherapy in comparison to surgery alone. This is true for all lymph node positive cases of non-small cell lung cancer (NSCLC) with a tumor size of 4 cm or more. Worldwide, the application of adjuvant chemotherapy for these indications is regarded as standard treatment. Due to the positive results of adjuvant chemotherapy, nearly all studies focusing on neoadjuvant chemotherapy were stopped early because control arms with surgery alone were no longer regarded as ethically justified; however, in meta-analyses the effect of neoadjuvant chemotherapy seems be as strong as the effect of adjuvant chemotherapy. In clinical practice neoadjuvant chemotherapy is not routinely established in early stage disease. This approach is more often applied in advanced stages, such as N2 lymph node involvement or in patients where the tumor most probably requires pneumectomy for resection. In the last decade the options for systemic treatment of NSCLC have dramatically changed. In addition to chemotherapy, targeted treatment of patients with molecularly altered tumors and immunotherapy have been used very successfully in advanced stages. The options might also have a high impact on survival in early stages and the integration of these treatment modalities in the management of early stage disease is warranted. This article summarizes the established and new options in additive systemic treatment and presents the current state of treatment.

Review and perspective on adjuvant and neoadjuvant immunotherapies in NSCLC

Postoperative patients have risk recurring, even for completed resected early stage non-small-cell lung cancer (NSCLC). To control the recurrence rate, neoadjuvant and adjuvant therapies have been applied widely in clinical practice; however, neoadjuvant and adjuvant immunotherapy clinical trials on NSCLC are still being explored. In this review, we summarized the research progress and outline the issues need to be solved on adjuvant and neoadjuvant immunotherapies in NSCLC.

The Accuracy of Clinical Staging of Stage I-IIIa Non-Small Cell Lung Cancer: An Analysis Based on Individual Participant Data

BACKGROUND

Clinical staging of non-small cell lung cancer (NSCLC) helps determine the prognosis and treatment of patients; few data exist on the accuracy of clinical staging and the impact on treatment and survival of patients. We assessed whether participant or trial characteristics were associated with clinical staging accuracy as well as impact on survival.

METHODS

We used individual participant data from randomized controlled trials (RCTs), supplied for a meta-analysis of preoperative chemotherapy (± radiotherapy) vs surgery alone (± radiotherapy) in NSCLC. We assessed agreement between clinical TNM (cTNM) stage at randomization and pathologic TNM (pTNM) stage, for participants in the control group.

RESULTS

Results are based on 698 patients who received surgery alone (± radiotherapy) with data for cTNM and pTNM stage. Forty-six percent of cases were cTNM stage I, 23% were cTNM stage II, and 31% were cTNM stage IIIa. cTNM stage disagreed with pTNM stage in 48% of cases, with 34% clinically understaged and 14% clinically overstaged. Agreement was not associated with age (P = .12), sex (P = .62), histology (P = .82), staging method (P = .32), or year of randomization (P = .98). Poorer survival in understaged patients was explained by the underlying pTNM stage. Clinical staging failed to detect T4 disease in 10% of cases and misclassified nodal disease in 38%.

CONCLUSIONS

This study demonstrates suboptimal agreement between clinical and pathologic staging. Discrepancies between clinical and pathologic T and N staging could have led to different treatment decisions in 10% and 38% of cases, respectively. There is therefore a need for further research into improving staging accuracy for patients with stage I-IIIa NSCLC.

Occult stage IIIA-N2 patients have excellent overall survival with initial surgery

Background

Patients may be found to have stage IIIA-N2 at the final pathology after the initial surgery. We want to determine the survival rate in this unique group of patients.

Methods

We reviewed all patients who underwent surgical resection for lung cancer from 2000 to 2011 who had pathologic stage N2 without induction therapy. We determined the clinicopathologic characteristics and survival rate in this unique group of patients.

Results

A total of 101 patients met the inclusion criteria. The average age of the group was 65 years old with 53 (53%) females. The chest computed tomography (CT) scans showed 30 patients (30%) with mediastinal lymphadenopathy (>1 cm) and 13 (13%) with multistation disease. The positron emission tomography-computed tomography (PET-CT) showed 24 patients (24%) with N2 positive uptake. Invasive mediastinal staging prior to surgery occurred in 43 patients (43%). Eighty-four patients underwent a lobectomy (83%), 7 with bilobectomy (7%), and 10 with pneumonectomy (10%). The most common pathology was adenocarcinoma with 73 patients (72%) and the second most common was squamous cell carcinoma with 22 patients (22%). Most of the patients completed the adjuvant chemoradiation therapy (86%). The 5-year survival rate was 48% and the 10-year survival rate was 24%.

Conclusions

Pathologic stage IIIA-N2 non-small cell lung cancer (NSCLC) is a heterogeneous disease process with a very small group of patients undergoing initial surgery. Patients with occult stage IIIA-N2 who undergo initial surgery have an excellent overall survival rate.

Long-term effects of neoadjuvant radiotherapy, adjuvant radiotherapy, and chemotherapy-only on survival of locally advanced non-small cell lung Cancer undergoing surgery: a propensity-matched analysis

Background

The optimal timing of radiotherapy (RT) with respect to surgery remains controversial for locally advanced non-small cell lung cancer (LA NSCLC) undergoing surgery and the long-term effect of neoadjuvant RT, adjuvant RT, and chemotherapy-only on survival is unknown.

Methods

A retrospective study with Greedy 5 → 1 Digit propensity score matching technique was performed for locally advanced NSCLC patients identified from the Surveillance, Epidemiology, and End Results (SEER) database during 2004 to 2012. Kaplan-Meier and the log-rank test were conducted to compare NSCLC-specific survival. Cox proportional hazards multivariable regression was performed to assess the impact of different treatment regimens on cancer-specific mortality after adjustment for demographic factors, histology type, tumor grade, tumor size, nodal stage, and extent of resection.

Results

One thousand, two hundred and seventy-eight locally advanced NSCLC patients undergoing surgery were identified after propensity matching. Cox regression analyses showed the risk of cancer-specific mortality is not significantly different among neoadjuvant RT, adjuvant RT, and chemotherapy-only. Subgroup analyses showed that for patients with T1/2 & N2/3, the surgery plus chemotherapy-only group showed markedly higher mortality risk (HR = 1.42, 95%CI:1.10–1.83) than the neoadjuvant RT group. Other risk factors include older age, higher tumor grade, larger tumor size, and greater lymph node involvement.

Conclusions

The findings of this study suggest that the benefit of additional neoadjuvant or adjuvant RT to chemotherapy may be linked to a proper selection of LA NSCLC patients who undergo surgery. The timing of radiotherapy should be decided on the premise of fully considering patients’ condition and the quality of life after treatment.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4900-x) contains supplementary material, which is available to authorized users.

Induction Cisplatin Docetaxel Followed by Surgery and Erlotinib in Non-Small Cell Lung Cancer

BACKGROUND

Data from meta-analyses support the use of induction or adjuvant platinum-based chemotherapy for locally advanced non-small cell lung cancers (NSCLCs). This phase 2 study assessed the role of induction cisplatin and docetaxel followed by surgery in patients with resectable stage I to III NSCLCs, followed by 12 months of adjuvant erlotinib.

METHODS

Patients with resectable stage I to III NSCLCs received cisplatin 80 mg/m2, docetaxel 75 mg/m2 every 21 days for 3 cycles, followed by surgery, followed by adjuvant erlotinib for 12 months. The primary endpoint included safety. Long-term efficacy outcomes and exploratory analysis of intermediary endpoints are also reported (NCT00254384).

RESULTS

Forty-seven eligible patients received a median of 3 cycles of induction treatment, 37 underwent surgical resection, and only 21 received adjuvant erlotinib. Two patients died in the perioperative period (1 sepsis during chemotherapy, 1 acute respiratory distress syndrome postoperatively). Most common grade 3 to 5 toxicities during chemotherapy included hypokalemia (8%), infection (7%), and granulocytopenia (25%). During adjuvant erlotinib, 14% of patients experienced grade 2 rash. Median overall survival was 3.4 years. Major pathologic responses in the primary tumor were observed in 19% (7 of 37) of patients and correlated with improved long-term overall survival. Complete pathologic response in mediastinal/hilar nodes also correlated with superior survival.

CONCLUSIONS

Induction cisplatin and docetaxel was well tolerated. Adjuvant erlotinib did not improve outcomes compared with historical controls. Major pathologic response predicted for improved long-term survival and is a suitable intermediary endpoint for future phase 2 studies.

Before or After: Evolving Neoadjuvant Approaches to Locally Advanced Non-Small Cell Lung Cancer

The treatment of patients with stage IIIA (N2) non-small cell lung cancer (NSCLC) is one of the most challenging and controversial areas of thoracic oncology. This heterogeneous group is characterized by varying tumor size and location, the potential for involvement of surrounding structures, and ipsilateral mediastinal lymph node spread. Neoadjuvant chemotherapy, administered prior to definitive local therapy, has been found to improve survival in patients with stage IIIA (N2) NSCLC. Concurrent chemoradiation has also been evaluated in phase III studies in efforts to improve control of locoregional disease. In certain instances, a tri-modality approach involving concurrent chemoradiation followed by surgery, may offer patients the best chance for cure. In this article, we provide an overview of the trials evaluating neoadjuvant therapy in patients with stage IIIA (N2) NSCLC that have resulted in current practice strategies, and we highlight the areas of uncertainty in the management of this challenging disease. We also review the current ongoing research and future directions in the management of stage IIIA (N2) NSCLC.

Neoadjuvant chemotherapy followed by surgery versus upfront surgery in non-metastatic non-small cell lung cancer: systematic review and meta-analysis of randomized controlled trials

Background

The favorable effect of postoperative chemotherapy on long-term survival has been well acknowledged in non-small cell lung cancer (NSCLC), while the role of neoadjuvant chemotherapy (NAC) remains obscure. This meta-analysis enrolling high-quality randomized controlled trials (RCTs) aimed at comparing NAC followed by surgery with upfront surgery (US) in efficacy and safety among non-metastatic NSCLC patients.

Materials and Methods

Relevant literatures were searched systematically from MEDLINE, EMBASE, and the Cochrane Library. We also screened references of relevant publications and conference proceedings. Primary outcomes were overall survival (OS), disease free survival (DFS), 3-year and 5-year survival rates, mortality, and recurrence. Secondary outcomes included tumor-free (R0) resection rates, response rate, and postoperative complications. Subgroup analysis according to ethnicity was further conducted.

Results

A total of 11 eligible RCTs comparing NAC (n = 1624) with US (n = 1639) and published from 1998 to 2013 were included. Compared to US, NAC contributed to longer OS and DFS, higher 3-year and 5-year DFS rates, and lower incidences of total mortality, overall recurrence and metastasis, and tended to cause higher 5-year OS rates. NAC was associated with reduced risks in recurrence compared to US. Patients receiving NAC had lower surgery and resection rates, but higher R0 resection incidence among resected cases. NAC especially benefited occident patients. The overall NAC response rate was 52.1%, and NAC-related toxicity rate was 58.3%.

Conclusion

NAC may provide better survival, reduced recurrence, and improved R0 resection rates among NSCLC patients who had surgery, especially in occident patients. Further studies are needed to clarify the ethnic differences.

Induction chemotherapy for T3N0M0 non-small-cell lung cancer increases the rate of complete resection but does not confer improved survival

OBJECTIVES

The objective of this study was to evaluate outcomes of induction therapy prior to an operation in patients with cT3 non-small-cell lung cancer (NSCLC).

METHODS

Patients diagnosed with cT3N0M0 NSCLC from 2006 to 2011 in the National Cancer Database who were treated with lobectomy or pneumonectomy were stratified by treatment strategy: an operation first versus induction chemotherapy. Propensity scores were developed and matched cohorts were generated. Short-term outcomes included margin status, 30- and 90-day mortality rates, readmission and length of stay. Survival analyses using Kaplan-Meier methods were performed on both the unadjusted and propensity matched cohorts.

RESULTS

A total of 3791 cT3N0M0 patients were identified for inclusion, of which 580 (15%) were treated with induction chemotherapy. Prior to adjustment, patients treated with induction chemotherapy were younger, had a higher comorbidity burden and were more likely to have private insurance (all P  < 0.001). Following matching, patients receiving induction chemotherapy were more likely to subsequently undergo an open procedure (87.3 vs 77.8%, P  = 0.005). These patients were more likely to obtain R0 resection (93.1% vs 90.0%, P  = 0.04) and were thereby less likely to have positive margins at the time of resection (6.9% vs 10.0%, P  = 0.03). Patients who received induction therapy had higher rates of 90-day mortality (6.6% vs 3.4%) but there was no difference in long-term survival between the groups.

CONCLUSIONS

Despite yielding increased rates of R0 resection, induction chemotherapy for cT3N0M0 NSCLC is not associated with improved survival and should not be considered routinely. Further studies are warranted to elucidate cohorts that may benefit from induction therapy.

Efficacy of postoperative radiotherapy in patients with pathological stage N2 epidermal growth factor receptor wild type adenocarcinoma and squamous cell carcinoma lung cancer

PURPOSE

Few large, prospective, randomized studies have compared the effects of postoperative radiotherapy (PORT) in pathological N2 (pN2) with those of surgical resection alone. in terms of long-term survival in lung adenocarcinoma (adenoCA; wild-type [WT] epidermal growth factor receptor [EGFR]) and squamous cell carcinoma (squCA) settings. This nationwide cohort study clarifies the role of PORT in the survival of pN2 lung adenoCA (WT EGFR) and squCA patientsPatients and Methods: We analyzed data of patients with adenoCA (WT EGFR) and squCA collected from the Taiwan Cancer Registry database. The patients were categorized into five groups according to the treatment modality: Group 1 (surgery alone), Group 2 (adjuvant chemotherapy [CT] alone), Group 3 (adjuvant radiotherapy [RT] alone), Group 4 (adjuvant concurrent chemoradiotherapy [CCRT]), and Group 5 (adjuvant sequential CT and intensity-modulated RT [IMRT]).

RESULTS

We enrolled 588 lung adenoCA (WT EGFR) and squCA patients without distant metastasis. After adjustments for age at surgery, surgical years, and Charlson comorbidity index scores, the multivariate Cox regression analysis demonstrated that adjusted HRs (aHRs; 95% confidence intervals [CIs]) for the overall mortality of female lung adenoCA (WT EGFR) patients were 0.257 (0.111-0.594), 0.530 (0.226-1.243), 0.192 (0.069-0.534), and 0.399 (0.172-0.928) in Groups 2, 3, 4, and 5, respectively. For male lung squCA patients, the aHRs (95% CIs) for overall mortality were 0.269 (0.160-0.451), 0.802 (0.458-1.327), 0.597 (0.358-0.998), and 0.456 (0.265-0.783) in Groups 2, 3, 4, and 5, respectively.

CONCLUSIONS

Adjuvant CCRT or sequential CT and IMRT at ≥5000 cGy significantly reduced the mortality rate of female lung adenoCA (WT EGFR) and male squCA pN2 patients.

Cisplatin-enriching cancer stem cells confer multidrug resistance in non-small cell lung cancer via enhancing TRIB1/HDAC activity

Chemotherapeutic agents are generally used as a frontline therapy for non-small cell lung cancer (NSCLC). However, resistance to chemotherapy arises rapidly in NSCLC, and the reasons for chemotherapy resistance have not been fully determined. Here, we found cisplatin, but not paclitaxel and doxorubicin, induced the enrichment of cancer stem cell (CSC) and conferred multidrug resistance in NSCLC cell lines. In vivo study confirmed drug-resistant tumors displayed the enhanced expressions of CSC transcription factors. Mechanistically, cisplatin treatment resulted in C/EBP-β-dependent increasing of TRIB1. The crucial role of TRIB1 in cisplatin-induced enrichment of CSC and drug resistance was verified by knockdown TRIB1. Interestingly, cisplatin treatment also contributed to the increasement of HDAC, the interaction of TRIB1 with HDAC, and inactivation of p53. Similarly, the silencing of HDAC led to reduction of cisplatin-induced CSC, and combined knockdown of HDAC and TRIB1 exhibited enhanced effect. Additionally, the combination of HDAC inhibitor and cisplatin showed a reinforced antitumor action in NSCLC cell lines with TRIB1-dependent manner and remarkably shrink tumors in xenograft models. Moreover, cisplatin-treated NSCLC patients with high levels of TRIB1 exhibited a significantly poorer prognosis. Our findings illustrate a novel perspective in the evolution of chemotherapy resistance and provide a promising approach for the treatment of patients with NSCLC.

The long-term prognosis of induction chemotherapy followed by surgery for N2 non-small cell lung cancer: A retrospective case series study

INTRODUCTION

The long-term prognosis of induction chemotherapy followed by surgery for N2 non-small lung cell cancer (NSCLC) remains controversial.

PATIENTS AND METHODS

We retrospectively reviewed the data and assessed the prognosis of 31 N2-NSCLC patients who underwent induction chemotherapy followed by surgery at our institution between January 1999 and December 2013. Potential prognostic factors, such as age, gender, tumor histology, tumor marker levels, tumor size, the number of N2 lymph nodes, the time from the last induction chemotherapy to the date of surgery, induction chemotherapy, RECIST response, downstaging status, pathological stage, adjuvant chemotherapy, and EF, were analyzed.

RESULTS

The chemotherapy regimens of 30 of the 31 patients included a platinum agent. Complete resection was performed in 96.7% of the cases. Pathological downstaging was induced in 9 (29%) of the 31 patients. The median follow-up period was 7.89 years. The median DFI was 13.9 months. The recurrence rate was 74.2%. The 5-year OS was 56.9%. Univariate analyses revealed that none of the factors significantly affected OS, while the tumor histology had a significant effect on the DFI.

CONCLUSION

Although the recurrence rate in our study was similar to previous studies, our survival data were much better than those of past reports. Although the tumor histology was the only factor that had a significant association with DFI in the current study, the possibility of bias exists.

Cisplatin plus vinorelbine as induction treatment in stage IIIA non-small cell lung cancer

Survival rates in patients with stage IIIA non-small cell lung cancer (NSCLC) remain low despite curative treatment. This is due to tumor recurrence at distant sites. The aim of neoadjuvant chemotherapy (NA-CT) is to eradicate occult micrometastatic disease and improve survival in patients that are not candidates for surgery following induction therapy. A total of 21 patients with ipsilateral mediastinal node involvement (N2) with potentially resectable disease, who had been diagnosed with stage IIIA (T1-3 N1-2 and T4N0) NSCLC and who had received cisplatin and vinorelbine as induction treatment were included in this retrospective study. Patients who responded to the treatment underwent surgery, and those who were unresponsive received radical radiotherapy. Follow-up was conducted between March 2008 and April 2014. The median age of patients was 61 years, and all patients exhibited a good Eastern Cooperative Oncology Group performance status. The majority of patients were histologically diagnosed with adenocarcinoma (48%) or squamous cell carcinoma (38%), which was a poor prognostic factor for overall survival (OS). A total of 7 patients underwent surgery (of which 6 were down-staged), with a 3-year survival rate of 42.8%. The most significant factor associated with response to induction treatment was multistation nodal involvement. The complete resection rate for surgical patients was 85.7%. Unresectable patients had a 3-year survival rate of 25.8%. OS time for the whole cohort was 28.5 months, and the 3- and 5-year OS rates were 28.5% and 4.7%, respectively. CT-induced toxicity did not affect any treatment regime or surgical procedures. In conclusion, the use of cisplatin plus vinorelbine is feasible in a neoadjuvant setting, with good response rates and acceptable toxicity. Multistation N2 involvement is the main prognostic factor for a poor response to induction treatment.

Salvage surgery for primary lung cancer after chemotherapy in octogenarians

An 81‐year‐old female patient was admitted to our institute because of abnormal X‐ray results. Chest computed tomography showed a 7.7 × 5.3 cm mass located in the left lower lobe and multiple swollen lymph nodes. 18F‐fluorodeoxyglucose‐positron emission tomography indicated high standard uptake values in the mass and swollen lymph nodes. The patient was diagnosed with stage cT3N2M0‐IIIA squamous cell carcinoma. Although the patient had multiple lymph node metastases and severe obstructive pulmonary function, four cycles of platinum doublet chemotherapy were initially performed and no side effect greater than grade 3 was experienced. As the lung cancer was downstaged to ycT2aN0M0‐IB and pulmonary function had improved, a bronchodilating preparation, an uneventful left lower lobectomy, and a lymphadenectomy were performed. The patient was discharged 39 days after surgery and exhibited good health for a year at pathological stage ypT1aN0M0‐IA (Ef2).

Preoperative functional workup for patients with advanced lung cancer

Locally advanced lung cancer remains a surgical indication in selected patients. This condition often demands larger resections. As a consequence preoperative functional workup is of paramount importance to stratify the risk and choose the most appropriate treatment. We reviewed the current evidence on functional evaluation with a special focus on specific aspects related to locally advanced lung cancer stages (i.e., risk after neoadjuvant treatment, pneumonectomy). Evidence is discussed to provide information that could assist clinicians in their preoperative workup of these challenging patients.

Perioperative outcomes and lymph node assessment after induction therapy in patients with clinical N1 or N2 non-small cell lung cancer

BACKGROUND

Induction therapy has been shown to benefit patients with resectable stage-2 or stage-3 non-small cell lung cancer (NSCLC). We aimed to determine if induction chemotherapy (CTx) with or without radiation therapy (± RT) for NSCLC with clinical lymph node (LN) involvement (cN1 or cN2) affects LN dissection or perioperative outcomes during robotic-assisted video thoracoscopic (RAVTS) lobectomy.

METHODS

We retrospectively analyzed patients who underwent RAVTS lobectomy for NSCLC over 45 months. We assessed clinical LN status by CT scan, PET scan, endobronchial ultrasound, and/or mediastinoscopy. We grouped patients with cN1 or cN2 as: "no induction therapy", "induction CTx alone" (ICTx), or "induction CTx + RT" (ICTx + RT). Intraoperative estimated blood loss (EBL), operative times, tumor size, LN status, and restaging were noted.

RESULTS

Of 256 NSCLC patients who had lobectomy, there were 52 cN1 or cN2 patients, of whom 39 patients had "no induction", 7 had ICTx, and 6 had ICTx + RT. Higher rates of recurrent laryngeal nerve (RLN) injury, tracheal/bronchial injury, and pulmonary embolism were observed with ICTx ± RT (P=0.02, 0.04, and 0.02, respectively). Total number of complications was not significantly different, nor were perioperative outcomes, such as EBL, operative time, and in-hospital mortality. Fewer N2 LN stations were assessed after ICTx ± RT (3.7±0.2 vs. 4.2±0.2 stations; P=0.04), but total number of LNs reported were not significantly different (13.0±2.3 vs. 16.2±1.0 LNs, P=0.22). Of "no induction" patients, 15.4% were upstaged pathologically; no patients were upstaged after induction therapy. While 30.8% of ICTx ± RT patients were downstaged, 38.5% of "no induction" patients were also downstaged on final pathology.

CONCLUSIONS

Induction CTx ± RT for cN1 or cN2 NSCLC patients did not affect EBL, operative times, or in-house mortality after RAVTS lobectomy. Patients undergoing RAVTS lobectomy after ICTx+ RT may be at greater risk for RLN injury, tracheal/bronchial injury, and pulmonary embolism. Fewer N2 LN stations, but not numbers of LNs, are assessed after ICTx ± RT. Induction therapy does not lead to increased downstaging.

CT scan prior to radiotherapy in unresectable, locally advanced, non-small cell carcinoma of the lung: is it always necessary?

PURPOSE

There is broad consensus regarding evaluating response to chemotherapy (CHT) by means of computerized tomography (CT) in patients with localized or locally advanced non-small cell lung carcinoma (NSCLC). We present a study comparing the usefulness of CT versus chest X-ray (XR) and clinical findings when indicating radiotherapy (RT) following CHT.

METHODS

Ninety-eight of 150 subjects with unresectable locally advanced NSCLC were blindly and independently evaluated by XR and CT, with pairs of chest XR and CT (before and after CHT). A null hypothesis (H0) was established of the conditioned probability of detecting progression by CT and not by XR of 10 % or more, with a statistical power of 80 %.

RESULTS

Sensitivity, specificity, positive and negative predictive value of XR versus CT were 98, 89, 99, and 80 % respectively. A 4 % (p = 0.0451) probability of improvement of CT versus XR was calculated, enabling the H0 to be ruled out.

CONCLUSION

The CT failed to prove to be significantly superior to the chest XR + clinical picture in indicating a change in treatment approach in patients with unresectable locally advanced NSCLC after CHT.

From fighting depression to conquering tumors: a novel tricyclic thiazepine compound as a tubulin polymerization inhibitor

A novel tricyclic thiazepine derivative, 6-(p-tolyl)benzo[f] pyrido[2,3-b][1,4] thiazepine 11,11-dioxide (TBPT), exhibits potent inhibitory effects in two non-small-cell lung cancer cell lines, H460 and its drug-resistant variant, H460_TaxR, while exhibiting much less toxic effects on normal human fibroblasts. After five injections of TBPT at a dose of 60 mg/kg, it inhibits H460_TaxR tumor growth in xenografted mouse models by 66.7% without causing observable toxicity to normal tissues. Based on gene perturbation data and a series of investigations, we reveal that TBPT is not a P-glycoprotein substrate and it inhibits microtubule formation by targeting tubulin, thereby causing cell cycle arrest at the G2/M stage and eventually inducing apoptosis. This redeployment of anti-depressant compound scaffold for anticancer applications provides a promising future for conquering drug-resistant tumors with fewer side effects.

Surgery following neoadjuvant chemotherapy for non-small-cell lung cancer patients with unexpected persistent pathological N2 disease

Patients with mediastinal lymph node (LN) downstaging following neoadjuvant chemotherapy exhibit improved outcomes compared with patients with persistent N2 disease. The aim of this study was to compare clinicopathological characteristics and survival between patients with unexpected and expected persistent N2 disease following surgery for non-small-cell lung cancer (NSCLC). This retrospective analysis included 348 patients with NSCLC who underwent surgery following chemotherapy at the Shanghai Pulmonary Hospital, Tongji University School of Medicine, between 1995 and 2012. According to the results of the imaging examinations and postoperative pathology, the patients were divided into three groups, namely groups I (nodal downstaging, pN0-1), II (expected persistent N2 disease) and III (unexpected persistent N2 disease). The rates of overall survival (OS) and disease-free survival (DFS) were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify the independent risk factors for OS and DFS. The mortality rate was 1.1% during the postoperative period. Perioperative complications occurred in 45 patients (12.9%). The 5-year OS rate was 32.2, 6.3 and 25.9% in groups I, II and III, respectively (group I vs. III, P=0.023; and group III vs. II, P<0.001). The 5-year DFS rate was 30.1, 5.1 and 22.4% in groups I, II and III, respectively (group I vs. III, P=0.012; and group III vs. II, P<0.001). Grouping, predicted forced expiratory volume in 1 sec, N downstaging and skip N2 metastasis were identified as independent predictive factors associated with OS, whereas the independent risk factors associated with DFS were grouping and N downstaging. Patients with unexpected persistent N2 disease exhibited better survival compared with those with expected persistent N2 disease. Surgery following chemotherapy remains the optimal approach for a proportion of patients with persistent N2 disease.

Serum HE4: An Independent Prognostic Factor in Non-Small Cell Lung Cancer

Human epididymis secretory protein 4 (HE4) is a secreted glycosylated protein encoded by the WAP four-disulfide core domain 2 (WFDC2) gene, located on a chromosome 20 segment that is frequently amplified in many cancers. This study aimed at determining serum HE4 prognostic value in non-small cell lung cancer (NSCLC), following the REMARK guidelines. Serum samples from 346 consecutive patients with histologically proven and previously untreated NSCLC and 41 patients with benign pulmonary disease were collected at the Montpellier-Nimes Academic Hospital. Work-up investigations performed to determine the disease characteristics and treatment algorithms were congruent with international guidelines. HE4 levels in serum were measured with an ELISA test (Fujirebio Diagnostics) that uses two monoclonal antibodies, 2H5 and 3D8, against the C-WFDC domain of HE4. The area under the ROC curve (i.e., overall ability of HE4 to discriminate between controls and patients) was 0.78 (95% confidence interval [CI], 0.738–0.821; z test P <0.0001). Serum HE4 levels were significantly higher in patients with worse performance status, advanced TNM stage and positive nodal status. In the Cox model, overall survival was shorter in patients with high pretreatment serum HE4 (above 140 pmol/L) than in patients with serum H4 level ≤ 140 pmol/L [median survival: 17.7 weeks (95% CI, 11.9 to 24.9) and 46.4 weeks (95% CI, 38.6 to 56.3), respectively; hazard ratio: 1.48 (95% CI, 1.12 to 1.95) for high HE4; adjusted P = 0.0057]. High serum HE4 level at diagnosis is an independent determinant of poor prognosis in NSCLC.

Multicenter Phase II Study Evaluating Two Cycles of Docetaxel, Cisplatin and Cetuximab as Induction Regimen Prior to Surgery in Chemotherapy-Naive Patients with NSCLC Stage IB-IIIA (INN06-Study)

Background

Different strategies for neoadjuvant chemotherapy in patients with early stage NSCLC have already been evaluated. The aim of this study was to evaluate the tolerability and efficacy of a chemoimmunotherapy when limited to two cycles.

Methods

Between 01/2007 and 03/2010 41 patients with primarily resectable NSCLC stage IB to IIIA were included. Treatment consisted of two cycles cisplatin (40 mg/m² d1+2) and docetaxel (75 mg/m² d1) q3 weeks, accompanied by the administration of cetuximab (400 mg/m² d1, then 250 mg weekly). The primary endpoint was radiological response according to RECIST.

Results

40 patients were evaluable for toxicity, 39 for response. The main grade 3/4 toxicities were: neutropenia 25%, leucopenia 11%, febrile neutropenia 6%, nausea 8% and rash 8%. 20 patients achieved a partial response, 17 a stable disease, 2 were not evaluable. 37 patients (95%) underwent surgery and in three of them a complete pathological response was achieved. At a median follow-up of 44.2 months, 41% of the patients had died, median progression-free survival was 22.5 months.

Conclusions

Two cycles of cisplatin/ docetaxel/ cetuximab showed promising efficacy in the neoadjuvant treatment of early-stage NSCLC and rapid operation was possible in 95% of patients. Toxicities were manageable and as expected.

Trial Registration

EU Clinical Trials Register; Eudract-Nr: 2006-004639-31

Evolution of induction chemotherapy for non-small cell lung cancer over the last 30 years: A surgical appraisal

BACKGROUND

Induction chemotherapy (ICT) is supposed to reduce the risk of micrometastatic progression and improve resectability of non-small cell lung cancer (NSCLC). However, best indications for ICT strategy remain unclear in published meta-analyses. Based on this observation, an evaluation of daily practice is of importance. Therefore, we reviewed indications and efficacy time trends in our 30-year series.

METHODS

A database including all patients with NSCLC who underwent surgical resection in two French centers from 1980 to 2009 (n = 5563) was prospectively set and retrospectively reviewed. The indications, clinical and pathologic response rates, and overall survival of ICT patients (n = 732) were analyzed during three successive time-periods: P1 from 1980 to 1989, P2 from 1990 to 1999, and P3 from 2000 to 2009.

RESULTS

The proportion of patients who benefited from ICT increased over time, from 2.8% (n = 35) in P1 to 12.5% (n = 274) in P2, and 20.2% (n = 423) in P3. Indications evolved over time with more N2 patients (n = 211; 49.8%) and less initially unresectable patients (n = 72; 17%) in P3. The clinical response rate between P1 and P2 increased. Five and 10-year survival rates of ICT patients were 35.2% and 21.5%, respectively. In multivariate analysis, time-period, age, type of resection, histology, and pathologic response to chemotherapy were significant prognostic factors.

CONCLUSIONS

Our report on the off-trial use of induction therapy during the last 30 years demonstrates an increased use of ICT, a progressive focus on N2 disease, and improved response rates.

Neoadjuvant chemotherapy in early-stage non-small cell lung cancer

Surgical resection followed by adjuvant chemotherapy is the standard of care for completely resected stages II and III non-small cell lung cancer (NSCLC) patients. In order to improve survival in patients with early-stage NSCLC, efforts have been focused on the use of chemotherapy and radiotherapy before surgery with the aim of reducing the risk of relapse. Neoadjuvant chemotherapy is an attractive treatment option which is employed in different tumors and may well be associated with certain advantages in NSCLC patients such as being effective in treating occult microscopic systemic disease, downstaging mediastinal lymph node and improving the success of surgery by tumor reduction. Furthermore, chemotherapy compliance prior to surgery is generally better than after surgery. The potential disadvantages are treatment-related toxicities and the delay of surgery. At present, neoadjuvant chemotherapy is still considered an experimental treatment modality in early-stage disease and its role should be more clearly defined.