Evolving Therapeutic Scenario of Stage III Non-Small-Cell Lung Cancer

Lung cancer remains the leading cause of cancer-related death with an incidence that continues to increase in both sexes and all ages. However, 80% to 90% of lung cancers are non-small cell lung cancer (NSCLC) and the remaining 10% to 20% are small cell lung cancer. Adenocarcinoma is the most common histologic subtype of lung cancer worldwide. More frequently, lung cancer diagnosis is made in advanced stages. Stage III NSCLC refers to locoregionally advanced disease without metastases and represents about 30% NSCLC cases. Despite the absence of metastases at diagnosis, the outcome is generally poor. Stage III comprises a heterogeneous group and optimal management requires the input of a multidisciplinary team. All modalities of oncologic treatment are involved: surgery, chemotherapy, radiotherapy, and more recently, immunotherapy and targeted therapy. We will discuss the different therapeutic options in stage III NSCLC, both in operable and inoperable scenarios, and the role of immunotherapy and targeted therapy.

Oncological advantage of nonintubated thoracic surgery: Better compliance of adjuvant treatment after lung lobectomy

BACKGROUND

Video-assisted thoracoscopic (VATS) surgery contributes to improved survival, adjuvant chemotherapy delivery and less postoperative complications. Nonintubated thoracic surgery (NITS) VATS procedures improves immunological responses in lung cancer patients; however, there is no data regarding adjuvant chemotherapy delivery effectiveness following NITS lobectomies. In this study, we aimed to compare protocol compliance and toxic complications during adjuvant chemotherapy after intubated and nonintubated VATS lobectomies in non-small cell lung cancer (NSCLC).

METHODS

We retrospectively reviewed the medical records of 66, stage IB-IIIB NSCLC patients who underwent intubated or nonintubated VATS lobectomy and received adjuvant chemotherapy.

RESULTS

A total of 38 patients (17 males, mean age 64 years) underwent conventional VATS and 28 (7 males; mean age 63 years) uniportal VATS NITS. Both groups had comparable demographic data, preoperative pulmonary function, and Eastern Cooperative Oncology Group (ECOG) status. Among the intubated and nonintubated patients, 82% and 75% were diagnosed with adenocarcinoma, respectively. The incidence of adenocarcinoma and squamous cell carcinoma cases were similar in both groups; however, the pathological staging showed significant differences, as 5 (18%) nonintubated patients had stage IB lung cancer, compared with the intubated group (P = 0.01). Further distribution of stages was similar between the groups. We observed significant differences in chest tube duration and operation time in the nonintubated group (P < 0.01). Among nonintubated patients, 92% completed the planned chemotherapy protocol, compared to 71% of the intubated group (P = 0.035). Grade 1/2 toxicity occurred significantly more often in the intubated group (16% vs. 0%, P = 0.03) and there was a lower incidence of grade 4 neutropenia in the nonintubated group (0% vs. 16%, P = 0.03).

CONCLUSIONS

Our results showed that the nonintubated procedure resulted in improved adjuvant chemotherapy compliance and lower toxicity rates after lobectomy.

KEY POINTS

SIGNIFICANT FINDINGS OF THE STUDY: Oncological advantage of the non-intubated thoracic surgery: better compliance with therapy protocol. What this study adds NITS lobectomies contribute to better administration of adjuvant chemotherapy with the planned cycle number and dosage.

Validation of the 12-gene Predictive Signature for Adjuvant Chemotherapy Response in Lung Cancer

PURPOSE

Response to adjuvant chemotherapy after tumor resection varies widely among patients with non-small cell lung cancer (NSCLC); therefore, it is of clinical importance to prospectively predict who will benefit from adjuvant chemotherapy before starting the treatment. The goal of this study is to validate a 12-gene adjuvant chemotherapy predictive signature developed from a previous study using a clinical-grade assay.

EXPERIMENTAL DESIGN

We developed a clinical-grade assay for formalin-fixed, paraffin-embedded (FFPE) samples using the NanoString nCounter platform to measure the mRNA expression of the previously published 12-gene set. The predictive performance was validated in a cohort of 207 patients with early-stage resected NSCLC with matched propensity score of adjuvant chemotherapy.

RESULTS

The effects of adjuvant chemotherapy were significantly different in patients from the predicted adjuvant chemotherapy benefit group and those in the predicted adjuvant chemotherapy nonbenefit group (P = 0.0056 for interaction between predicted risk group and adjuvant chemotherapy). Specifically, in the predicted adjuvant chemotherapy benefit group, the patients receiving adjuvant chemotherapy had significant recurrence-free survival (RFS) benefit (HR = 0.34; P = 0.016; adjuvant chemotherapy vs. nonadjuvant chemotherapy), while in the predicted adjuvant chemotherapy nonbenefit group, the patients receiving adjuvant chemotherapy actually had worse RFS (HR = 1.86; P = 0.14; adjuvant chemotherapy vs. nonadjuvant chemotherapy) than those who did not receive adjuvant chemotherapy.

CONCLUSIONS

This study validated that the 12-gene signature and the FFPE-based clinical assay predict that patients whose resected lung adenocarcinomas exhibit an adjuvant chemotherapy benefit gene expression pattern and who then receive adjuvant chemotherapy have significant survival advantage compared with patients whose tumors exhibit the benefit pattern but do not receive adjuvant chemotherapy.

Collagen gel droplet-embedded culture drug sensitivity test for adjuvant chemotherapy after complete resection of non-small-cell lung cancer

PURPOSE

We conducted a prospective clinical study to individualize adjuvant chemotherapy after complete resection of non-small-cell lung cancer (NSCLC), based on the drug sensitivity test.

METHODS

Patients with resectable c-stage IB-IIIA NSCLC were registered between 2005 and 2010. We performed the collagen gel droplet-embedded culture drug sensitivity test (CD-DST) on a fresh surgical specimen to assess in vitro chemosensitivity and evaluated the prognostic outcome after adjuvant chemotherapy with carboplatin/paclitaxel based on the CD-DST.

RESULTS

Among 92 registered patients, 87 were eligible for inclusion in the analysis. The success rate of CD-DST was 86% and chemosensitivity to carboplatin and/or paclitaxel was evident in 57 (76%) of the 75 patients. Adjuvant chemotherapy was completed in 22 (73%) of 30 patients. The 5-year overall survival rates were 71, 73, and 75% for all, CD-DST success, and chemosensitive patients, respectively. The 5-year disease-free survival and overall survival rates of the chemosensitive patients who completed adjuvant chemotherapy using carboplatin/paclitaxel were 68 and 82%, respectively. The 5-year disease-free survival and overall survival rates of the patients with stage II-IIIA chemosensitive NSCLC were 58 and 75%, respectively. Comparative analyses of the chemosensitive and non-chemosensitive/CD-DST failure groups showed no significant survival difference.

CONCLUSIONS

CD-DST can be used to evaluate chemosensitivity after lung cancer surgery; however, its clinical efficacy for assessing individualized treatment remains uncertain.

Adjuvant immunotherapy for non-small cell lung cancer

Non-small cell lung cancer (NSCLC) is the biggest cancer killer in the United States and worldwide. In 2011, there are estimated to be 221,130 new cases of lung cancer in the United States. Over a million people will die of lung cancer worldwide this year alone. When possible, surgery to remove the tumor is the best treatment strategy for patients with NSCLC. However, even with adjuvant (postoperative) chemotherapy and radiation, more than 40% of patients will develop recurrences locally or systemically and ultimately succumb to their disease. Thus, there is an urgent need for developing superior approaches to treat patients who undergo surgery for NSCLC to eliminate residual disease that is likely responsible for these recurrences. Our group and others have been interested in using immunotherapy to augment the efficacy of current treatment strategies. Immunotherapy is very effective against minimal disease burden and small deposits of tumor cells that are accessible by the circulating immune cells. Therefore, this strategy may be ideally suited as an adjunct to surgery to seek and destroy microscopic tumor deposits that remain after surgery. This review describes the mechanistic underpinnings of immunotherapy and how it is currently being used to target residual disease and prevent postoperative recurrences after pulmonary resection in NSCLC.

Prognostic value and therapeutic consequences of vascular invasion in non-small cell lung carcinoma

The prognostic relevance of blood vessel invasion (BVI) in non-small cell lung carcinoma (NSCLC) remains controversial, as is the question of whether its finding should influence therapeutic decisions after an R0 resection. One hundred and twelve cases of NSCLC were included in the study. All had been treated by potentially curative surgical resection of the primary tumor and systematic lymphadenectomy. In all cases, lymphatic metastatic spread was at its earliest stage and only one regional lymph node was involved, 27.0+/-8.9 nodes per patient being examined histologically. Most of the cases were pT2 (75.9%) and pN1 (81.3%), and all were MX/M0 and R0. 62.5% were at stage IIB, 25.9% at stage IIIA, and 9.8% at stage IIA. BVI was found in 45.5% of the tumors (V1), and 18.8% exhibited both lymphatic invasion and BVI (L1V1). Local recurrence occurred in 10.7% of the patients, distant metastasis in 24.1%, and both forms of tumor progression simultaneously in a further 7.1%. Thus 31.2% of the patients developed distant metastases by hematogenous spread (to the brain, bones, lung, adrenal, and liver, in descending order of frequency), mostly within two years of surgery. Late metastasis is not typical of NSCLC. Adenocarcinomas showed a strong tendency to be associated with a poorer prognosis than squamous cell carcinomas, probably because of their more frequent involvement of blood vessels. Five-year survival (Kaplan-Meier method) was significantly lower in V1 cases (37.2%) than in V0 cases (56.0%; p = 0.0249). Adjuvant mediastinal radiation in node-positive cases of NSCLC may prevent local recurrence but is unlikely to influence the development of distant metastases. The histological detection of BVI is of prognostic relevance and should be considered for inclusion in the staging criteria and indications for adjuvant chemotherapy.

Expression of excision repair cross-complementation group 1 and class III beta-tubulin predict survival after chemotherapy for completely resected non-small cell lung cancer

In this study, we examined the expression of excision repair cross-complementation group 1 (ERCC1) protein in 90 completely resected lung cancer samples from patients who received adjuvant or neo-adjuvant platinum-based chemotherapy. Epidermal growth factor receptor (EGFR) was also studied in these samples. We also examined class III beta-tubulin protein expression in 50 patients treated with a platinum-based drug plus paclitaxel. Among 90 patients treated with platinum-based chemotherapy, the loss of ERCC1 protein expression was associated with a better prognosis (p=0.0068). The effect of ERCC1 expression on survival was not seen in a separate set of 59 patients who underwent curative resection but did not receive adjuvant chemotherapy. Among 50 patients treated with a platinum-based drug plus paclitaxel, loss of class III beta-tubulin protein expression was also associated with a better prognosis (p=0.0303). When combined, patients with a tumor that was negative for both ERCC1 and class III beta-tubulin had a significantly longer overall survival than those with a tumor that expressed either ERCC1 or class III beta-tubulin (p=0.0230). There was no relationship between the presence of an EGFR mutation and the patients' survival after the platinum-based chemotherapy. In conclusion, we found that the loss of ERCC1 and class III beta-tubulin protein expression were predictors of better survival in patients who received a platinum-based plus taxane chemotherapy.

Excision Repair Cross-Complementation Group 1 Enzyme as a Molecular Determinant of Responsiveness to Platinum-Based Chemotherapy for non Small-Cell Lung Cancer

Although platinum-based chemotherapy remains the “standard” in advanced non small-cell lung cancer, not all patients derive clinical benefit from such a treatment. Hence, the development of predictive biomarkers able to identify lung cancer patients who are most likely to benefit from cisplatin-based chemotherapy has become a scientific priority. Among the molecular pathways involved in DNA damage control after chemotherapy, the nucleotide excision repair (NER) is a critical process for the repair of DNA damage caused by cisplatin-induced DNA adducts. Many reports have explored the role of the excision repair cross-complementation group 1 enzyme (ERCC1) expression in the repair mechanism of cisplatin-induced DNA adducts in cancer cells.

Using immunohistochemistry in resected tumors from patients included in the International Adjuvant Lung Cancer Trial, the study of important biomarkers showed that high ERCC1 protein expression was associated with improved survival in chemo-naïve patients. On the contrary, the benefit of adjuvant cisplatin-based chemotherapy was more profound in patients with low ERCC1 expression. In a prospective cohort studying mRNA expression in tumor biopsies from patients receiving customized therapy with cisplatin and gemcitabine depending on the molecular profile of the tumour, results showed that patients with low ERCC1 mRNA expression had a longer median survival compared to those with high expression. These data suggest the potent use of ERCC1 as a molecular predictor of clinical resistance to platinum-based chemotherapy in the adjuvant setting of NSCLC. Nevertheless, optimization of methodology, including standardization of technical procedures, as well as validation of ERCC1 protein expression in large prospective cohorts, seem necessary before any routine immunohistochemical validation of ERCC1 can be implemented in daily practice.

[How to treat the relapse of NSCLC after surgery and chemotherapy? IFTC 0702 randomized phase III study]

BACKGROUND

As chemotherapy gains wider acceptance for the treatment of earlier stages of NSCLC, particularly in the adjuvant and neoadjuvant setting, physicians face a growing population of high performance status patients who have relapsed after their first-line chemotherapy. The type of second-line chemotherapy after initial adjuvant or neoadjuvant treatment with a platinum-based regimen remains largely undefined. The current study has been designed to compare the classical mono chemotherapy docetaxel with a docetaxel cisplatin doublet.

METHODS

Patients will be randomized in 2 arms. Arm: docetaxel cisplatin (cycles repeated every 21 days), 4 cycles followed by 2 cycles of docetaxel alone in case of objective response or stabilisation. Arm B: docetaxel alone (cycles repeated every 21 days), 4 cycles followed by 2 cycles of docetaxel alone in case of objective response or stabilisation.

EXPECTED RESULTS

300 patients will be randomized with a statistical hypothesis of a progression free survival of 3 months in the control arm and of 4.5 months in the experimental arm.

Clinical significance of aminopeptidase N in non-small cell lung cancer

PURPOSE

The aim of our study is to investigate the mechanism of metastasis, to detect novel metastasis-associated molecules, and to evaluate the molecules from the point of view of clinical application. A monoclonal antibody MH8-11, which we established, recognizes a glycoprotein that is identical to aminopeptidase N (APN/CD13). APN/CD13 degrades the extracellular matrix, while it is also involved in cell motility and improves angiogenesis.

EXPERIMENTAL DESIGN

We investigated the expression of APN/CD13 in 194 cases of non-small cell lung cancer (NSCLC) by immunohistochemical analyses and reverse transcription-PCR assay to determine the significance of this prognostic factor; 95 tumors were stage I, 36 were stage II, 39 were stage IIIA, and 24 were stage IIIB. Moreover, we investigated that the relationship between the expression of APN/CD13 and angiogenesis and prognosis for patients with NSCLC.

RESULTS

We found a correlation between the expression of APN/CD13 and angiogenesis (r = 0.659; P < 0.0001). In the 194 patients with NSCLC, we found 68 patients to be APN/CD13+ and 126 patients to be APN/CD13-. The 5-year survival rate in patients with APN/CD13+ tumors was significantly lower than in those whose tumors had negative APN/CD13 (48.3% versus 67.1%; P = 0.0001).

CONCLUSION

Our data suggest the expression of APN/CD13 for patients with NSCLC to be associated with a poor prognosis and angiogenesis. This is the first study to show the relationship between the expression of APN/CD13 and the prognosis of patients with NSCLC. The inhibition of APN/CD13 may be an effective new molecular target therapy for patients with NSCLC.

Fluorodeoxyglucose uptake of primary non-small cell lung cancer at positron emission tomography: new contrary data on prognostic role

PURPOSE

This prospective study evaluated the prognostic significance of (18)F-fluorodeoxyglucose ((18)F-FDG) uptake in primary non-small cell lung cancer (NSCLC) at positron emission tomography, in a carefully staged population, while correcting for partial volume effects.

EXPERIMENTAL DESIGN

Two hundred eight potentially resectable NSCLC patients were referred for FDG positron emission tomography staging after thoracic computed tomography. Each tumor stage was confirmed surgically, or for some stage IV tumors by additional imaging. The tumor maximum pixel-standardized uptake value (maxSUV) and the maxSUV partial volume corrected for lesion size (PVCmaxSUV) were compared with overall survival and disease-free survival using Cox proportional hazards regression.

RESULTS

Stage distribution: stage I, 36%; stage II, 15%; stage III, 30%; stage IV, 19%. Patients were followed for a median of 33.6 months, with 90 deaths from NSCLC (median survival for all stages, 43.3 months). With respect to overall survival, the most significant cutoff value for both maxSUV and PVCmaxSUV was 7. MaxSUV > or =7 was significantly associated with an increased risk of death from NSCLC in univariable analysis, whereas PVCmaxSUV > or =7 was only marginally associated. However, in multivariable analyses, neither maxSUV > or =7 nor PVCmaxSUV > or =7 provided significant additional prognostic information over stage, tumor size, and age. In the 103 patients who underwent surgical resection only, surgical stage, but not maxSUV or PVCmaxSUV, was univariably associated with survival or recurrence. SUV definitions based on lean body mass, body surface area, and plasma glucose correction yielded identical results.

CONCLUSIONS

As expected, tumor stage is prognostic in NSCLC. However, tumor FDG uptake does not provide additional prognostic information. This prospective study contradicts prior reports.

Adjuvant chemotherapy for non-small cell lung cancer: the new standard of care

Despite optimal surgical therapy for non-small cell lung cancer, approximately 50% of people ultimately die from recurrent disease. Clinical trials in the 1990s suggested a marginal survival advantage associated with adjuvant chemotherapy; however, as the benefit was relatively small and the chemotherapies were not well tolerated, adjuvant chemotherapy was not widely accepted. Over the past 3 years, several large randomized Phase III trials using modern platinum-based doublet regimens in selected patient populations have demonstrated significant survival advantages associated with adjuvant chemotherapy. The recent publication of the JBR10 study clearly exemplifies why this approach is now considered the standard of care for patients with operable non-small cell lung cancer.

Promoter hypermethylation for molecular nodal staging in non-small cell lung cancer

CONTEXT

Even among cases of non-small cell lung cancer (NSCLC) in the most favorable stage (IA), the disease-specific mortality is 25% or greater. One plausible explanation implicates the simplistic standard pathologic procedures used to designate lymph node involvement. A more sensitive assessment of the nodal status may improve staging.

OBJECTIVE

To determine the prognostic impact of detecting an abnormal molecular event (promoter hypermethylation in a set of relevant genes) in histologically uninvolved lymph nodes in resected NSCLC.

DESIGN

In this retrospective analysis of archived material, we examined DNA extracted from lymph nodes of stage I NSCLC (n = 180). Patients underwent surgery between 1991 and 1995 in a single institution. Methylation-specific polymerase chain reaction was used to detect promoter hypermethylation in a panel of 8 genes. Survival data were extracted from the computerized database at the Tumor Registry.

RESULTS

Evidence of promoter hypermethylation in at least 1 gene was detected in 67% of these N0 nodes. The most commonly hypermethylated gene was E-cadherin (53%). The hypermethylation frequency for the remaining genes were as follows: APC, 5%; p16, 9%; MGMT, 11%; hMLH1, 15%; RASSF1A, 4%; DAP kinase, 9%; and ATM, 19%. The presence of promoter hypermethylation in 2 or more genes did not influence the overall, median, or 5-year survival rates.

CONCLUSIONS

Identifying promoter hypermethylation (in our panel) in N0 lymph nodes in stage I NSCLC cannot be recommended for clinical decision making. Molecular abnormalities, including those found in cancer by qualitative methylation-specific polymerase chain reaction, are not synonymous with established, histologically detectable metastasis.

Impact of Elastic Staining on the Staging of Peripheral Lung Cancers

Accurate staging of lung cancer has a profound impact on patient management. For stage I nonsmall cell lung carcinomas (NSCLCs), the absence (stage IA) or presence (stage IB) of visceral pleural invasion represents a critical therapeutic branch point: patients with stage IB NSCLC benefit from adjuvant chemotherapy, whereas patients with stage IA NSCLC do not. Elastic staining has been advocated as a simple method for visualizing pleural invasion. The purpose of this study was to determine whether routine elastic staining of the resected peripheral NSCLCs alters tumor staging in a meaningful way. The study cases consisted of 100 consecutive peripheral NSCLCs resections that were pathologically staged as IA based on routine histologic assessment. Each case was stained with the Movats pentachrome elastic stain to aid identification of visceral pleural invasion. To assess current standards of surgical pathology practice, members of the American Association of Directors of Anatomic and Surgical Pathology were asked whether they never, sometimes, or always order elastic stains for peripheral NSCLCs that abut the pleura. Elastic staining resulted in a change of tumor stage from IA to IB in 19 (19%) cases. Of the 49 pathologists that responded to the survey, 25 (51%) never, 14 (29%) sometimes, and 10 (20%) always order an elastic stain for NSCLCs abutting the pleura. Elastic staining is currently not standard surgical pathology practice for the evaluation of peripheral NSCLCs, but it should be. Invasion of the pleura is an elusive finding that is best appreciated with an elastic stain. Our experience suggests that routine elastic tissue staining should be performed as a standard method of assessing pleural involvement for pleural-based nonsmall cell lung carcinomas.

Lung Cancer in the Elderly

Purpose

Elderly patients often have comorbidities and other characteristics that make the selection of treatment daunting.

Methods

We have reviewed the available evidence in the literature to gauge the results of therapy for elderly lung cancer patients.

Results

The beneficial results achieved with adjuvant chemotherapy in the general population with early non–small-cell lung cancer (NSCLC) cannot be automatically extrapolated to the elderly, who are at higher risk of toxicity. Retrospective analyses of combined chemoradiotherapy in locally advanced NSCLC patients suggest equivalent therapeutic benefit for younger and older patients, despite heightened toxicity. There have been no elderly-specific phase III trials for locally advanced NSCLC. For advanced NSCLC, on the basis of evidence-based data, single-agent chemotherapy remains the standard of care for nonselected elderly patients. However, retrospective analyses suggest that the efficacy of platinum-based combination chemotherapy is similar in fit older and younger patients, with increased but acceptable toxicity for elderly patients. In limited-disease small-cell lung cancer (SCLC), sequential chemoradiotherapy is clearly less toxic compared with a standard concurrent approach, but our assessment of treatment is hindered by the absence of prospective elderly-specific trials. Although prophylactic cranial irradiation has emerged as a standard strategy, it should be omitted in patients with cognitive impairment. In extensive SCLC, etoposide in combination with either cisplatin or carboplatin has emerged as standard treatment; hematopoietic support may be necessary.

Conclusion

With the exception of advanced NSCLC, prospective elderly-specific studies are lacking. Available data suggest that outcomes in the fit elderly mirror results observed in younger patients, although toxicity is generally worse.

Adjuvant chemotherapy in elderly patients with non-small-cell lung cancer

BACKGROUND

More than two thirds of patients who die of lung cancer in the United States are over 65 years of age. More than 50% of lung cancer patients are diagnosed over the age of 65 and about 30% over the age of 70.

METHODS

The authors review recent data from large randomized trials on adjuvant chemotherapy in patients with NSCLC. They discuss age-related changes in organ function, comorbidities and frailty in the elderly, and chemotherapy treatment in elderly patients with NSCLC.

RESULTS

Randomized trials suggest that postoperative chemotherapy improves survival after surgery in patients with stage IB to IIIA NSCLC, and awareness of the efficacy of this approach is growing in the scientific community. Clinical data obtained in the young population cannot be automatically adopted in the elderly counterpart. Elderly patients tolerate chemotherapy poorly because of comorbidity and organ failure, and after lung surgery they are considered at higher risk of chemotherapy-induced toxicity. The survival benefit obtained with platin-based chemotherapy may vanish or decrease in the elderly due to a potential higher toxic death rate or lower compliance to treatment.

CONCLUSIONS

Modified schedules or attenuated dose of platin-containing chemotherapy should be investigated in the adjuvant setting by specifically designed trials. Specifically designed prospective trials are needed to elucidate the role of this approach in the elderly.

Optimal Adjuvant Therapy for Non‐Small Cell Lung Cancer—How to Handle Stage I Disease

The standard of care for resected stage II-IIIA non-small cell lung cancer (NSCLC) now includes adjuvant chemotherapy based on the results of three phase III studies using cisplatin-based regimens--the International Adjuvant Lung Trial, the National Cancer Institute of Canada JBR.10 trial, and the Adjuvant Navelbine International Trialist Association trial. The role of adjuvant chemotherapy for stage I disease remains controversial. A recent meta-analysis (the Lung Adjuvant Cisplatin Evaluation) showed potential harm with the addition of adjuvant cisplatin for stage IA disease and no survival benefit for this modality in stage IB disease. Updated results from the Cancer and Leukemia Group B 9633 trial, the only trial to focus exclusively on stage IB patients, no longer show a statistically significant survival benefit from adjuvant chemotherapy in this population, except for the subgroup of patients with larger tumors. It may be that trials have been underpowered to detect a small benefit for patients with stage IB disease, or there may really not be benefit to adding adjuvant therapy for this stage of disease. Additional markers, such as tumor size or the presence or absence of certain tumor proteins like ERCC1, may help to determine which patients with resected stage I NSCLC may benefit from adjuvant chemotherapy. Strategies such as inhibition of angiogenesis pathways and the epidermal growth factor receptor are under exploration.

Matrix Metalloproteinase Polymorphisms and Survival in Stage I Non–Small Cell Lung Cancer

PURPOSE

The matrix metalloproteinases (MMP) are a family of enzymes that can degrade extracellular matrix and facilitate invasion through the basement membrane. Several polymorphisms in MMP-1, MMP-2, MMP-3, and MMP-12 have been described, some of which lead to differential transcription. We hypothesized that polymorphisms in these MMP genes may be associated with survival outcomes in early-stage non-small cell lung cancer (NSCLC).

EXPERIMENTAL DESIGN

We evaluated the relationship between MMP-1, MMP-2, MMP-3, and MMP-12 polymorphisms and both recurrence-free survival (RFS) and overall survival (OS) among 382 patients with stage I NSCLC. Analyses of genotype associations with survival outcomes were done using Cox proportional hazards models and Kaplan-Meier methods and the log-rank test.

RESULTS

Patients carrying the variant G allele of the MMP-12 1082A/G polymorphism had significantly worse outcomes [crude hazard ratio (HR) for OS 1.74; 95% confidence interval (95% CI), 1.18-2.58, P=0.006; crude HR for RFS, 1.53; 95% CI, 1.05-2.23, P=0.03]. After adjusting for age, sex, stage, pack-years of smoking, and histologic subtype, the MMP-12 1082A/G polymorphism remained significantly associated with survival outcomes [adjusted HR (AHR) for OS, 1.94; 95% CI, 1.28-2.97, P=0.002; AHR for RFS, 1.61; 95% CI, 1.07-2.41, P=0.02]. None of the other MMP polymorphisms was significantly associated with survival.

CONCLUSIONS

Our results show that patients with stage I NSCLC carrying the variant G allele of the MMP-12 1082A/G polymorphism have worse survival.

Adjuvant chemotherapy in the elderly: whom to treat, what regimen?

As the elderly population continues to grow, adjuvant chemotherapy treatment in the elderly is becoming an increasingly important issue for the practicing oncologist. Decisions regarding adjuvant treatment involve a careful assessment of the risk for recurrent disease and side effects from treatment, balancing these risks against the beneficial effects of treatment. In this review, we discuss methods for assessing the elderly patient in terms of life expectancy, comorbid disease, and functional capacity. This assessment can then be used to help identify appropriate candidates for adjuvant chemotherapy. Tools for estimating the risk for relapse and mortality and the reduction in these risks with various forms of treatment are useful for clarifying treatment options. Elderly patients have been underrepresented in clinical trials, and patients are often given less intense and possibly inferior standard treatment as a function of age. Ongoing clinical trials targeting the elderly patient may help answer questions about the relative risks and benefits of adjuvant treatment in this age group. Recent data show that most fit elderly patients derive a benefit from standard adjuvant chemotherapy regimens that is equal to that of younger patients.

Cancer and Leukemia Group B Surgery Committee

Surgeons play a vital role in the Cancer and Leukemia Group B by providing patients and specimens for studies of the common solid tumors, and more recently, by serving as investigators who conduct surgically focused research protocols and contribute to the correlative science studies in the Group. Surgical activities encompass thoracic, gastrointestinal, breast, and genitourinary cancers and melanoma. Surgical quality assurance is also an important focus. This article will describe the development and importance of a robust and vigorous surgical component to a strong cooperative group and highlight the many trials conducted by the Cancer and Leukemia Group B surgeons and their contributions to advancement of the care of the patient with solid organ malignancy.

End Points for Adjuvant Therapy Trials: Has the Time Come to Accept Disease‐Free Survival as a Surrogate End Point for Overall Survival?

The intent of adjuvant therapy is to eradicate micro-metastatic residual disease following curative resection with the goal of preventing or delaying recurrence. The time-honored standard for demonstrating efficacy of new adjuvant therapies is an improvement in overall survival (OS). This typically requires phase III trials of large sample size with lengthy follow-up. With the intent of reducing the cost and time of completing such trials, there is considerable interest in developing alternative or surrogate end points. A surrogate end point may be employed as a substitute to directly assess the effects of an intervention on an already accepted clinical end point such as mortality. When used judiciously, surrogate end points can accelerate the evaluation of new therapies, resulting in the more timely dissemination of effective therapies to patients. The current review provides a perspective on the suitability and validity of disease-free survival (DFS) as an alternative end point for OS. Criteria for establishing surrogacy and the advantages and limitations associated with the use of DFS as a primary end point in adjuvant clinical trials and as the basis for approval of new adjuvant therapies are discussed.

Prognostic factors in non-small cell lung cancer surgery

AIMS

Complete surgical resection of primary tumours remains the treatment with the greatest likelihood for survival in early-stage non-small cell lung cancer (NSCLC). Although TNM stage is the most important prognostic parameter in NSCLC, additional parameters are required to explain the large variability in postoperative outcome. The present review aims at providing an overview of the currently known prognostic markers for postoperative outcome.

METHODS

We performed an electronic literature search on the MEDLINE database to identify relevant studies describing the risk factors in NSCLC surgery. The references reported in all the identified studies were used for completion of the literature search.

RESULTS

Poor pulmonary function, cardiovascular disease, male gender, advanced age, TNM stage, non-squamous cell histology, pneumonectomy, low hospital volume and little experience of the surgeon were identified as risk factors for postoperative outcome. However, with the exception of TNM stage and extent of resection, the literature demonstrates conflicting results on the prognostic power of most factors. The role of molecular biological factors, neoadjuvant treatment and adjuvant treatment is not well investigated yet.

CONCLUSIONS

The advantage of knowing about the existence of comorbidity and prognostic risk factors may provide the clinician with the ability to identify poor prognostic patients and establish the most appropriate treatment strategy. The assessment of prognostic factors remains an area of active investigation and a promising field of research in optimising therapy of NSCLC patients.

How Today's Developments in the Treatment of Non‐Small Cell Lung Cancer Will Change Tomorrow's Standards of Care

Cisplatin (Platinol; Bristol-Myers Squibb, Princeton, NJ, http://www.bms.com) and carboplatin (Paraplatin; Bristol-Myers Squibb), together with newer chemotherapies, such as docetaxel (Taxotere; Aventis Pharmaceuticals Inc., Bridgewater, NJ, http://www.aventispharma-us.com), paclitaxel (Taxol; Bristol-Myers Squibb), vinorelbine (Navelbine; GlaxoSmith-Kline, Philadelphia, http://www.gsk.com), pemetrexed (Alimta; Eli Lilly and Company, Indianapolis, http://www.lilly.com), and gemcitabine (Gemzar; Eli Lilly and Company), have improved treatment outcomes in both advanced non-small cell lung cancer (NSCLC) and in the adjuvant/neoadjuvant setting. Newer systemic treatments for NSCLC, used in advanced stage IV management, are beginning to be studied in earlier stages of the disease, when treatment is better tolerated and potentially curative. Hopefully, newer agents with proven efficacies in advanced disease will enhance curability. Following the successful addition of bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA, http://www.gene.com) to carboplatin/paclitaxel in advanced disease, bevacizumab is now being incorporated into adjuvant and neoadjuvant trials. Trials in stage IB-IIIA patients will study neoadjuvant docetaxel/cisplatin/bevacizumab. The discovery that patients with exon 19 and 21 mutations in the epidermal growth factor receptor gene EGFR have around an 80% response rate to gefitinib (Iressa; AstraZeneca Pharmaceuticals, Wilmington, DE, http:// www.astrazeneca-us.com) and that this response confers survival benefit indicates its potential utility for mutation-positive patients with advanced- and earlier-stage disease. Clinical characteristics, such as never smoking status and adenocarcinoma, and especially bronchioloalveolar carcinoma histological features, can also identify individuals likely to respond to EGFR tyrosine kinase inhibitors. Studies of neoadjuvant erlotinib (Tarceva; OSI Pharmaceuticals, Inc., Melville, NY, http://www.osip.com) in operable NSCLC are planned. One such study includes cisplatin and docetaxel. Effective development of active agents and disease management based on molecular profiling of lung tumors will change tomorrow's standard of care.

Adjuvant chemotherapy for non-small cell lung cancer: contribution of the International Adjuvant Lung Trial

The recently reported International Adjuvant Lung Cancer Trial (IALT) was designed to assess the potential benefit of three to four cycles of adjuvant cisplatin-based chemotherapy after complete resection of non-small cell lung cancer (NSCLC). Each center predetermined the cisplatin dose (total 300-400 mg/m(2)), the combined drug (etoposide or a Vinca alkaloid), and the radiotherapy policy. From 1995 to 2000, 1,867 patients were randomized in 148 centers from 33 countries. On September 1, 2002, median follow-up was 56 months and >98% of patients had an updated follow-up. Overall survival was significantly different between the two arms: 5-year survival rate was 44.5% in the chemotherapy arm versus 40.4% in the control arm [relative risk = 0.86 (0.76-0.98), P < 0.03]. Disease-free survival, incidence of local recurrence, and incidence of distant metastases (but not brain metastases) were likewise significantly different, with an advantage for the chemotherapy arm. We concluded that adjuvant cisplatin-based chemotherapy in resected NSCLC should become part of the standard management of operable NSCLC. Two other recently reported randomized prospective studies also showed a significant benefit for postoperative platin-based doublets in stage IB and II NSCLC and confirmed the role of adjuvant chemotherapy as part of the treatment of these patients. The Lung Adjuvant Cisplatin Evaluation program, a pooled analysis of all recent platin-based adjuvant trials, and the IALT-Bio study, which will investigate over 30 markers in the IALT patients' specimens, should allow us to better define the populations more likely to benefit from postoperative chemotherapy.

Prognostic implications of cell cycle, apoptosis, and angiogenesis biomarkers in non-small cell lung cancer: a review

Lung cancer is the leading cause of cancer death in the U.S. with survival restricted to a subset of those patients able to undergo surgical resection. However, even with surgery, recurrence rates range from 30% to 60%, depending on the pathologic stage. With the advent of partially effective, but potentially toxic adjuvant chemotherapy, it has become increasingly important to discover biomarkers that will identify those patients who have the highest likelihood of recurrence and who thus might benefit most from adjuvant chemotherapy. Hundreds of papers have appeared over the past several decades proposing a variety of molecular markers or proteins that may have prognostic significance in non-small cell lung cancer. This review analyzes the largest and most rigorous of these studies with the aim of compiling the most important prognostic markers in early stage non-small cell lung cancer. In this review, we focused on biomarkers primarily involved in one of three major pathways: cell cycle regulation, apoptosis, and angiogenesis. Although no single marker has yet been shown to be perfect in predicting patient outcome, a profile based on the best of these markers may prove useful in directing patient therapy. The markers with the strongest evidence as independent predictors of patient outcome include cyclin E, cyclin B1, p21, p27, p16, survivin, collagen XVIII, and vascular endothelial cell growth factor.

Phase I trial of the matrix metalloproteinase inhibitor marimastat combined with carboplatin and paclitaxel in patients with advanced non-small cell lung cancer

PURPOSE

Marimastat is an orally bioavailable inhibitor of matrix metalloproteinases. A phase I study was initiated to determine whether conventional doses of carboplatin and paclitaxel are tolerated when combined with marimastat and to assess the influence of marimastat on paclitaxel pharmacokinetics.

EXPERIMENTAL DESIGN

Three dose levels were evaluated. Marimastat (10 or 20 mg oral administration b.i.d.) was administered continuously with paclitaxel (175 or 200 mg/m(2) as a 3-hour i.v. infusion) and carboplatin (at a dose providing an area under the free drug plasma concentration-time curve of 7 mg min/mL) administered each 3 weeks. Toxicity and response were evaluated throughout the intended four cycles of combined therapy. The plasma pharmacokinetics of paclitaxel was determined in each patient both without concurrent marimastat and after receiving marimastat for 1 week.

RESULTS

Twenty-two chemotherapy-naive patients with stage IIIb (27%) or stage IV (73%) non-small cell lung cancer were enrolled. Their median age was 56 years (range, 39-73 years), 50% were female, and their performance status (Eastern Cooperative Oncology Group) ranged from 0 to 2. Treatment was well tolerated, as 18 (82%) of the patients completed all four cycles of chemotherapy without dose-limiting toxicity. Grade 2 musculoskeletal toxicities were reported in 3 of 12 patients receiving marimastat (20 mg b.i.d.). Nine patients required dose reductions, predominantly related to low-grade myelosuppression. Partial responses occurred in 12 of 21 (57%) evaluable patients with disease stabilization in another 5 (19%). Marimastat had no effect on paclitaxel pharmacokinetics.

CONCLUSIONS

The administration of marimastat (10 mg b.i.d.) with paclitaxel (200 mg/m(2)) and carboplatin at an area under the free drug plasma concentration-time curve of 7 mg min/mL was well tolerated with no apparent pharmacokinetic interaction. Study of this drug combination in the adjuvant setting should be considered if tissue inhibition of matrix metalloproteinase activity can first be shown.

Localized Non-Small Cell Lung Cancer: Adjuvant Radiotherapy in the Era of Effective Systemic Therapy

Investigators in Europe, Canada, and the United States recently established a definitive role for adjuvant systemic chemotherapy following resection of early-stage non-small cell lung cancer (NSCLC). This was no small accomplishment, as upward of 20 randomized trials had previously been conducted. The role of postoperative radiotherapy (PORT) has been studied with far less vigor in the modern era. A 1998 meta-analysis of randomized trials suggesting that PORT was detrimental to survival included studies of doubtful quality. The value of PORT should be considered in the same context as recent chemotherapy trials. Advances in imaging have improved the accuracy of staging, patient selection, and target definition. Modern dosimetry and accelerator technologies have advanced the capacity to deliver radiation to the target with less tissue toxicity. Evolving philosophies in dosing and fractionation should improve the therapeutic ratio. Finally, it is reasonable to assume that the importance of local control will be enhanced in the setting of better systemic therapies. We will review the data on PORT and address critical issues in the design of trials to assess the role of modern radiotherapy in the integrated approach to management of early-stage NSCLC.

Patient Subsets Benefiting from Adjuvant Therapy Following Surgical Resection of Non-Small Cell Lung Cancer

Adjuvant chemotherapy is the standard of therapy for some patients with stages I, II, and III breast and colon cancer. The therapeutic efficacy of adjuvant chemotherapy following surgical resection of early stage non-small cell lung cancer (NSCLC) has been less clear. A meta-analysis was reported in 1995 of patients who underwent surgical resection for early stage NSCLC and were then randomized to either observation or chemotherapy. This meta-analysis showed a 13% reduction in the hazard ratio of death, leading to a 5% absolute improvement in survival 5 years after the start of adjuvant cisplatin-based chemotherapy treatment compared with observation only. Multiple prospective randomized trials for patients with NSCLC were planned and undertaken to attempt to validate the observations of the meta-analysis. Six trials with > or =150 patients with early stage NSCLC (stages I-IIIA) on each arm have been reported in the last 2 years. Four of the six trials show a survival advantage for the patients with early stage NSCLC treated with adjuvant chemotherapy compared with those who underwent observation. The survival benefit in these four studies varies from a 4% to a 16% survival advantage at 4 to 5 years after the start of chemotherapy. The hazard ratio of death for the patients treated with chemotherapy ranged from 0.61 to 0.86 compared with patients on observation. Thus, the information available at the current time supports the administration of chemotherapy for patients with stages IB and II NSCLC. Further research will be needed to define the role of adjuvant chemotherapy and its use in conjunction with chest radiotherapy for the treatment of patients with resected stages IA and IIIA NSCLC.

The Role of Targeted Agents in Adjuvant Therapy for Non-Small Cell Lung Cancer

The recent survival benefit of adjuvant chemotherapy in early stage non-small cell lung cancer provides optimism for the future success of targeted therapy in this setting. It is important that we begin to explore molecularly targeted agents in the adjuvant arena, but how best to accomplish this in the face of these new findings presents a challenge. Criteria for selecting promising targeted therapies and optimal trial designs to evaluate them expeditiously in the adjuvant setting are clearly needed.

Sequential Platinum-Based Chemotherapy-Thoracic Radiotherapy in Early Stage Non-Small Cell Lung Cancer

Combined chemoradiotherapy (CTRT) is intended to reduce the risk of local regional recurrence and distant relapse in patients with early stage non-small cell lung cancer (NSCLC). Sequential CTRT allows full doses of each modality while avoiding the additive toxicity that occurs with concurrent therapy. This review will encompass studies in the three main settings where sequential CTRT has been applied in early stage NSCLC: as adjuvant therapy after resection, as neoadjuvant chemotherapy and surgery followed by radiotherapy, and in unresectable stage III disease.

The ALPI Trial: The Italian/European Experience with Adjuvant Chemotherapy in Resectable Non-Small Lung Cancer

Postoperative treatments for lung cancer have been evaluated for more than two decades, but in the majority of the studies no significant and clinically meaningful effect on survival has been shown. In 1995, a meta-analysis of eight cisplatin-based adjuvant chemotherapy trials in 1,394 patients with non-small cell lung cancer showed a 13% reduction in the risk of death (P = 0.08). The nonstatistically significant benefit reported in the meta-analysis prompted the planning of several randomized studies of platinum-based chemotherapy. Three studies addressed the issue of adjuvant chemotherapy in all the resected stages of non-small cell lung cancer (I-IIIA): the Italian/European study Adjuvant Lung Cancer Project Italy, the International Adjuvant Lung Cancer study, and the British Big Lung Trial. In contrast to the International Adjuvant Lung Cancer, the Adjuvant Lung Cancer Project Italy and the underpowered British Big Lung Trial failed to prospectively confirm a significant role of adjuvant chemotherapy in completely resected non-small cell lung cancer. In this article, we will discuss the findings of the Adjuvant Lung Cancer Project Italy study in the context of the International Adjuvant Lung Cancer and British Big Lung Trial.

Multimodality Therapy for Stage III Non–Small-Cell Lung Cancer

The treatment of stage III non–small-cell lung cancer has evolved over the last two decades, with combined-modality therapy the current standard of care. As a result, intermediate and long-term survival has improved for patients in this common stage category, compared to the poor outcomes achieved with the historical standard of once-daily radiation therapy alone. This review summarizes two decades of clinical research regarding bimodality and trimodality approaches for the heterogenous stage subsets within the stage III designation, discusses the rationale and status of prophylactic brain irradiation, and concludes with perspectives on progress and future directions. Chemotherapy plus radiotherapy given concurrently is the optimal treatment for the group of patients with advanced stage III disease. The potential role of a surgical resection following chemotherapy (with or without radiation) in this setting is still controversial. The only subsets for which trimodality treatments are clearly preferred include T4N0-1 disease and superior sulcus tumors. The other major stage III subgroup has a minimal disease burden with low tumor volume and/or microscopic N2 disease, thus technically could undergo a surgical resection upfront. Induction chemotherapy before surgery may yield a survival advantage, although the phase III trials in this area are not conclusive. Given the marked survival benefit from adjuvant chemotherapy after surgery in even earlier stages of non–small-cell lung cancer, the proper sequence of surgery and chemotherapy (before v after surgery) remains an important unresolved question in this subgroup. Furthermore, how to incorporate radiation therapy, as well as whether it should be given at all in this subset of patients, are other important issues actively under study in ongoing trials.

Which Patients with Stage III Non‐Small Cell Lung Cancer Should Undergo Surgical Resection?

The treatment of patients with stage III NSCLC remains controversial. Stage III NSCLC comprises a fairly heterogeneous group of tumors, and furthermore only sparse data from randomized clinical trials exist to guide therapy decisions. This review article proposes a management algorithm for patients with stage III NSCLC that is based upon the currently available data on surgical therapy, chemotherapy, and radiation therapy. By necessity, given the paucity of strong data, a good deal of opinion is offered. The choice to proceed with aggressive, combined modality treatment is presented in light of extent of local disease as well as patient performance status.