Combined modality treatment for stage III non-small cell lung cancer

There are increasing reports of studies in which combined modality treatment is being tested in stage III non-small cell lung cancer. Randomized trials in which sequential chemoradiotherapy has been compared to radiation alone and in which single agent cisplatin and simultaneous thoracic radiation were compared to radiation are reviewed and discussed. The largest and the most mature phase II trials of preoperative chemotherapy are also included in this review. Similarly the results from recently reported small randomized trials evaluating preoperative treatment are described. Potential future directions for clinical trials are suggested, including the incorporation of new agents in combined modality regimens.

New aspects in the staging of lung cancer. Prospective validation of the International Union Against Cancer TNM classification

BACKGROUND AND METHODS

To validate the new TNM definitions for lung cancer (International Union Against Cancer [UICC] TNM classification, 4th edition, 1987), the data of 3823 patients were analyzed prospectively in terms of concordance between clinical (TNM) and pathologically confirmed classification (pTNM), the value of the various diagnostic techniques in estimating the pathologically confirmed classification, and the prognostic relevance of the new TNM definitions.

RESULTS

With regard to the primary tumor (T), clinical and pathologic classifications were identical in 63%; with regard to lymph node involvement (N), the agreement was 47%; for distant metastasis agreement occurred in 91% of cases and for the stages it occurred in 56%. As to the primary tumor (T), the accuracy of radiography (59%) was nearly identical to that of computed tomography (CT) (58%). Both techniques were less precise in determining the extent of lymph node involvement (CT, correct assessments in 50%; radiography, correct assessments in 43%). The statistically significant differences in the prognosis for the T, N, and M categories and for the stages and the categories of the new R classification could be confirmed. Allowance should be made for the different prognosis between T1N0M0 and T2N0M0 by the new Substages IA and Ib of Stage I.

CONCLUSIONS

By the new TNM definitions for bronchus carcinoma, international conformity became feasible and practical, and the improvement of its prognostic relevance provided a more reliable basis for establishing guidelines for individual oncologic concepts.

Radiation therapy following resection of non-small cell bronchogenic carcinoma

Between 1970 and 1982, 102 patients received postoperative radiotherapy after attempted curative resection of bronchogenic carcinoma at The University of Texas M. D. Anderson Cancer Center. Surviving patients had a minimum follow-up of 3 years. Eight patients had pathological Stage I disease, 29 Stage II, and 65 Stage III. The 5-year actuarial survivals for patients with stages I, II, and III disease were 83%, 55%, and 38%, respectively (p = .04). Corresponding values for patients with N0, N1, and N2 disease were 74%, 56%, and 28% (p = .01). No significant differences in survival were seen based on T stage or tumor histology. Nine patients had gross residual disease following surgery, and 19 had microscopic residual disease. The 5-year actuarial survival was 78% for 12 patients without nodal disease who had known gross (4 patients) or microscopic (8 patients) residual tumor following attempted curative resection. The pathologic status of the hilar and mediastinal lymph nodes was the most significant factor affecting the frequency of metastatic relapse, with 19% of patients with N0, 33% of those with N1, and 69% of those with N2 disease developing distant disease. The low overall rate of recurrence intrathoracically (16%) confirms that postoperative radiotherapy is effective in preventing local relapse even in patients with proven nodal involvement. The impact of adjuvant radiation therapy on survival cannot be determined from these data, and further data are needed, preferably from well designed prospective studies.

Neoadjuvant treatment in locally advanced non-small cell lung cancer

Any neoadjuvant or preoperative treatment program that would increase survival in clinically advanced non-small cell lung cancer (NSCLC) patients would be of significant benefit. In addition to improving patient survival, the program should be associated with minimal toxicity and surgical mortality. The rationale for any preoperative program is that the ability to resect the advanced cancer will be enhanced and micrometastasis will be eradicated. We have analyzed 323 patients enrolled in various types of neoadjuvant and preoperative studies. Review of this data indicates that cisplatin containing regimens produce relatively high responder rates in locally advanced NSCLC patients, resectability rate can be increased by a neoadjuvant program and chemotherapeutic toxicity and operative mortality are not prohibitive. Survival data frequently includes T3N0-1 patients, but there does appear to be increased survival at 3 and 4 years. These studies remain experimental and continued analysis is necessary before they can be accepted as standard therapy for clinically advanced NSCLC cancer.