Updated review of perioperative treatment for non-small-cell lung cancer in the new era of immune checkpoint inhibitors: past, present, and future

The perioperative treatments for non-small cell lung cancer (NSCLC) should control both local and microscopic systemic disease, because the survival of patients with NSCLC who underwent surgical resection alone has been dismal except in stage IA patients. One way to improve surgical outcome is the administration of chemotherapy before or after the surgical procedure. During the last two decades, many clinical studies have focused on developing optimal adjuvant or neoadjuvant cisplatin-based chemotherapy regimens that can be combined with surgical treatment and/or radiotherapy. Based on the results of those clinical studies, multimodality therapy has been considered to be an appropriate treatment approach for locally advanced NSCLC patients. When nodal involvement is discovered postoperatively, adjuvant cisplatin-based chemotherapy has conferred an overall survival benefit. More recently, neoadjuvant and/or adjuvant use of immunotherapy adding to the cisplatin-based chemotherapy has been revealed to improve survival of the patients with locally advanced NSCLC in many large-scale clinical trials; although, optimal treatment strategies are still evolving.

The Value of Radiotherapy in Patients With Resectable Stage IIIA Non-Small-Cell Lung Cancer in the Era of Individualized Treatment: A Population-Based Analysis

INTRODUCTION

No consensus has been achieved on the benefit of radiotherapy for resected stage IIIA NSCLC patients. The division of stage IIIA has changed significantly in 2017. This study aims to explore the effects of radiotherapy on the survival of patients with resectable stage IIIA NSCLC in the new era.

PATIENTS AND METHODS

Patients diagnosed with NSCLC between 2010 and 2018 were identified in the 8th edition TNM classification from the Surveillance, Epidemiology, and End Results database. A nomogram was developed by integrating all independent predictors for lung cancer-specific survival (LCSS). The Propensity Score Matching (PSM) and subgroup analysis were applied to mitigate potential bias. Survival analyses were conducted using the Kaplan Meier curves and Cox proportional hazards regression.

RESULTS

A total of 2632 stage IIIA NSCLC patients were enrolled. The C-index of the nomogram for the prediction of LCSS was 0.636 (95% CI, 0.616-0.656). In the group of patients with N2 stage who featured more than 5 positive regional lymph nodes, compared with non-PORT, PORT did prolong postoperative survival time (50 vs. 31 months; P= .005). N2 patients with visceral pleural invasion (VPI), older (age >65), or had a larger tumor (size >3 cm) could also benefit from adjuvant radiotherapy.

CONCLUSION

Treatment protocol for stage IIIA NSCLC patients should be individualized. Based on our findings, N2 patients with more than 5 positive regional lymph nodes, VPI, larger tumor size (greater than 3 cm), and older (age above 65) could benefit from adjuvant radiotherapy. Further well-designed randomized trials are warranted.

Neoadjuvant Therapy and Factors Influencing Survival in Locally Advanced Non-Small Cell Lung Cancer

AIM

We aimed to investigate the effectiveness of neoadjuvant therapy (NAT) and clinicopathological characteristics in locally advanced non-small cell lung cancer (NSCLC) (IIIA-IIIB), as well as the influence of the post-NAT treatment modalities on survival.

MATERIALS AND METHODS

This study included patients who presented to the Dicle University Medical Oncology Clinic and received NAT for a diagnosis of locally advanced NSCLC between 2004 and 2020. Clinicopathological and radiological data of the 57 patients whose data could be retrieved from the hospital archive system were retrospectively reviewed. Patients' overall survival (OS) and failure-free survival (FFS) times and the factors influencing these times were evaluated.

RESULTS

This study included a total of 57 patients consisting of five (8.8%) females and 52 (91.2%) males. The median patient age at diagnosis was 58 (30-75) years. All patients had received four courses of chemotherapy during the neoadjuvant period. When the factors influencing OS were evaluated, the post-NAT modality was found to have a statistically significant effect on survival. FFS times were 12, 13, and 16 months in the chemotherapy, chemoradiotherapy, and surgery arms, respectively (log-rank p=0.035). FFS was longer in those who underwent surgery (Hazard ratio (HR): 0.33, 95 % CI: 0.14-0.77, (p=0.01)). OS times were 20, 21, and 55 months in the chemotherapy, chemoradiotherapy, and surgery arms, respectively (log-rank p=0.05). OS was longer in the arm undergoing surgery compared to the other arms (HR: 0.36, 95% CI: 0.14-0.87, (p=0.02)). Five-year survival rates for the chemotherapy, chemoradiotherapy, and surgery arms were 14.3%, 21.4%, and 40%, respectively.

CONCLUSIONS

This study shows that achieving an operable status is the most important indicator of survival and that patients undergoing surgery have a marked advantage in OS and FFS compared with patients receiving chemoradiotherapy or palliative chemotherapy.

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.

Prognostic Factors of IIIAN2 Non-Small-Cell Lung Cancer after Complete Resection: A Systemic Review and Meta-analysis

METHODS

An extensive data search was conducted from all leading databases including PubMed, Google Scholar, Embase, and Cochrane. Fifteen studies were selected according to the PRISMA model of data selected to conduct this systemic review meta-analysis.

RESULTS

Total 4444 patients were evaluated among fifteen selected studies. A number of lymph nodes involved (n = 3965), level of lymph nodes (n = 3422), and complete tumor resection (n = 3255) were the most reported prognostic factors.

CONCLUSION

This study exhibits the overall significance of all prognostic factors of NSCLC IIIAN2 pathology for better patient management. However, other management strategies also play a significant contribution to achieving a better survival rate and less recurrence possibility.

Induction therapy is not associated with improved survival in large cT4N0 non-small cell lung cancers

BACKGROUND

The 8^th edition staging for non-small cell lung cancer reclassified tumors >7 cm as stage IIIA (T4N0); previously, such tumors without nodal disease were considered stage IIB (T3N0). This study tested the hypothesis that induction chemotherapy for these stage IIIA patients does not improve survival compared to primary surgery.

METHODS

The National Cancer Database was queried for non-small cell lung cancer patients with tumor size >7 cm who underwent surgical resection from 2010 - 2015. Patients with clinically node-positive disease or tumor invasion of major structures were excluded. Patients undergoing induction chemotherapy followed by surgery (IC) were compared to patients undergoing primary surgery (PS). Propensity-score matching was performed.

RESULTS

In total, 1,610 patients with cT4N0 disease based on tumor size >7 cm and no tumor invasion underwent surgical resection: 1,346 (83.6%) comprised the PS group and 264 (16.4%) the IC group. After propensity-score matching, IC had a higher rate of pN0 (78.4% vs 66.0%, p<0.001) and less lymphovascular invasion (13.9% vs 26.3%, p<0.001), but longer postoperative stay (6 vs 5 days, p<0.001) and higher 30-day mortality (3.5% vs 0%, p=0.002). Median 5-year survival was similar between IC and PS (53.5% vs 62.2%, p=0.075), and IC was not independently associated with survival (HR 1.45, p=0.146).

CONCLUSIONS

Patients with cT4N0 non-small cell lung cancer based on tumor size >7 cm and no tumor invasion of major structures have similar overall survival with either IC or PS. IC should not be routinely given for this subset of stage IIIA patients.

Dose-dense Paclitaxel and Carboplatin as Neoadjuvant Chemotherapy for Stage IIB/IIIA Non-small Cell Lung Cancer - A Phase II trial

AIMS

The approach to potentially resectable non-small cell lung cancer (NSCLC) remains controversial. There is a benefit of neoadjuvant chemotherapy (NACT), but the ideal regimen is unknown. We evaluated the efficacy and safety of dose-dense NACT in potentially resectable NSCLC in this phase II trial.

MATERIALS AND METHODS

Paclitaxel at 80 mg/m² on days 1, 8 and 15 with AUC-6 carboplatin on day 1, 3 weekly for four cycles was evaluated as NACT. Patients with Eastern Cooperative Oncology Group performance status 0-2, stage IIB and IIIA (with only non-bulky N2 nodes) were included. The primary end point was the objective response rate. Secondary end points included toxicity, progression-free survival, recurrence-free survival, complete resection rate and overall survival. The relative dose intensity (RDI) was calculated to define tolerability (CTRI/2016/05/006916).

RESULTS

In total, 37 patients were enrolled (median age 55 years). Most (78.8%) were smokers. Most patients had adenocarcinoma (57.6%) and stage IIIA disease (81.0%) according to the seventh American Joint Committee on Cancer staging system. Seventy-eight per cent of patients completed four cycles. The objective response rate was 75.6% with a complete response in 10.8%. The mean RDI of paclitaxel was 88.61%, with 68.0% of patients able to maintain an RDI ≥85.0%. In total, 187 toxicity events were recorded (120 grade 1, 64 grade 2 and three grade 3 events). Common toxicities were peripheral neuropathy (20.3%), myalgia (19.8%), nausea (15.7%) and neutropenia (10.2%). There were no treatment-related deaths. Seventeen patients underwent surgery (lobectomy 82.4%). After a median follow-up of 47 months (95% confidence interval 27-50.7 months), the median progression-free survival was 9.6 months (7.4-17.4) and overall survival was 29.2 months (16.0-37.2).

CONCLUSION

Dose-dense paclitaxel-carboplatin is feasible, safe and efficacious and should be evaluated further in potentially resectable NSCLC.

Care of patients with non-small-cell lung cancer stage III - the Central European real-world experience

Background

Management of non-small-cell lung cancer (NSCLC) is affected by regional specificities. The present study aimed at determining diagnostic and therapeutic procedures including outcome of patients with NSCLC stage III in the real-world setting in Central European countries to define areas for improvements_.

Patients and methods

This multicentre, prospective and non-interventional study collected data of patients with NSCLC stage III in a web-based registry and analysed them centrally.

Results

Between March 2014 and March 2017, patients (n=583) with the following characteristics were entered: 32% females, 7% never-smokers; ECOG performance status (PS) 0, 1, 2 and 3 in 25%, 58%, 12% and 5%, respectively; 21% prior weight loss; 53% squamous carcinoma, 38% adenocarcinoma; 10% EGFR mutations. Staging procedures included chest X-ray (97% of patients), chest CT (96%), PET-CT (27%), brain imaging (20%), bronchoscopy (89%), endobronchial ultrasound (EBUS) (13%) and CT-guided biopsy (9%). Stages IIIA/IIIB were diagnosed in 55%/45% of patients, respectively. N2/N3 nodes were diagnosed in 60%/23% and pathologically confirmed in 29% of patients. Most patients (56%) were treated by combined modalities. Surgery plus chemotherapy was administered to 20%, definitive chemoradiotherapy to 34%, chemotherapy only to 26%, radiotherapy only to 12% and best supportive care (BSC) to 5% of patients. Median survival and progression-free survival times were 16.8 (15.3;18.5) and 11.2 (10.2;12.2) months, respectively. Stage IIIA, female gender, no weight loss, pathological mediastinal lymph node verification, surgery and combined modality therapy were associated with longer survival.

Conclusions

The real-world study demonstrated a broad heterogeneity in the management o f stage III NSCLC in Central European countries and suggested to increase the rates of PET-CT imaging, brain imaging and invasive mediastinal staging.

Adjuvant therapy in stage IIIA-N2 non-small cell lung cancer after neoadjuvant concurrent chemoradiotherapy followed by surgery

Background

This study aimed to determine whether adjuvant therapy improves survival in patients with stage IIIA-N2 non-small cell lung cancer (NSCLC) after neoadjuvant concurrent chemoradiotherapy (CCRT) followed by surgery.

Methods

We retrospectively reviewed 467 consecutive patients with stage IIIA-N2 NSCLC who received neoadjuvant CCRT followed by surgery between 2004 and 2013. From these, we identified 398 eligible patients and their clinical outcomes were compared according to whether adjuvant therapy was provided.

Results

In total, 296 patients (74%) received adjuvant therapy consisting of chemotherapy alone (n=71) radiotherapy alone (n=118) and both chemotherapy and radiotherapy (n=107). Adjuvant therapy was not given to remaining 102 patients. Patients who receiving adjuvant therapy were significantly younger (P=0.001), and predominantly male (P=0.014) compared to patients who did not receive adjuvant therapy. Regarding to the pathologic response, the adjuvant therapy group had a significantly poor pathologic response. However, the 5-year overall survival (OS) rate did not significantly differ between the groups (adjuvant therapy group, 52.9%; no adjuvant therapy group, 54.9%; P=0.369). After adjusting for age, sex, type of operation, cell type and yp stage, adjuvant therapy was significantly associated with better OS (hazard ratio =0.59; 95% CI, 0.38–0.92; P=0.019) and disease free survival (hazard ratio =0.62; 95% CI, 0.44–0.87; P=0.006).

Conclusions

Our data indicate that adjuvant therapy is more often given to patients with poor pathologic findings. Adjuvant treatment after trimodal therapy is a significant predictor of survival after adjustment of clinical variables.

Neoadjuvant chemotherapy followed by surgery in lung cancer: Indian scenario

A vast majority of the patients with lung cancer in India present as advanced stage disease and a significant number among them have nonmetastatic locally advanced tumors which require multimodality management with curative intent. We analyzed the treatment outcome of the patients treated with of neoadjuvant chemotherapy followed by surgery approach. This was a retrospective analysis of institutional database of all non-small cell lung cancer patients who underwent neoadjuvant chemotherapy followed by curative intent surgery with/without adjuvant therapy from 2012 to 2018. Patients included were those with N2 disease; T4 or T3 disease requiring pneumonectomy or extensive adjacent structures resection. Mediastinal staging was done by PET-CT (Positron Emission Tomography - Computed Tomography) along with Endobronchial ultrasound in most cases. All the patients received platinum-based doublet chemotherapy for 3-6 cycles before surgery. Response to neoadjuvant chemotherapy and survival were analyzed. A total of 44 patients fulfilled the eligibility criteria. Majority were males (81.8%) and smokers (75%). Squamous cell carcinoma (50%) was the most common subtype. Total 43.2% patients had either T3 or T4 tumors. N2 disease (either single station or multistation) was observed in 67.2% cases. A complete pathologic response was observed in 22.7% cases. In addition, 6.8% patients had ≤10% viable tumor in the resected specimen. Residual disease in N2 nodes were found in 25% cases. Median follow-up was 35.9 months. Patients with residual N2 disease showed a trend toward inferior survival. In multivariate analysis smoking, pretreatment tumor category and final pathologic stage were significant factors for disease free but not for overall survival. This study shows that neoadjuvant chemotherapy is a feasible and effective modality for downstaging locally advanced cases of non-small cell lung cancer among the Indian patients. Patients with less than 10% residual tumor burden had a better survival. The role of surgery in those with persistently N2 needs further evaluation.

Prognostic value of adjuvant therapy in T4 non-small cell lung cancer: An inverse probability of treatment weighting analysis

Background

According to the current clinical guidelines, chemoradiotherapy is considered the standard treatment for locally advanced non‐small cell lung cancer (NSCLC). We analyzed the prognostic effect of adjuvant chemotherapy (ACT) in resected patients using the new eighth tumor node metastasis (TNM) staging systems based on the Surveillance, Epidemiology and End Results database.

Methods

We identified 3008 patients with stage IIIA NSCLC (T4N0M0) who underwent sublobar resection, lobectomy, or pneumonectomy. Covariates affecting treatment selection or survival were included as part of propensity score models for matching and weighting. The effect of ACT on survival was assessed, stratified by postoperative radiation therapy (PORT) use, tumor size, and age.

Results

Analyses of 2016 patients were conducted with standardized differences in covariates < 10% after matching. ACT was associated with significantly improved five‐year overall survival (51.1% vs. 39.7%; P = 0.0260) in patients aged 21–65 with > 7 cm tumors, even after adjusting for the presence or absence of the superior sulcus (P = 0.0003). No significant outcomes were observed using other stratifications in the matched analysis. Moreover, ACT with PORT conferred a potential survival benefit in 21–65‐year‐old patients with 0–7 cm tumors (for all causes of death: hazard ratio 0.414, 95% confidence interval 0.251–0.684).

Conclusion

In this population‐based cohort, ACT prolonged the survival of patients aged 21–65 with a tumor > 7 cm, with or without PORT. Inverse probability of treatment weighting can estimate the treatment effect and is suitable for use with survival data.

Right-Sided Versus Left-Sided Pneumonectomy After Induction Therapy for Non-Small Cell Lung Cancer

BACKGROUND

A right-sided pneumonectomy after induction therapy for non-small cell lung cancer (NSCLC) has been shown to be associated with significant perioperative risk. We examined the effect of laterality on long-term survival after induction therapy and pneumonectomy using the National Cancer Data Base.

METHODS

Perioperative and long-term outcomes of patients who underwent pneumonectomy after induction chemotherapy, with or without radiotherapy, from 2004 to 2014 in the National Cancer Data Base were evaluated using multivariable Cox proportional hazards modeling and propensity score-matched analysis.

RESULTS

During the study period, 1,465 patients (right, 693 [47.3%]; left, 772 [52.7%]) met inclusion criteria. Right-sided pneumonectomy was associated with significantly higher 30-day (8.2% [57 of 693] vs 4.2% [32 of 772], p < 0.01) and 90-day mortality (13.6% [94 of 693] vs 7.9% [61 of 772], p < 0.01), and right-sided pneumonectomy was a predictor of higher 90-day mortality (odds ratio, 2.23; p < 0.01). However, overall 5-year survival between right and left pneumonectomy was not significantly different in unadjusted (37.6% [95% confidence interval {CI}, 0.34 to 0.42] vs 35% [95% CI, 0.32 to 0.39], log-rank p = 0.94) or multivariable analysis (hazard ratio, 1.07; 95% CI, 0.92 to 1.25; p = 0.40). A propensity score-matched analysis of 810 patients found no significant differences in 5-year survival between the right-sided versus left-sided groups (34.7% [95% CI, 0.30 to 0.40] vs 34.1%, [95% CI, 0.29 to 0.39], log-rank p = 0.86).

CONCLUSIONS

In this national analysis, right-sided pneumonectomy after induction therapy was associated with a significantly higher perioperative but not worse long-term mortality compared to a left-sided procedure.

Role of pneumonectomy for lung cancer in current scenario: An Indian perspective

BACKGROUND

Surgical treatment for lung cancer has evolved from pneumonectomy to lobectomy/sleeve resection around the world. Although condemned for poor outcomes, pneumonectomy may still be required in a select group of patients in developing countries. With the better patient selection, optimization of medical comorbidities, better perioperative care; pneumonectomy may show better results. Thus, there is a need to reconsider the role of pneumonectomy in patients with locally advanced lung cancer in the current scenario.

PATIENTS AND METHODS

The aim of this study was to analyze the demographic and clinicopathologic profile of lung cancer patients and the role of pneumonectomy at a tertiary cancer center in India. The records of patients, who underwent surgery for lung cancer at our institute from January 2011 to April 2014, were analyzed retrospectively, and various parameters in pneumonectomy were compared to lobectomy patients.

RESULTS

Out of 48 patients undergoing major lung resections, nearly 80% patients were symptomatic at presentation and were mostly in advanced stages, thus requiring neoadjuvant chemotherapy in 45.8% cases and pneumonectomy in 41.6% patients. There was no difference in morbidity and mortality in pneumonectomy (25%, 5%) versus lobectomy (21.2%, 3.5%). Disease-free survival at 1, 2, and 3 years after pneumonectomy (71.8%, 51.4%, and 42.8%) was comparable to lobectomy (73.3%, 66.1%, and 55.6%). After neoadjuvant therapy, survival was not affected by the type of surgery.

CONCLUSIONS

In the Indian scenario, as the majority of lung cancer patients present at an advanced stage, pneumonectomy still plays a major role, and the acceptable postoperative outcome can be achieved with aggressive perioperative management.

Neoadjuvant and adjuvant therapy for Stage III non-small cell lung cancer

The treatments for advanced non-small cell lung cancer (NSCLC) should control both local and microscopic systemic disease, because the 5-year survival of patients with Stage III NSCLC who underwent surgical resection alone has been dismal. One way to improve surgical outcome is the administration of chemotherapy before or after the surgical procedure. During the last two decades, many clinical studies have focused on developing optimal adjuvant or neoadjuvant chemotherapy regimens that can be combined with surgical treatment and/or radiotherapy. Based on the results of those clinical studies, multimodality therapy is considered to be an appropriate treatment approach for Stage IIIA NSCLC patients; although, optimal treatment strategies are still evolving. When N2 nodal involvement is discovered postoperatively, adjuvant cisplatin-based chemotherapy confers an overall survival benefit. The addition of postoperative radiotherapy might be considered for patients with nodal metastases. Although definitive chemoradiation remains a standard of care for cN2 NSCLC, alternative approaches such as induction chemotherapy or chemoradiotherapy and surgery can be considered for a selective group of patients. When surgical resection can be performed after induction therapy with low risk and a good chance of complete resection, the outcome may be optimal. The decision to proceed with resection after induction therapy must include a detailed preoperative pulmonary function evaluation as well as a critical intraoperative assessment of the feasibility of complete resection.

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.

PGC-1alpha levels correlate with survival in patients with stage III NSCLC and may define a new biomarker to metabolism-targeted therapy

Lung cancer remains the leading cause of cancer-related death worldwide, with one-third diagnosed with locally advanced (stage III) disease. Preoperative induction chemo-radiotherapy is key for the treatment of these patients, however conventional cisplatin based approaches has apparently reached a plateau of effectiveness. In the search for new therapies, the targeting of tumor metabolism is revealed as an interesting option to improve the patient’s responses. Here we describe the importance of PGC-1alpha and GAPDH/MT-CO1 ratio levels as surrogates of the Warburg effect from a series of 28 stage III NSCLC patients, on PFS, OS and PET uptake. Moreover, our results show a great variability between tumors of different individuals, ranging from very glycolytic to more OXPHOS-dependent tumors, which compromises the success of therapies directed to metabolism. In this sense, using 3 different cell lines, we describe the relevance of Warburg effect on the response to metabolism-targeted therapies. Specifically, we show that the inhibitory effect of metformin on cell viability depends on cell’s dependence on the OXPHOS system. The results on cell lines, together with the results of PGC-1alpha and GAPDH/MT-CO1 as biomarkers on patient’s biopsies, would point out what type of patients would benefit more from the use of these drugs.

Surgical Management of Stage IIIA Non-Small Cell Lung Cancer

According to the eighth edition of the tumor–node–metastasis classification, stage III non-small cell lung cancer is subdivided into stages IIIA, IIIB, and IIIC. They represent a heterogeneous group of bronchogenic carcinomas with locoregional involvement by extension of the primary tumor and/or ipsilateral or contralateral lymph node involvement. Surgical indications have not been definitely established but, in general, long-term survival is only obtained in those patients in whom a complete resection is obtained. This mini-review mainly focusses on stage IIIA disease comprising patients with locoregionally advanced lung cancers. Different subcategories of N2 involvement exist, which range from unexpected N2 disease after thorough preoperative staging or “surprise” N2, to bulky N2 involvement, mostly treated by chemoradiation, and finally, the intermediate category of potentially resectable N2 disease treated with a combined modality regimen. After induction therapy for preoperative N2 involvement, best surgical results are obtained with proven mediastinal downstaging when a lobectomy is feasible to obtain a microscopic complete resection. However, no definite, universally accepted guidelines exist. A relatively new entity is salvage surgery applied for recurrent disease after full-dose chemoradiation when no other therapeutic options exist. Equally, only a small subset of patients with T4N0-1 disease qualify for surgical resection after thorough discussion within a multidisciplinary tumor board on the condition that a complete resection is feasible. Targeted therapies and immunotherapy have recently become part of our therapeutic armamentarium, and it might be expected that they will be incorporated in current regimens after careful evaluation in randomized clinical trials.

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.

Preoperative predictors of distant recurrence in patients with clinical stage IA lung adenocarcinoma undergoing complete resection

Objective

We aimed to identify patients with clinical Stage IA lung adenocarcinoma who are at high risk for distant recurrence to preoperatively organize treatment strategies.

Methods

We analyzed correlations between preoperative clinical factors and the incidence of distant recurrence in 609 patients with clinical Stage IA lung adenocarcinoma that had been completely resected at four institutions. We excluded 24 patients with only locoregional recurrence and analyzed data from 585 patients.

Results

Distant recurrence after complete resection was identified in 34 patients during a median follow-up period of 41.4 months. Multivariate Cox analysis identified solid tumor size on high-resolution computed tomography and the maximum standardized uptake value on F-18-fluorodeoxyglucose positron emission tomography/computed tomography as independent predictors for distant recurrence-free survival. Receiver operating characteristic analyses showed that solid tumor size ≥1.7 cm and the maximum standardized uptake value ≥3.3 were optimal criteria with which to detect patients at high risk for distant recurrence. In fact, 3-year distant recurrence rates were higher in patients who met the criteria for high risk (n = 85) than those who did not (n = 500) (28.1% vs. 3.7%; P < 0.001). A similar trend was also found in patients with pathological node negative.

Conclusions

Solid tumor size on high-resolution computed tomography and the maximum standardized uptake value on F-18-fluorodeoxyglucose positron emission tomography/computed tomography were clinical predictors of distant recurrence among patients with clinical Stage IA lung adenocarcinoma. Our findings might be useful to determine personalized therapeutic strategies including systemic therapy.

Immune contexture and histological response after neoadjuvant chemotherapy predict clinical outcome of lung cancer patients

There is now growing evidence that the immune contexture influences cancer progression and clinical outcome of patients with non-small cell lung cancer (NSCLC). If chemotherapy is widely used to treat patients with advanced-stage NSCLC, it remains unclear how it could modify the immune contexture and impact its prognostic value. Here, we analyzed two retrospective cohorts, respectively composed of 122 stage III-N2 NSCLC patients treated with chemotherapy before surgery and 39 stage-matched patients treated by surgery only. In patients treated with neoadjuvant chemotherapy, the histological characteristics, the expression of PD-L1 protein, and the tumor immune microenvironment (CD8⁺ T cells, DC-LAMP⁺ mature dendritic cells, and CD68⁺ macrophages) were evaluated and their prognostic value assessed together with standard clinical parameters. By analyzing pre- and post-treatment specimens, we did not find any changes in the PD-L1 expression. We also found that the tumor immune contexture in patients treated with neoadjuvant chemotherapy exhibited a similar pattern that the one found in chemotherapy-naive patients, with comparable densities of tumor-infiltrating CD8⁺ and DC-LAMP⁺ cells and a similar spatial organization. The percentage of residual viable tumor cells and the immune pattern (CD8⁺ and DC-LAMP⁺ cell densities) were significantly associated with the clinical outcome and allowed the identification of short- and long-term survivors, respectively. In multivariate analysis, the immune pattern was found to be the strongest independent prognostic factor. In conclusion, this study decrypts the complex interplay between cancer and immune cells in patients undergoing chemotherapy and supports potential beneficial synergistic effect of immunotherapy and chemotherapy.

Correlation of DNA Repair Gene Polymorphisms With Clinical Outcome in Patients With Locally Advanced Non-Small-Cell Lung Cancer Receiving Induction Chemotherapy Followed by Surgery

OBJECTIVE

The aim of this study was to evaluate whether xeroderma pigmentosum group D (XPD) and ribonucleotide reductase subunit M1 (RRM1) polymorphisms influenced clinical outcome in patients with stage IIIA-B non-small-cell lung cancer (NSCLC) treated with neoadjuvant gemcitabine/cisplatin/docetaxel followed by surgery.

MATERIALS AND METHODS

A total of 109 patients with stage IIIA and IIIB NSCLC were prospectively genotyped to examine a potential association between XPD 312 (aspartic acid [Asp]/asparagine [Asn]), XPD 751 (lysine [Lys]/glutamine [Gln]), and RRM1 (-37 C/A) polymorphisms with response and survival.

RESULTS

The median survival was 32.14 months for carriers of XPD 312 Asp/Asp and 12.04 months for those with the variant Asn allele (P = .05). In addition, event-free survival was longer for patients with the XPD 312 Asp/Asp genotype compared with patients with Asp/Asn or Asn/Asn (P = .03). A similar but nonsignificant trend was observed for the XPD 751 genotype. In a multivariate analysis, complete resection and age emerged as prognostic factors for overall survival; in patients with incomplete resection or exploratory thoracotomy, XPD 312 was the most significant prognostic factor (P = .03).

CONCLUSION

The XPD 312 single nucleotide polymorphism is a prognostic factor for survival in patients with locally advanced NSCLC receiving induction chemotherapy followed by surgery. The Asn allele is associated with unfavorable outcome and could be used for better stratification of patients.

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.

Effectiveness of a thoracic multidisciplinary clinic in the treatment of stage III non-small-cell lung cancer

Introduction

The Institute of Medicine, the American Society of Clinical Oncology, and the European Society of Medical Oncology promote a multidisciplinary approach for the treatment of cancer. Stage III non-small-cell lung cancer (NSCLC) represents a heterogeneous group of diseases necessitating coordination of care among medical, radiation, and surgical oncology. The optimal care of stage III NSCLC underscores the need for a multidisciplinary approach.

Methods

From tumor registry data, we identified all cases of stage III NSCLC seen at Lehigh Valley Health Network between March 2010 and March 2013. The care received by patients when seen in the thoracic multidisciplinary clinic (MDC) was compared with the care received when not seen in the thoracic MDC.

Results

All patients seen in the MDC, compared to <50% of patients seen outside the MDC, were evaluated by more than one physician prior to beginning the treatment. Time to initiate treatment was shorter in MDC patients than in non-MDC patients. Patients seen in the MDC had a greater concordance with clinical pathways. A greater percentage of patients seen in the thoracic MDC had pathologic staging of their mediastinum. Patients seen in the MDC were more likely to receive all of their care at Lehigh Valley Health Network.

Conclusion

Multidisciplinary care is essential in the treatment of patients with stage III NSCLC. Greater utilization of MDCs for this complex group of patients will result in more efficient coordination of care, pretreatment evaluation, and therapy, which in turn should translate to improve patients’ outcomes.

Definitive radiotherapy with or without chemotherapy for clinical stage T4N0-1 non-small cell lung cancer

Purpose

To determine failure patterns and survival outcomes of T4N0-1 non-small cell lung cancer (NSCLC) treated with definitive radiotherapy.

Materials and Methods

Ninety-five patients with T4N0-1 NSCLC who received definitive radiotherapy with or without chemotherapy from May 2003 to October 2014 were retrospectively reviewed. The standard radiotherapy scheme was 66 Gy in 30 fractions. The main concurrent chemotherapy regimen was 50 mg/m² weekly paclitaxel combined with 20 mg/m² cisplatin or AUC 2 carboplatin. The primary outcome was overall survival (OS). Secondary outcomes were failure patterns and toxicities.

Results

The median age was 64 years (range, 34 to 90 years). Eighty-eight percent of patients (n = 84) had an Eastern Cooperative Oncology Group performance status of 0-1, and 42% (n = 40) experienced pretreatment weight loss. Sixty percent of patients (n = 57) had no metastatic regional lymph nodes. The median radiation dose was EQD2 67.1 Gy (range, 56.9 to 83.3 Gy). Seventy-one patients (75%) were treated with concurrent chemotherapy; of these, 13 were also administered neoadjuvant chemotherapy. At a median follow-up of 21 months (range, 1 to 102 months), 3-year OS was 44%. The 3-year cumulative incidences of local recurrence and distant recurrence were 48.8% and 36.3%, respectively. Pretreatment weight loss and combined chemotherapy were significant factors for OS. Acute esophagitis over grade 3 occurred in three patients and grade 3 chronic esophagitis occurred in one patient. There was no grade 3-4 radiation pneumonitis.

Conclusion

Definitive radiotherapy for T4N0-1 NSCLC results in favorable survival with acceptable toxicity rates. Local recurrence is the major recurrence pattern. Intensity modulated radiotherapy and radio-sensitizing agents would be needed to improve local tumor control.

Outcome of Patients With pN2 "Potentially Resectable" Nonsmall Cell Lung Cancer Who Underwent Surgery After Induction Chemotherapy

Patients with stage IIIA-ipsilateral mediastinal lymph node involvement (N2) non-small cell lung cancer (NSCLC) represent a heterogeneous group with different clinical presentation. The aim of this study was to analyze a series of patients with "potentially resectable" stage IIIA-pathologically proven N2 (pN2) NSCLC undergoing induction chemotherapy followed by surgery to evaluate their long-term outcomes and to identify prognostic factors. Out of 287 patients who underwent induction chemotherapy for NSCLC with ipsilateral mediastinal lymph node involvement pathologically proven, we retrospectively evaluated 141 (49%) patients with no clinical evidence of progression after induction chemotherapy and candidates for surgery. Most of them (73%) underwent at least 3 cycles of cisplatin-based chemotherapy. We used the Kaplan-Meier method to plot survival and the log-rank test to assess the survival difference between groups. Multivariable analysis was performed using Cox proportional hazards regression. A total of 15 (10.6%) patients underwent explorative thoracotomy; 126 patients underwent surgical anatomical resection after a median 27 days (range: 21-30) from the last cycle of chemotherapy. A total of 113 (89.7%) patients had a radical resection. A total of 22 (17.5%) patients had a complete pathologic lymph node downstaging (pN0), and 8 (6.3%) patients had a complete pathological response (pT0N0). The median overall survival was 24 months, with a 5-year overall survival of 30%. At multivariable analysis, downstaging and number of cycles of chemotherapy were independent prognostic factors (P = 0.006); downstaging benefit was mostly because of complete pathological response (hazards ratio = 0.23, 95% CI: 0.07-0.76). In conclusion, more than 3 cycles of chemotherapy and pathological downstaging could significantly improve 5-year survival in selected patients with "potentially resectable" pathologically proven N2 disease.

The long-term outcomes of induction chemoradiotherapy followed by surgery for locally advanced non-small cell lung cancer

Background

Although the concept of induction therapy followed by surgical resection for locally advanced non-small cell lung cancer (LA-NSCLC) has found general acceptance, the appropriate indications and the strategy for this treatment are still controversial.

Methods

From 2000 through 2008, 36 patients received concurrent chemoradiotherapy followed by surgery. We retrospectively reviewed these cases, analyzed the outcomes and examined the prognosis.

Results

The median radiation dose given was 60 Gy. Chemotherapy included a platinum agent in all cases; cisplatin-based chemotherapy was administered to 9 cases, and a carboplatin-based chemotherapy regimen was administered to 27. A complete resection was performed in 94% of the patients. Seventeen (47.2%) patients exhibited a complete pathological response, and downstaging was induced in 26 (72%) cases. The morbidity and 30-day mortality rates were 11.1 and 0%, respectively. The 5-year overall survival rate in the patients with complete resection (n = 33) was 83.3%.

Conclusions

Induction chemoradiotherapy followed by surgery for LA-NSCLC provided a favorable prognosis for selected patients. A complete pathological response was found in about half of cases. This strategy is feasible and was associated with low morbidity and high resectability rates, suggesting that it contributed to improving the treatment results.

Standard treatment option in stage III non-small-cell lung cancer: case against trimodal therapy and consolidation drug therapy

Prospective randomized trials and meta-analyses established concurrent radiochemotherapy (RT-CHT) as standard treatment approach in patients with inoperable, locally advanced (stage IIIA and B) non-small-cell lung cancer (NSCLC). In patients with either clinically (c) or pathologically (p) staged disease (stage IIIA), including those with pN2 disease, trimodal therapy was also frequently practiced in the past and is currently still advocated by large cooperative groups and organizations. Similarly, consolidation CHT provided after concurrent RT-CHT was suggested to be feasible and effective in inoperable stage III NSCLC. Contrasting these practices and suggestions, there is no evidence that trimodal therapy in stage IIIA (clinically or pathologically staged) or consolidation CHT in inoperable stage III NSCLC plays any role in its treatment. In both cases, evidence clearly demonstrates that concurrent RT-CHT is of similar efficacy and less toxic, and it should be considered a standard treatment option for all patients with stage III NSCLC.

Multicenter phase II study evaluating docetaxel and cisplatin as neoadjuvant induction regimen prior to surgery or radiochemotherapy with docetaxel, followed by adjuvant docetaxel therapy in chemonaive patients with NSCLC stage II, IIIA and IIIB (TAX-AT 1.203 Trial)

OBJECTIVES

Neoadjuvant therapy with a platinum based doublet is an option in NSCLC patients with upfront resectable disease. However, the role of neoadjuvant induction in stages IIIA and IIIB and in initially not resectable patients is unclear.

PATIENTS AND METHODS

In this phase II trial, 78 patients with locally advanced NSCLC, of whom 56 were considered not resectable at initial diagnosis, were treated with three neoadjuvant cycles of docetaxel and cisplatin and subjected to radical surgery if resectable. Definitive radiochemotherapy (RCT) using weekly docetaxel was the prespecified alternative if patients were not resectable at restaging. The primary objective was response to neoadjuvant induction.

RESULTS

After induction, 36 (46%) were radically operated and 24 (31%) were treated with RCT. Overall, 32 patients (41%) completed the entire study plan. Partial response to induction therapy was observed in 43 patients (55%); furthermore, 19 of 56 initially not resectable cases (34%) became resectable upon induction. Median progression-free (PFS) and overall survival (OS) were 8.5 and 16.4 months for the whole cohort. Encouragingly, conversion to resectability was predictive for favorable outcome. On the other hand, patients who were not resectable at restaging and received RCT were characterized by a rather unfavorable prognosis (5-year and 10-year OS, whole cohort: 20% and 12%; RCT: 8% and 0%; surgery: 37% and 24%, respectively).

CONCLUSION

Neoadjuvant induction with the doublet docetaxel/cisplatin and subsequent radical resection resulted in favorable survival. Of note, conversion to resectability was mandatory for the chance of cure in patients considered initially not resectable.

[Impact of induction therapies on pathology and outcome after surgical resection of non-small lung cancer: a 30-year experience of 859 patients]

The management of localized non-small cell lung cancer (NSCLC) has been modified over the last decades, with induction therapies being increasingly recommended as a prerequisite to surgical resection. However, the relative impact of chemo- and chemoradiotherapy on tumours' pathology and patients' survival is still discussed.

METHODS

We set a retrospective study including every patient who underwent surgical resection for NSCLC in 2 French centres from 1980 to 2009. We then compared the tumours' pathology and patients' survival according to the use of induction chemotherapy (group 1) or induction chemoradiotherapy (group 2).

RESULTS

There were 733 patients in group 1 and 126 patients in group 2. In group 1, 669 patients (91%) had platinum-based chemotherapy, for 2 to 3 cycles in 564 cases (77%). In group 2, chemoradiotheray was concomitant in 68 patients (54%), and sequential in 58 patients (46%). As compared with group 1, group 2 was characterized by younger age (mean 59.8±9.5 vs 56.4±9.6, respectively, P<.001), a higher rate of tumours deemed unresectable before induction treatment (25% vs 44%, P<.001), and a higher proportion of T4 (25% vs 44%, P<.001) or N2 diseases (56% vs 69%, P=.005). The type of resection, postoperative complications, and postoperative mortality were not significantly different between groups. On final pathologic report, as compared with group 1, there were more N0 and N1 disease in group 2 (N0: 43% vs 58%, P=.002; N1: 22% vs 10%, P=.002) while the rate of N2 disease was comparable (34% vs 32%, P=ns). The median, 5-, and 10-year survivals were 28 months, 35%, and 21% for group 1, and 29 months, 36%, and 23% for group 2, respectively (P=ns).

CONCLUSION

As compared with induction chemotherapy, induction chemoradiotherapy was performed in more advanced NSCLC, and resulted in better downstaging, similar postoperative course, and comparable long-term outcome after surgical resection.

Variability in the treatment of elderly patients with stage IIIA (N2) non-small-cell lung cancer

INTRODUCTION

: We evaluated treatment patterns of elderly patients with stage IIIA (N2) non-small-cell lung cancer (NSCLC).

METHODS

: The use of surgery, chemotherapy, and radiation for patients with stage IIIA (T1-T3N2M0) NSCLC in the Surveillance, Epidemiology, and End Results-Medicare database from 2004 to 2007 was analyzed. Treatment variability was assessed using a multivariable logistic regression model that included treatment, patient, tumor, and census track variables. Overall survival was analyzed using the Kaplan-Meier approach and Cox proportional hazard models.

RESULTS

: The most common treatments for 2958 patients with stage IIIA (N2) NSCLC were radiation with chemotherapy (n = 1065, 36%), no treatment (n = 534, 18%), and radiation alone (n = 383, 13%). Surgery was performed in 709 patients (24%): 235 patients (8%) had surgery alone, 40 patients (1%) had surgery with radiation, 222 patients had surgery with chemotherapy (8%), and 212 patients (7%) had surgery, chemotherapy, and radiation. Younger age (p < 0.0001), lower T-status (p < 0.0001), female sex (p = 0.04), and living in a census track with a higher median income (p = 0.03) predicted surgery use. Older age (p < 0.0001) was the only factor that predicted that patients did not get any therapy. The 3-year overall survival was 21.8 ± 1.5% for all patients, 42.1 ± 3.8% for patients that had surgery, and 15.4 ± 1.5% for patients that did not have surgery. Increasing age, higher T-stage and Charlson Comorbidity Index, and not having surgery, radiation, or chemotherapy were all risk factors for worse survival (all p values < 0.001).

CONCLUSIONS

: Treatment of elderly patients with stage IIIA (N2) NSCLC is highly variable and varies not only with specific patient and tumor characteristics but also with regional income level.

Modern post-operative radiotherapy for stage III non-small cell lung cancer may improve local control and survival: a meta-analysis

BACKGROUND

We hypothesized that modern postoperative radiotherapy (PORT) could decrease local recurrence (LR) and improve overall survival (OS) in patients with stage IIIA-N2 non-small-cell lung cancer (NSCLC).

METHODS

To investigate the effect of modern PORT on LR and OS, we identified published phase III trials for PORT and stratified them according to use or non-use of linear accelerators. Non-individual patient data were used to model the potential benefit of modern PORT in stage IIIA-N2 NSCLC treated with induction chemotherapy and resection.

RESULTS

Of the PORT phase III studies, eleven trials (2387 patients) were included for OS analysis and eight (1677 patients) for LR. PORT decreased LR, whether given with cobalt, cobalt and linear accelerators, or with linear accelerators only. An increase in OS was only seen when PORT was given with linear accelerators, along with the most significant effect on LR (relative risk for LR and OS 0.31 (p=0.01) and 0.76 (p=0.02) for PORT vs. controls, respectively). Four trials (357 patients) were suitable to assess LR rates in stage III NSCLC treated with surgery, in most cases after induction chemotherapy. LR as first relapse was 30% (105/357) after 5 years. In the modeling part, PORT with linear accelerators was estimated to reduce LR rates to 10% as first relapse and to increase the absolute 5-year OS by 13%.

CONCLUSIONS

This modeling study generates the hypothesis that modern PORT may increase both LR and OS in stage IIIA-N2 NSCLC even in patients being treated with induction chemotherapy and surgery.

Role of induction therapy: surgical resection of non-small cell lung cancer after induction therapy

Patients with Stage III non-small cell lung cancer are best managed by multimodality therapy. Patients with N2 disease can be treated with induction therapy (usually chemotherapy) followed by surgical resection. Patients whose medical comorbidities preclude surgery should be treated with definitive chemoradiotherapy. T3 or T4 tumors involving the superior sulcus or spine are best managed with induction chemoradiotherapy and surgical resection.

[Resected non-small cell bronchogenic carcinoma stage pIIIA-N2. Which patients will benefit most from adjuvant therapy?]

BACKGROUND

Controversy persists as regards the indications and results of surgery in the treatment of patients with stage pIIIA-N2 non-small cell lung cancer (NSCLC). The objective of this study was to analyze the overall survival of a multicentre series of these patients and the role of adjuvant treatment, looking for factors that may define subgroups of patients with an increased benefit from this treatment.

METHODS

A retrospective study was conducted on 287 patients, with stage pIIIA-N2 NSCLC subjected to complete resection, taken from a multi-institutional database of 2.994 prospectively collected consecutive patients who underwent surgery for lung cancer. Adjuvant treatment was administered in 238 cases (82.9%). Analyses were made of the age, gender, histological type, administration of induction and adjuvant chemotherapy and/or radiation therapy treatments.

RESULTS

The 5-year survival was 24%, with a median survival of 22 months. Survival was 26.5% among patients receiving with adjuvant treatment, versus 10.7% for those without it (P=.069). Age modified the effect of adjuvant treatment on survival (interaction P=.049). In patients under 70 years of age with squamous cell carcinoma, adjuvant treatment reduced the mortality rate by 37% (hazard ratio: 0,63; 95% CI; 0,42-0,95; P=.036).

CONCLUSIONS

Completely resected patients with stage pIIIA-N2 NSCLC receiving adjuvant treatment reached higher survival rates than those who did not. Maximum benefit was achieved by the subgroup of patients under 70 years of age with squamous cell carcinoma.

The role of chemotherapy in the management of stage IIIA non-small cell lung cancer

Patients with confirmed stage IIIA non-small cell lung cancer (NSCLC) represent a very heterogeneous group which includes those with limited microscopic ipsilateral mediastinal lymph node involvement discovered after a surgical resection, as well as those who have radiologically evident bulky subcarinal lymph node involvement at presentation. Different therapeutic options in stage IIIA disease include neoadjuvant chemo- or chemoradiotherapy followed by surgery, primary surgery followed by adjuvant chemotherapy with or without sequential adjuvant radiation therapy or definitive chemoradiation without surgery. The roles of surgery and radiation in stage IIIA disease are controversial, and there is inadequate data from randomized trials to inform the optimal therapeutic strategy. In contrast, chemotherapy has a clear indication in the curative setting. Data from randomized trials indicates that cisplatin-based chemotherapy should be given in either adjuvant or neoadjuvant settings to patients who are undergoing curative surgical resection and who are candidates for cisplatin therapy. In definitive chemoradiotherapy, cisplatin-based therapy is recommended although a carboplatin-based regimen may be given if patients cannot receive cisplatin. Finally, all patients with stage IIIA NSCLC should be evaluated early in a multidisciplinary setting that includes medical and radiation oncologists and thoracic surgeons with experience in lung cancer therapy.

Predictors for locoregional recurrence for clinical stage III-N2 non-small cell lung cancer with nodal downstaging after induction chemotherapy and surgery

Purpose

Pathologic downstaging following chemotherapy for stage III-N2 NSCLC is a well-known positive prognostic indicator. However, the predictive factors for locoregional recurrence (LRR) in these patients are largely unknown.

Methods

Between 1998 and 2008, 153 patients with clinically or pathologically staged III-N2 NSCLC from two cancer centers in the United States were treated with induction chemotherapy and surgery. All had pathologic N0-1 disease, and none received postoperative radiotherapy. LRR were defined as recurrence at the surgical site, lymph nodes (levels 1–14 including supraclavicular), or both.

Results

Median follow-up was 39.3 months. Pretreatment N2 status was confirmed pathologically (18.2 %) or by PET/CT (81.8 %). Overall, the 5-year LRR rate was 30.8 % (n = 38), with LRR being the first site of failure in 51 % (22/+99877943). Five-year overall survival for patients with LRR compared with those without was 21 versus 60.1 % (p < 0.001). Using multivariate analysis, significant predictors for LRR were pN1 disease at time of surgery (p < 0.001, HR 3.43, 95 % CI 1.80–6.56) and a trend for squamous histology (p = 0.072, HR 1.93, 95 % CI 0.94–3.98). Five-year LRR rate for pN1 versus pN0 disease was 62 versus 20 %. Neither single versus multistation N2 disease (p = 0.291) nor initial staging technique (p = 0.306) were predictors for LRR. N1 status also was predictive for higher distant recurrence (p = 0.021, HR 1.91, 95 % CI 1.1–3.3) but only trended for poorer survival (p = 0.123, HR 1.48, 95 % CI 0.9–2.44).

Conclusions

LRR remains high in resected stage III-N2 NSCLC patients after induction chemotherapy and nodal downstaging, particularly in patients with persistent N1 disease.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-012-2800-x) contains supplementary material, which is available to authorized users.

The role of consolidation therapy for stage III non-small cell lung cancer with persistent N2 disease after induction chemotherapy

BACKGROUND

Persistent pathologic mediastinal nodal involvement after induction chemotherapy and surgical resection is a negative prognostic factor for stage III-N2 non-small cell lung cancer patients. This population has high rates of local-regional failure and distant failure, yet the effectiveness of additional therapies is not clear. We assessed the role of consolidative therapies (postoperative radiation therapy and chemotherapy) for such patients.

METHODS

In all, 179 patients with stage III-N2 non-small cell lung cancer at MD Anderson Cancer Center were treated with induction chemotherapy followed by surgery from 1998 through 2008; 61 patients in this cohort had persistent, pathologically confirmed, mediastinal nodal disease, and were treated with postoperative radiation therapy. Local-regional failure was defined as recurrence at the surgical site or lymph nodes (levels 1 to 14, including supraclavicular), or both. Overall survival was calculated using the Kaplan-Meier method, and survival outcomes were assessed by log rank tests. Univariate and multivariate Cox proportional hazards models were used to identify factors influencing local-regional failure, distant failure, and overall survival.

RESULTS

All patients received postoperative radiation therapy after surgery, but approximately 25% of the patients also received additional chemotherapy: 9 (15%) with concurrent chemotherapy, 4 (7%) received adjuvant sequential chemotherapy, and 2 (3%) received both. Multivariate analysis indicated that additional postoperative chemotherapy significantly reduced distant failure (hazard ratio 0.183, 95% confidence interval: 0.052 to 0.649, p=0.009) and improved overall survival (hazard ratio 0.233, 95% confidence interval: 0.089 to 0.612, p=0.003). However, additional postoperative chemotherapy had no affect on local-regional failure.

CONCLUSIONS

Aggressive consolidative therapies may improve outcomes for patients with persistent N2 disease after induction chemotherapy and surgery.

Pathological response and prognosis of stage III non-small cell lung cancer patients treated with induction chemoradiation

AIM

The aim of this study was to clarify the relationship between pathological effects and the prognosis of patients with stage III non-small cell lung cancer (NSCLC) treated with induction chemoradiation.

METHODS

Patients who were untreated and potentially resectable with stage III NSCLC were enrolled. They received carboplatin and docetaxel with concurrent radiotherapy (5 × 2 Gy/week with a total dose of 40 Gy) followed by surgery. We assessed the relationship between the pathological effect (Ef) (Ef 1: slight pathological response, Ef 2: moderate pathological response, Ef 3: complete pathological response) and prognosis.

RESULTS

In all, 30 patients with stage III NSCLC (24 men and 6 women, mean age 60.7 years, 17 with adenocarcinomas and 13 with squamous cell carcinomas, 21 with clinical stage IIIA and nine with stage IIIB) participated in the trial and underwent induction chemoradiation. A total of 27 patients (90%) with complete response, partial response and stable disease had surgical resection. The pathological effect was Ef 1 and Ef 2 in 10 patients each, and Ef 3 in seven patients. Median survival was 10.9 months in patients with Ef 1 and 49.6 months in patients with Ef 2. Six out of seven Ef 3 patients are alive at the time of writing with a mean survival of 77.1 months (14-104 months). There was a significant difference in overall survival based on pathological effect rating (P = 0.0036).

CONCLUSION

The Ef rating was well correlated with prognosis after induction chemoradiation.

Multidisciplinary approach in stage III non-small-cell lung cancer: standard of care and open questions

Lung cancer is the most frequent cause of cancer death worldwide and its global incidence has been steadily increasing during recent decades. A third of patients with newly diagnosed non-small-cell lung cancer (NSCLC) present with locally advanced disease. There is not a single widely accepted standard of care for these patients because of the wide spectrum of presentation of the disease. Although feasible and safe in experienced hands, evidence that surgical resection after induction treatment improves overall survival (OS) is lacking. For resectable or potentially resectable stage III, the findings of two phase III trials suggest that surgical resection should not be considered a standard of care but rather reserved for selected patients after critical multidisciplinary assessment, in whom surgery improves survival after downstaging if pneumonectomy can be avoided or in some T4N0-1 resectable tumours. For unresectable stage III NSCLC the standard of care is a combination of chemotherapy and radiotherapy. In those patients with good performance status and minimal weight loss, the concurrent approach has resulted in a statistically significant improvement in OS rates compared with a sequential approach in randomised clinical trials, although several questions remain unresolved.